The article by Mendenhall et al represents a comprehensive review of their own experience, as well as other large experiences in the literature, aimed at addressing the controversy of whether neck stage predicts local control after irradiation of head and neck cancer. The authors systematically explore this controversy in the setting of both definitive and postoperative therapy. Based on this review, and our own experience, we conclude that there are no significant data showing a correlation between neck stage and local control at the primary tumor site following irradiation of head and neck carcinoma.
In the Setting of Definitive Therapy
Does neck stage predict local control after definitive irradiation alone? The authors present the results of 11 reviews, including over 4,000 patients with head and neck cancer, that have addressed this question. Of the 11 series, 9 showed no correlation between neck stage and local control after primary irradiation.
The two series that did show a correlation were the Wall et al experience in patients with carcinomas of the supraglottic larynx [1] and the Withers et al report pertaining to the cumulative experience in 676 patients with tonsillar carcinoma pooled from nine institutions [2]. With regard to the latter, there was sufficient heterogeneity in staging evaluations, patient populations, treatment techniques, and other undocumented potential determinants of tumor control among the institutions that conclusions from such an analysis necessitate prospective confirmation.
As for the Wall et al analysis, a statistically significant (ie, P value equal to or less than .05) correlation between lymph node status and primary tumor control was found only after subgroup analysis and was limited to patients with T3 and T4 lesions and single or multiple lymph nodes(s) more than 3 cm. In addition, the analysis did not account for primary tumor volume and its potential relationship to extent of neck disease, a quantitative factor only recently found to be predictive of local tumor control in supraglottic and other head and neck carcinomas, and perhaps more sensitive than T stage [3,4].
In the Setting of Postoperative Therapy
The authors also present the results of four reviews, involving over 2,000 patients, that have addressed the question, does neck stage significantly predict local control after surgery, with or without radiotherapy? Of the four series, three showed no correlation between neck stage and local control. The inverse correlation found in the Hahn et al experience in patients with carcinomas of the supraglottis and pyriform sinus was a global finding of their entire series, which was not stratified according to T stage, primary site, or treatment group [5].
In our own recently reported experience of 57 patients with advanced squamous cell carcinomas of the head and neck, all of whom underwent resection of the primary lesion, neck dissection, and postoperative radiotherapy, multivariate analysis found only margin status (P = .002) and tumor grade (P = .007) to be significantly related to local control. Neither the presence of pathologically positive nodes nor neck stage was related to local control [6].
Summary
Based on the comprehensive review by Mendenhall et al, as well as our own experience, we conclude that currently there are no significant data showing a correlation between neck stage and local control at the primary tumor site following irradiation of head and neck carcinoma in both the definitive and postoperative setting.
A mechanism by which this issue may perhaps be better addressed is by archiving and analyzing the available database(s) from previous or ongoing prospective studies in which patients were staged and treated in a uniform manner. In the setting of postoperative therapy, an example of such a study would be the Radiation Therapy Oncology Group (RTOG) Trial 73-03, a prospective randomized study evaluating preoperative vs postoperative radiotherapy in patients with advanced head and neck carcinoma [7]. In addition, the existing RTOG database of over 2,000 patients with head and neck cancer, which has recently been analyzed with regard to the issue of staging prognostication, may be useful in addressing the issue of neck stage correlating with local control in the setting of definitive therapy [8].
In the meantime, like Mendenhahl et al, we also do not recommend a change in primary treatment philosophy for primary tumors based solely on the extent of nodal involvement in the neck.
A 52-year-old man presented with an erythematous lesion in the axilla of unknown duration. Surgical excision was performed. What is your diagnosis?
