9
Section of Laryngology
Table I
was Crile's description of radical neck dissection in 1906, and that modifications of this procedure, including extended surgery, have made little or no difference to survival rates. It is hoped that some means may soon be found of identifying those patients with head and neck cancer who do badly - the majority. As a start, it is proposed that patients with an antral carcinoma and a gland in the neck, and patients with hypopharyngeal carcinoma and bilateral neck glands should not be treated by surgery. A retrospective analysis is made of matched pairs drawn from a personal series, one patient in each pair having had a prophylactic neck dissection, and one having been submitted to a policy of 'wait and see'. The survival rate for patients undergoing prophylactic neck dissection was worse than that of the wait and see group; this difference was statistically significant.
Neck dissection (T staging) Ti 1 Oropharynx Hypopharynx 4 Larynx 5
T2 T3 T4 1 1 3 7 5 5
Table 2 Percentage survival
Yearly intervals 1 2 3 4 5
Prophylactic neck dissection 60 46 35 34 28
'Wait and see' 74 62 57 54 38
Table 3 Cause of death
Recurrence in neck Primary
Prophylactic neck dissection 3
'Wait and see' 3
5
1
4 6
2 9
18
15
recurrence
Metastases Intercurrent disease
Total
85
REFERENCES Crile G W (1906) Journal ofthe American Medical Association 47, 1780 McKelvie P (1974) Canadian Journal of Otolaryngology (in press) Union Internationale Contre le Cancer (1973) TNM Classification of Malignant Tumours. Geneva
Dr J M Henk
reasons: a surgeon must do what he feels to be right for any particular patient at any particular time -it can therefore be very difficult for a surgeon to allocate patients with a fatal disease to one of several different treatment regimes if he feels in his heart that one is better than the other. If the patients undergoing major surgery are allocated randomly to two groups, it is very unlikely that the two groups will be matched for age, sex, site, &c., so that it may be more accurate to choose matched pairs retrospectively, provided that if more than one choice is available for matching, it is done randomly (as was the case in this investigation). A prolonged investigation has the disadvantage that over a long time patterns of referral, skills, judgement and treatment policies change; as an example of this, hypopharyngeal carcinoma could be quoted in the last ten years treatment policy of the primary tumour has changed at least twice in many institutions and has in fact changed four times in this institution. Conclusions should therefore be drawn very cautiously, if at all, from the present study, but no evidence has emerged to lead one to suspect that prophylactic neck dissection is of benefit.
Summary It is suggested that the last major improvement in the surgical treatment of head and neck cancer
(Velindre Hospital, Velindre Road, Whitchurch, Cardiff)
Radiosensitivity of Lymph Node Metastases Lymph node metastases in the neck are usually treated where possible by block dissection. One of the arguments often put forward to support this policy is that secondary carcinoma in lymph nodes is more radio-resistant than the primary from which it is derived. This idea developed from experience in the management of oral cancer in the period between 1930 and 1950, when primary tumours were frequently treated by radium needle implant. From the radiobiological point of view this is an excellent method of treatment; the low dose-rate largely overcomes the problem of the hypoxic tumour cell, the treatment time is short preventing any likelihood of repopulation of the tumour during irradiation, and radiation is sharply localized to the tumour bearing volume; the disadvantages are that great skill and practice are needed to perform satisfactory implants and the technique is only applicable to tumours at a limited number of sites. Before the advent of supervoltage equipment there was no satisfactory technique available to deliver adequate radiotherapy to lymph nodes in the neck. Where treatment was attempted by orthovoltage X-rays, results were not satisfactory. Nevertheless, Martin (1950) was able to
10
86 Proc. roy. Soc. Med. Volume 68 February 1975 Table 1 Analysis of cases with differing response of primary and nodes Primary controlled, node failure
NI TI T2 1 1 T3 T4 1
N2 N3 1 2 1 9 4
Primaryfailure, nodes controlled
NJ 1 2 7 1
N2 N3 I - 5 - -
Table 2 Three-year local control rates for nodes No. of cases Nodes
treated Ni 46 N2 7 N3 72
controlled(%)
65 43 32
report a series of patients with carcinoma of the oral cavity where lymph node metastases were treated with a combination of radium needle implant and deep X-ray, obtaining a five-year survival rate of 27%, equal to that of a larger series of similar cases treated surgically. Dobbie (1953) reported a small series of patients with advanced head and neck cancer with lymph node metastases who were treated palliatively by deep X-ray; he found that the primary and lymph nodes usually responded alike. With supervoltage radiation it is possible to deliver radiation homogeneously to primary and lymph nodes en bloc. Previously reported series show that it is usual either to cure both primary and nodes or to fail with both. Node failure with controlled primary is rather less common than the converse (Hanks et al. 1969, Wizenburg et al. 1972). In Cardiff between 1965 and 1970 a series of 125 patients with advanced head and neck carcinoma with lymph node metastases were treated by supervoltage radiotherapy to primary and nodes en bloc, as part of a prospective controlled clinical trial of hyperbaric oxygen (Henk et al. 1970). Only those patients with palpable lymph nodes in the neck larger than 1.5 cm in diameter which were considered by at least two observers to contain metastatic disease are included in this report. The local tumour control rates three years after treatment were as follows: primary and nodes controlled, 31 %; primary and nodes recurrent, 39%; primary controlled, nodes recurrent, 16%; primary recurrent, nodes controlled, 14 %. Where the primary and nodes responded differently, there was usually considerable disparity in size between the two. A breakdown of such cases according to the TNM system is shown in Table 1. These figures, together with those of the authors quoted above, lend no support to the idea that secondary carcinoma in lymph nodes is
more radio-resistant than the primary from which it is derived, a concept which should be discarded. The three-year local control rates for nodes alone are shown in Table 2. These figures compare favourably with most reported surgical series, especially as surgery could have been attempted in only a very small minority of the N3 cases. Both preoperative radiotherapy (Strong 1969) and postoperative radiotherapy (Tapley & Fletcher 1973) reduce the local recurrence rate after block dissection. There is now probably little or no place for the treatment of lymph node metastases by block dissection alone. The choice of treatment lies between a combination of surgery and radiotherapy, or radiotherapy alone. REFERENCES Dobbie J L (1953) British Journal ofRadiology 27,656-659 Hanks G E, Bagshaw M A & Kaplan H S (1969) American Journal of Roentgenology 105, 74-82 Henk J M, Kunkler P B, Shah N K, Smith C W, Sutherland W H & Wassif S B (1970) Clinical Radiology 21, 223-231 Martin C L (1950) Radiology 55, 62-67 Strong E W (1969) Surgical Clinics ofNorth America 49, 271-276 Tapley N D & Fletcher G H (1973) American Journal of Roentgenology 117, 575-583 Wizenburg M J, Bloedorn F G, Weiner S & Gracia J (1972) Cancer 29, 1455-1462
The following paper was also read:
Handling of the Late Neck Metastases Professor T Palva (University ofHelsinki, Finland) Meeting 3 May 1974 The following short papers were read: Two Rare Tumours Involving the Infratemporal Fossa: Alveolar Soft Part Sarcoma and Hiemangiopericytoma Mr G Buchanan (Institute ofLaryngology and Otology, London) Fibrous Dysplasia of the Head and Neck Professor D M L Williams (Kingston General Hospital, Kingston, Ontario, Canada) The First Laryngectomy Mr P M Stell (University ofLiverpool) Experiences with Intravital Staining in Parotid Surgery Mr A D Cheesman (Royal National Throat, Nose & Ear Hospital, Gray's Inn Road, London WCI)
The meeting is to be reported in the Journal of Laryngology and Otology.
Section of Laryngology
Table I
was Crile's description of radical neck dissection in 1906, and that modifications of this procedure, including extended surgery, have made little or no difference to survival rates. It is hoped that some means may soon be found of identifying those patients with head and neck cancer who do badly - the majority. As a start, it is proposed that patients with an antral carcinoma and a gland in the neck, and patients with hypopharyngeal carcinoma and bilateral neck glands should not be treated by surgery. A retrospective analysis is made of matched pairs drawn from a personal series, one patient in each pair having had a prophylactic neck dissection, and one having been submitted to a policy of 'wait and see'. The survival rate for patients undergoing prophylactic neck dissection was worse than that of the wait and see group; this difference was statistically significant.
Neck dissection (T staging) Ti 1 Oropharynx Hypopharynx 4 Larynx 5
T2 T3 T4 1 1 3 7 5 5
Table 2 Percentage survival
Yearly intervals 1 2 3 4 5
Prophylactic neck dissection 60 46 35 34 28
'Wait and see' 74 62 57 54 38
Table 3 Cause of death
Recurrence in neck Primary
Prophylactic neck dissection 3
'Wait and see' 3
5
1
4 6
2 9
18
15
recurrence
Metastases Intercurrent disease
Total
85
REFERENCES Crile G W (1906) Journal ofthe American Medical Association 47, 1780 McKelvie P (1974) Canadian Journal of Otolaryngology (in press) Union Internationale Contre le Cancer (1973) TNM Classification of Malignant Tumours. Geneva
Dr J M Henk
reasons: a surgeon must do what he feels to be right for any particular patient at any particular time -it can therefore be very difficult for a surgeon to allocate patients with a fatal disease to one of several different treatment regimes if he feels in his heart that one is better than the other. If the patients undergoing major surgery are allocated randomly to two groups, it is very unlikely that the two groups will be matched for age, sex, site, &c., so that it may be more accurate to choose matched pairs retrospectively, provided that if more than one choice is available for matching, it is done randomly (as was the case in this investigation). A prolonged investigation has the disadvantage that over a long time patterns of referral, skills, judgement and treatment policies change; as an example of this, hypopharyngeal carcinoma could be quoted in the last ten years treatment policy of the primary tumour has changed at least twice in many institutions and has in fact changed four times in this institution. Conclusions should therefore be drawn very cautiously, if at all, from the present study, but no evidence has emerged to lead one to suspect that prophylactic neck dissection is of benefit.
Summary It is suggested that the last major improvement in the surgical treatment of head and neck cancer
(Velindre Hospital, Velindre Road, Whitchurch, Cardiff)
Radiosensitivity of Lymph Node Metastases Lymph node metastases in the neck are usually treated where possible by block dissection. One of the arguments often put forward to support this policy is that secondary carcinoma in lymph nodes is more radio-resistant than the primary from which it is derived. This idea developed from experience in the management of oral cancer in the period between 1930 and 1950, when primary tumours were frequently treated by radium needle implant. From the radiobiological point of view this is an excellent method of treatment; the low dose-rate largely overcomes the problem of the hypoxic tumour cell, the treatment time is short preventing any likelihood of repopulation of the tumour during irradiation, and radiation is sharply localized to the tumour bearing volume; the disadvantages are that great skill and practice are needed to perform satisfactory implants and the technique is only applicable to tumours at a limited number of sites. Before the advent of supervoltage equipment there was no satisfactory technique available to deliver adequate radiotherapy to lymph nodes in the neck. Where treatment was attempted by orthovoltage X-rays, results were not satisfactory. Nevertheless, Martin (1950) was able to
10
86 Proc. roy. Soc. Med. Volume 68 February 1975 Table 1 Analysis of cases with differing response of primary and nodes Primary controlled, node failure
NI TI T2 1 1 T3 T4 1
N2 N3 1 2 1 9 4
Primaryfailure, nodes controlled
NJ 1 2 7 1
N2 N3 I - 5 - -
Table 2 Three-year local control rates for nodes No. of cases Nodes
treated Ni 46 N2 7 N3 72
controlled(%)
65 43 32
report a series of patients with carcinoma of the oral cavity where lymph node metastases were treated with a combination of radium needle implant and deep X-ray, obtaining a five-year survival rate of 27%, equal to that of a larger series of similar cases treated surgically. Dobbie (1953) reported a small series of patients with advanced head and neck cancer with lymph node metastases who were treated palliatively by deep X-ray; he found that the primary and lymph nodes usually responded alike. With supervoltage radiation it is possible to deliver radiation homogeneously to primary and lymph nodes en bloc. Previously reported series show that it is usual either to cure both primary and nodes or to fail with both. Node failure with controlled primary is rather less common than the converse (Hanks et al. 1969, Wizenburg et al. 1972). In Cardiff between 1965 and 1970 a series of 125 patients with advanced head and neck carcinoma with lymph node metastases were treated by supervoltage radiotherapy to primary and nodes en bloc, as part of a prospective controlled clinical trial of hyperbaric oxygen (Henk et al. 1970). Only those patients with palpable lymph nodes in the neck larger than 1.5 cm in diameter which were considered by at least two observers to contain metastatic disease are included in this report. The local tumour control rates three years after treatment were as follows: primary and nodes controlled, 31 %; primary and nodes recurrent, 39%; primary controlled, nodes recurrent, 16%; primary recurrent, nodes controlled, 14 %. Where the primary and nodes responded differently, there was usually considerable disparity in size between the two. A breakdown of such cases according to the TNM system is shown in Table 1. These figures, together with those of the authors quoted above, lend no support to the idea that secondary carcinoma in lymph nodes is
more radio-resistant than the primary from which it is derived, a concept which should be discarded. The three-year local control rates for nodes alone are shown in Table 2. These figures compare favourably with most reported surgical series, especially as surgery could have been attempted in only a very small minority of the N3 cases. Both preoperative radiotherapy (Strong 1969) and postoperative radiotherapy (Tapley & Fletcher 1973) reduce the local recurrence rate after block dissection. There is now probably little or no place for the treatment of lymph node metastases by block dissection alone. The choice of treatment lies between a combination of surgery and radiotherapy, or radiotherapy alone. REFERENCES Dobbie J L (1953) British Journal ofRadiology 27,656-659 Hanks G E, Bagshaw M A & Kaplan H S (1969) American Journal of Roentgenology 105, 74-82 Henk J M, Kunkler P B, Shah N K, Smith C W, Sutherland W H & Wassif S B (1970) Clinical Radiology 21, 223-231 Martin C L (1950) Radiology 55, 62-67 Strong E W (1969) Surgical Clinics ofNorth America 49, 271-276 Tapley N D & Fletcher G H (1973) American Journal of Roentgenology 117, 575-583 Wizenburg M J, Bloedorn F G, Weiner S & Gracia J (1972) Cancer 29, 1455-1462
The following paper was also read:
Handling of the Late Neck Metastases Professor T Palva (University ofHelsinki, Finland) Meeting 3 May 1974 The following short papers were read: Two Rare Tumours Involving the Infratemporal Fossa: Alveolar Soft Part Sarcoma and Hiemangiopericytoma Mr G Buchanan (Institute ofLaryngology and Otology, London) Fibrous Dysplasia of the Head and Neck Professor D M L Williams (Kingston General Hospital, Kingston, Ontario, Canada) The First Laryngectomy Mr P M Stell (University ofLiverpool) Experiences with Intravital Staining in Parotid Surgery Mr A D Cheesman (Royal National Throat, Nose & Ear Hospital, Gray's Inn Road, London WCI)
The meeting is to be reported in the Journal of Laryngology and Otology.
