Residen Bedah

DR. I GUSTI NGURAH GDE DWI ARYANATA Stase Bedah Onkologi

Nov - Des 2018
 INTRODUCTION
• There is no current consensus about the treatment of the clinically negative
neck in CARCINOMA OF THE PAROTID GLAND.
• The decision when to carry out an ELECTIVE NECK DISSECTION (END)
and what levels to dissect remain poorly defined.
• Before 1966, at Memorial Sloan-Kettering Cancer Center (MSKCC) was
to carry out RADICAL NECK DISSECTION IN CLINICALLY DISEASE-
POSITIVE NECKS and OBSERVE PATIENTS WITH CLINICALLY NEGATIVE
NECKS.
• From 1966 onward, our practice changed because we observed that
some patients, notably patients with disease with HIGH T STAGE AND
HIGH-GRADE HISTOLOGIES, EXPERIENCED DISEASE RECURRENCE IN
THE NECK.
As a result of the controversy surrounding this topic, we decided to review our more
recent experience in neck treatment in patients with carcinoma of the parotid
gland to better define the indications and type of neck dissection in these patients.

• ELECTIVE NECK DISSECTION (END)?

• THERAPEUTIC NECK DISSECTION (TDN)?
MATERIALS AND METHODS
Inclusion and Exclusion Criteria :
• Patients with MALIGNANT SALIVARY GLAND TUMORS treated at our
institution between the years 1985 and 2009 were identified.
• Patients who had previous surgery, previous nonsurgical treatment
(radiotherapy or chemotherapy), nonsalivary malignancies (lymphoma,
sarcoma), metastases to the parotid gland, benign pathology, treatment
outside of MSKCC, and incomplete notes were excluded.
• 301 patients was eligible. Of these, 263 had carcinomas of the parotid
gland. The most common pathology was mucoepidermoid carcinoma (33 %),
followed by Carcinoma ex-pleomorphic adenoma (21 %), acinic cell
carcinoma (13 %), adenocarcinoma (10 %), and adenoid Cystic carcinoma (7
%). Patient, tumor, and treatment characteristics were collected by
retrospective review of patient charts.
• Patients were stratified by neck treatment into 3 groups:
• No neck dissection (NoND),
• Elective neck dissection END,
• Therapeutic neck dissection (TND).
• A total of 136 men and 127
women (median age 62 years)
were included in the study.
Clinicopathological characteristics of the END and TND groups compared to the
NoND group were determined by the Chi-Square (X2) test.
A p value of less than 0.05 was taken as statistically significant.
The pathological positivity of each neck level was quantified, and 5-year neck
recurrence-free survival (NRFS) was determined by the Kaplan–Meier statistic.
RESULT
Compared to the NoND group, patients in the END group were more likely to be over
60 years of age, to have clinical stage T3T4 disease, and to have more aggressive
pathology, with a greater percentage of high grade tumors, vascular invasion,
perineural invasion, and positive margins, as well as higher pT stage.
Most of the pathologic data were available after the fact —that is, after the neck
dissection— and thus it did not enter into the decision of selecting the patient for
END.
Only the clinical parameters of T stage and the histology were available before the
operation, and therefore the decision for END was based only on these factors.
The proportion of patients who had each neck level dissected and the pathological
positivity of each were and for levels I to V, respectively. Most patients whose
diseases was pN+ in the END group (93 %) had postoperative radiotherapy (PORT).
Of patients who had END, 4 patients had recurrence of neck disease (3 pN+, 1 pN-
). Of the 158 patients who had no END, (34 %) patients hadPORT as a result of
adverse features of the primary tumor. There was 1 recurrence in this group (Fig.
1).
FIG. 2 Proportion of metastases stratified by histology and
percentage positivity per neck level in patients undergoing
END
TREATMENT OF THE CN+ NECK
Comparison of the TND and NoND groups is shown in Table 1. As in the END patients,
those in the TND group were more likely to be over 60 years of age, to have clinical
stage T3T4 disease, and to have more aggressive pathology compared to the NoND
group.
Of the TND group, pathological positivity was found in 87 % patients. Figure 3 shows
the proportion of pathological positive nodes stratified by histology. As in END, high-
grade histologies accounted for pathological positivity of neck nodes. The proportion
of patients who had each neck level dissected and the pathological positivity of each
was 51.6, 77, 73, 53, and 40 % for levels I to V, respectively. The majority of
patients (92 %) had PORT. No patient experienced recurrent neck disease (Fig. 1).
FIG. 3 Proportion of metastases stratified by histology and
percentage positivity per neck level in patients undergoing
TND
DETAILS OF PATIENTS WITH RECURRENCE OF
NECK DISEASE
Table 2 and Fig. 1 show the neck failure and NRFS rates.
The NoND group had an excellent 5-year NRFS of 98.7 %. END patients who were
pN+ had a poorer 5-year NRFS compared to pN0 patients, 80.5 versus 97.3 % (p =
0.05).
Three patients who had an END experienced disease recurrence; all patients had
undergone comprehensive neck dissection (levels I toV) and PORT. The reason for
recurrence in these patients was aggressive pathology (high-grade
adenocarcinoma, carcinoma ex-pleomorphic adenoma, salivary duct carcinoma).
DISCUSSION
According to the literature, occult metastases are detected in 12–48 % of
patients.
This range in occult metastases is a reflection of the varied histologies that can
occur in parotid gland carcinoma, with tumors such as salivary duct
carcinoma or adenocarcinoma having high rates of neck metastases
compared to tumors such as adenoid cystic cancer or acinic cell cancer,
which have low rates.
The study by Armstrong in 1992 reported one of the largest series
of 474 patients.
• END was recommended only in patients deemed to be at high
risk, namely those with T3/T4 tumors and disease with high-
grade histologies.
• In addition, it was concluded that neck levels II to IV were mainly
at risk and should be electively dissected.
• Medina summarized the indications for END :
• High-grade tumors,
• T3T4 tumors,
• Tumors >3 cm in size,
• Facial paralysis,
• Age over 54 years,
• Extraglandular extension,
• Perilymphatic invasion.
• Further, some authors advocate a routine END in all cases of
primary parotid carcinoma, because :
• First, there is inaccuracy in the preoperative diagnosis of cytological grade; for example,
Kawata et al. 4 reported the rate at which the histological grade was accurately
diagnosed preoperatively was low, especially in those with low-grade malignancy.
• Second, the rate of occult metastases was high, with nodal disease detected in 61 % of
patients with high-grade and 23 % with intermediate-grade disease.
 In the present study, of 232 patients with a clinically disease-negative neck, only 74 were
selected to undergo END.
These patients more than 60 years old, had T3/T4 tumors, and had high-grade
histology. The findings on pathology of vascular invasion, perineural invasion, and positive
margins correlated well with the preoperative impression of aggressive histology. In these
patients, the occult rate of metastases was 35 %.

Our data therefore suggest that END should be considered for

these higher grade histologies and for any tumor that is T3 or
T4.
WHAT LEVEL SHOUD BE DISSECT??
• Klussmann et al. found that levels II, III, and V were
predominantly involved but that involvement of level I and/or level
IV were important risk factors for locoregional recurrence. The
authors therefore recommended that END should include dissection
of all neck levels, I to V.
• Armstrong et al. reported occult lymph node involvement
predominately in levels II to IV. In the current study, nodal
positivity was also more likely in levels II to IV.
However, consideration should be given to dissecting levels I or V, depending
on the size and location of the primary tumor. For example, for cancers
located more anteriorly, metastases to level I are more likely, whereas a large
tumor located in the parotid tail is at risk of spread to level V.
Efficacy of END
In our study, a comparison of efficacy between
those having NoND (observation) and those
having an END is not possible as a result of the
noncomparability of the 2 groups according to
clinicopathological variables, but also by the
fact that 69 % of our NoND group underwent
PORT.
 Efficacy of END
Others have proposed that END has a proven benefit over observation. For
example, Zbaren et al.6 reported on 41 patients who had END and 42
patients who had no END. Both groups had comparable clinical and tumor
characteristics.
Both groups also had comparable rates of PORT. The regional recurrence rates
were 12 % in the END group and 26 % in the observation groups. They also
reported the disease-free survival to be superior in the END group (86 vs. 69
%).

On the basis of these data, the authors recommended END for

all patients with parotid cancer.
IF THE NECK PROVES TO BE POSITIVE FOR DISEASE, PORT IS
GENERALLY ADVOCATED.

This is based on evidence from reduced recurrence of neck

disease in squamous cell cancer of the head and neck treated
with adjuvant PORT after neck dissection.
In addition, studies in parotid gland cancer have shown that
surgery and PORT resulted in excellent outcomes with minimal
side effects and preservation of good quality of life scores.
Armstrong et al. have also reported that the rate of recurrence of neck
disease was 29 % in patients with pN+ disease after END who did not
receive PORT, compared to 0 in those having PORT.
Therefore, PORT IS GENERALLY ADVOCATED FOR THE PN+ NECK AFTER
END.
ELECTIVE NECK RADIATION (ENI) VS END.
A recent article assessing END (n = 41) versus ENI (n = 18) for
high-grade salivary carcinoma reported a 10 % recurrence rate
in the END versus 0 recurrence in the ENI group.
However, again, these patients were not randomized to these
treatment arms.
At our institution, END is generally carried out if patients have clinical T3/T4
disease before surgery or if preoperative biopsy reveals a high-grade
malignancy.
When parotidectomy is carried out without neck dissection for a presumed
benign tumor or low-grade cancer, one can later find the cancer to be high
grade or have other worrisome features, such as perineural or vascular
invasion.

PORT FOR THE PRIMARY SURGICAL BED

AND NODAL BASINS
PORT
The control rate of neck disease in these
patients was excellent, with a 5-year
NRFS of 97 %.
 THERAPEUTIC NECK DISSECTION

RECOMMENDATION : COMPREHENSIVE NECK DISSECTION

AT LEVELS I TO V FOR ALL PATIENTS WITH A CLINICALLY
DISEASE-POSITIVE NECK.
RECURRENCE OF NECK DISEASE RISK IS HIGHER IN PATIENTS WITH CN+
DISEASE THAN N0 DISEASE.
 Rodriguez-Cuevas et al. reported recurrence to be 23.5 % in N+
compared to 3.2 % in N0 disease.
 In the current study, we found that patients who had a pathologically
disease-positive neck had a poorer NRFS of 84.8 %.
 Interestingly, the recurrence rate in patients having a TND was 0, whereas
patients with pN+ neck disease after END had a higher recurrence rate
(Fig. 1).
RECURRENCE OF NECK DISEASE RISK

NRFS of
84.8 %
We therefore analyzed the 3 END pN+ patients in more detail (Table 2). In all
3 patients, all levels (I to V) of the neck were dissected and all received PORT.
Therefore, treatment failure in these patients was a reflection of aggressive
histology rather than incomplete treatment.
CONCLUSION
1. Patients with cN0 disease, observation of the neck is safe in patients who are under 60
years of age with clinical T1 or T2 tumors and with disease with low-grade histology.
2. END should be carried out in patients with cT3T4 disease or high-grade histology.
3. At a minimum, levels II to IV should be dissected, with dissection of levels I and V being
done according to size and location of the primary tumor.
4. In patients with cN+ disease, all levels of the neck are at risk of metastatic disease, and
therefore comprehensive neck dissection of levels I to V is advocated.
5. In patients who do not have an END but have adverse features on pathological analysis,
PORT to the upper neck is recommended in addition to the primary surgical bed.