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Surgical Resection Is Necessary To Maximize Tumor Control in Function-Preserving, Aggressive Chemoradiation Protocols for Advanced Squamous Cancer of the Head and Neck (Stage III and IV)

From the Brown University Oncology Group (PR, TK), Miriam Hospital (HS), Rhode Island Hospital (PC, NR, WA, PN, RM, LL), and Roger Williams Medical Center (HW, RJK, KR-K), Providence, Rhode Island.

Correspondence: Address correspondence and reprint requests to Harold Wanebo, MD, Roger Williams Hospital, 825 Chalkstone Ave., Surgical Oncology, Providence, RI; Fax: 401-456-2035; E-mail: harold_wanebo{at}brown.edu

Background: The role of surgery in aggressive chemoradiation protocols for advanced head and neck cancer has been questioned because of the quoted high clinical response rates in many series.

Methods: The role of surgical resection was examined in an aggressive neoadjuvant protocol of weekly paclitaxel, carboplatin, and radiation for stage III and IV with completion of radiation to 72 Gy if biopsy at the primary site was negative after administration of 45 Gy. Of 43 patients enrolled, 38 completed the protocol. The clinical response was 100% (including 18 complete and 20 partial responses).

Results: The complete pathologic response (negative primary site biopsy at 45 Gy) was 25 of 38 (66%). Of patients who presented with N1 to N3 nodes, neck dissection revealed residual nodal metastases in 22%. Surgical resection of the primary site was required in 13 patients, including 5 with larynx cancer and 2 with base of tongue cancers. Four patients had resection with reconstruction for advanced mandible floor of mouth cancer, and one had resection of nasal-maxillary cancer. Functional resection was performed in 9 of 12 patients. The median progression free and overall survival was 64% and 68%, respectively, at median follow-up of 50 months. Nine patients developed recurrence (three local and six distant). There were no failures in the neck. Salvage surgery was performed in one patient with local and one with distant disease.

Conclusions: Surgical resection is an essential component of aggressive chemoradiation protocols to ensure tumor control at the primary site and in the neck.

Key Words: Head and neck • Surgical resection • Squamous cancer • Chemoradiation

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