Management of Head and Neck Squamous Cell Carcinoma With N3 Nodal Disease

Radical management of the N3 neck for head and neck squamous cell cancer (HNSCC) remains unclear. We aimed to investigate the use of primary surgery including neck dissection versus primary radiotherapy followed by imaging.

We retrospectively reviewed consecutive patients with HNSCC and N3 nodal disease, excluding nasopharyngeal primaries. Patients had either surgical management of the primary and neck dissection followed by postoperative radiotherapy or primary radiotherapy followed by surveillance if complete response was found on post-treatment imaging. Patients were imaged at a mean of 16 weeks post radiotherapy. Patients identified with presence of resectable residual disease on imaging were treated with neck dissection.

Between July 2012 and February 2023, 53 patients with T0-4N3M0 HNSCC were treated radically. The median (range) follow-up was 25.5 (3-146) months, with an opportunity for follow-up of 64 (19-147) months. Twenty-two patients had primary surgical management and 31 had primary radiotherapy. Two-year overall survival was 64% in patients treated with primary surgery, 55% in patients treated with primary radiotherapy, 87% in patients with complete response after radiotherapy, and 92% in complete responders who were p16 positive. Response assessment was done with positron emission tomography-computed tomography (PET-CT) in 77% of patients and predicted subsequent disease-free survival better than computed tomography (CT). p16-positive patients were more likely to achieve complete response (63% vs 25%), but extracapsular spread was not predictive of response.

Surveillance for patients with complete response on postradiotherapy PET-CT is a reasonable approach, especially for p16-positive patients, sparing them the morbidity of neck dissection. Patients with p16-negative disease are less likely to achieve a complete response and may be better managed with primary neck dissection.