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Management of the neck in parotid cancer
MANAGEMENT OF THE NECK IN PAROTID CANCER To the Editor: In the article “Management of the Neck in Parotid Carcinoma,” by Drs. Kelley and Spiro (Am J Surg. 1996; 172:695-697) the clinically significant dilemma of the role of elective neck dissection for primary malignant parotid tumors is nicely discussed. I am pleased to see that their conclusions are very similar to those that we arrived at in our published paper from 1983. Consideration of radiotherapy is done on a selective basis depending on local tumor characteristics and histology. Concurrent treatment of the clinically negative neck is appropriate to detect occult lymph node metastasis, provide better soft tissue three-dimensional resection margin, and are done more frequently in our series. It is unclear from the present paper as to the extent of elective lymph node neck dissection.‘*2 As was outlined in our two previous papers, lymph nodes at risk from primary malignant parotid tumors or metastatic skin malignancy to the parotid lymph nodes are the following: tail of parotid, lymph nodes along the external jugular vein, postauricular, jugulo-digastric, upper posterior cervical, and mid-jugular. If the malignant tumor is more anteriorly located, then nodes along the facial artery and submandibular triangle are also at risk. The frozen section and preoperative fine-needle aspiration biopsy are not always accurate predictors of the complete histopathology of the malignant tumor. Also, such biological markers as expression of P53 will not be available at the time of surgery. I would suggest that sometimes the frozen section is benign and a final histopathology confirms a malignant parotid tumor. Frequent elective upper regional neck dissection provides further meaningful information. If the lymph nodes are negative and there are no other strict criteria for adjunctive postoperative radiotherapy, then these patients may be spared the additional morbidity and cost of radiotherapy. There is minimal mor0 1998 by Excerpta All rights reserved.
Medica,
Inc.
bidity with a functional upper cervical lymph node dissection. Gilchrist L. Jackson, MD, FACS Surgical Oncology Kelsey-Seybold Hous ton,
Clinic Texas
1. Jackson GL, Luna MA, Byers, RM. Results of surgery alone and surgery combined with postoperative radiotherapy in the treatment of cancer of the parotid gland. Am J Surg. 146:497500. 2. Jackson GL, Ballantyne AJ. Role of parotidectomy for skin cancer of the head and neck. Am J Surg. 1982;i 42: 464-469.
The Reply: I appreciate Dr. Jackson’s response to our paper and agree with most of his comments. We initiated this study primarily to lend statistical support to our long-standing conservatism regarding lymphadenectomy in patients with parotid gland carcinoma. This was spelled out in a retrospective study of 288 previously untreated patients, which was published in 1975.’ It was then clear that neck failure is not a prominent feature of this disease and no clear evidence has since emerged to support elective neck dissection in most patients with parotid gland carcinoma who have a clinically negative neck. Elective lymphadenectomy is certainly reasonable in those few patients with sizeable, high-grade tumors, especially if recurrent. Moreover, we are in complete agreement with Dr. Jackson that a concurrent lymphadenectomy in N, patients with bulky tumors in the parotid tail may “. . . provide better soft tissue three-dimensional resection margin . . ..” Most will agree today that an elective neck dissection should be selective, not radical, removing nodes at levels 1, 2, and 3 in most instances. Those who favor more liberal use of elective neck dissection should note that neck failure occurred in only 4 of the 121 patients we studied (3.3%), 3 of whom had neck dissection as part of their initial management. With respect to obvious cervical metastases, current experience suggests that selective, rather than radical neck dissection may suffice in some patients, with the addition of postoperative irradiation. Adjunctive
radiotherapy is certainly appropriate in any patient with positive nodes, whether palpable or occult, but the need for irradiation in most patients with parotid cancer has more to do with the size of the primary tumor and the adequacy of the resection margins. As we have shown in a matched pair analysis, survival in patients with small, adequately excised parotid cancers was not improved when postoperative irradiation was employed.’ Although it would be highly desirable to address some of these questions in a prospective fashion, this is unlikely given the low incidence of parotid gland carcinoma and the prolonged observation necessary. Until better biological assessments are developed, management of these patients will continue to depend primarily on our judgment and experience. Ronald I-I. Spiro, MD Attending Surgeon, Head 83 Neck Service Memorial Sloan-Kettering
Cancer Cenwr New York, New York 1. Spiro RH, Huvos AG, Strong EW. Cancer of the parotid gland, a clinicopathologic study of 288 primary cases. Am J Surg. 1975;130:452-459. 2. Armstrong JG, Harrison LB, Spiro RH, et al. Malignant tumors of major salivary gland origin, a matched pair analysis of the role of combined surgery and postoperative radiotherapy.
Arch Otolaryngol 199O;i 16:290-293.
HORIZONS SURGERY
Head
Neck
Surg.
IN GENERAL
To the Editor: I am writing in reference to an article you and Dr. Galandiuk authored in the January 1997 issue of the American Journal of Surgery. The article, “Horizons in .General Surgery,” I thought was very appropriate for our times and is very relevant to my cur, rent situation. In this article you made reference to the fact that gen, era1 surgeons should recognize and capitalize on new opportunities. In “Dissolution of Traditional Surgical Disciplinary Boundaries,” you reviewed many disciplines that surgeons have now expanded. One dis, cipline not listed that is currently 0002-961 O/98/$1 PII SOOO2-9610(98)00090-7
9.00
4%
Medica,
Inc.
bidity with a functional upper cervical lymph node dissection. Gilchrist L. Jackson, MD, FACS Surgical Oncology Kelsey-Seybold Hous ton,
Clinic Texas
1. Jackson GL, Luna MA, Byers, RM. Results of surgery alone and surgery combined with postoperative radiotherapy in the treatment of cancer of the parotid gland. Am J Surg. 146:497500. 2. Jackson GL, Ballantyne AJ. Role of parotidectomy for skin cancer of the head and neck. Am J Surg. 1982;i 42: 464-469.
The Reply: I appreciate Dr. Jackson’s response to our paper and agree with most of his comments. We initiated this study primarily to lend statistical support to our long-standing conservatism regarding lymphadenectomy in patients with parotid gland carcinoma. This was spelled out in a retrospective study of 288 previously untreated patients, which was published in 1975.’ It was then clear that neck failure is not a prominent feature of this disease and no clear evidence has since emerged to support elective neck dissection in most patients with parotid gland carcinoma who have a clinically negative neck. Elective lymphadenectomy is certainly reasonable in those few patients with sizeable, high-grade tumors, especially if recurrent. Moreover, we are in complete agreement with Dr. Jackson that a concurrent lymphadenectomy in N, patients with bulky tumors in the parotid tail may “. . . provide better soft tissue three-dimensional resection margin . . ..” Most will agree today that an elective neck dissection should be selective, not radical, removing nodes at levels 1, 2, and 3 in most instances. Those who favor more liberal use of elective neck dissection should note that neck failure occurred in only 4 of the 121 patients we studied (3.3%), 3 of whom had neck dissection as part of their initial management. With respect to obvious cervical metastases, current experience suggests that selective, rather than radical neck dissection may suffice in some patients, with the addition of postoperative irradiation. Adjunctive
radiotherapy is certainly appropriate in any patient with positive nodes, whether palpable or occult, but the need for irradiation in most patients with parotid cancer has more to do with the size of the primary tumor and the adequacy of the resection margins. As we have shown in a matched pair analysis, survival in patients with small, adequately excised parotid cancers was not improved when postoperative irradiation was employed.’ Although it would be highly desirable to address some of these questions in a prospective fashion, this is unlikely given the low incidence of parotid gland carcinoma and the prolonged observation necessary. Until better biological assessments are developed, management of these patients will continue to depend primarily on our judgment and experience. Ronald I-I. Spiro, MD Attending Surgeon, Head 83 Neck Service Memorial Sloan-Kettering
Cancer Cenwr New York, New York 1. Spiro RH, Huvos AG, Strong EW. Cancer of the parotid gland, a clinicopathologic study of 288 primary cases. Am J Surg. 1975;130:452-459. 2. Armstrong JG, Harrison LB, Spiro RH, et al. Malignant tumors of major salivary gland origin, a matched pair analysis of the role of combined surgery and postoperative radiotherapy.
Arch Otolaryngol 199O;i 16:290-293.
HORIZONS SURGERY
Head
Neck
Surg.
IN GENERAL
To the Editor: I am writing in reference to an article you and Dr. Galandiuk authored in the January 1997 issue of the American Journal of Surgery. The article, “Horizons in .General Surgery,” I thought was very appropriate for our times and is very relevant to my cur, rent situation. In this article you made reference to the fact that gen, era1 surgeons should recognize and capitalize on new opportunities. In “Dissolution of Traditional Surgical Disciplinary Boundaries,” you reviewed many disciplines that surgeons have now expanded. One dis, cipline not listed that is currently 0002-961 O/98/$1 PII SOOO2-9610(98)00090-7
9.00
4%