Florent Carsuzaa1, Philippe Gorphe2, Sébastien Vergez3, Olivier Malard4, Nicolas Fakhry5, Christian Righini6, Pierre Philouze7, Audrey Lasne-Cardon8, Patrice Gallet9, Denis Tonnerre1, Alexandre Bozec10, Erwan de Mones11, Bertrand Baujat12, Laurent Laccourreye13, Emmanuel Babin8, Xavier Dufour1, Juliette Thariat14. 1. Head and Neck Surgery, University Hospital of Poitiers, France. 2. Department of Head and Neck Oncology, Gustave Roussy, University Paris-Saclay, Villejuif, France. 3. Institut Universitaire du Cancer de Toulouse Oncopole, University Hospital of Toulouse, France. 4. Head and Neck Surgery, University Hospital of Nantes, France. 5. Head and Neck Surgery, APHM, La Conception University Hospital, Marseille, France. 6. Head and Neck Surgery, University Hospital of Grenoble, France. 7. Head and Neck Surgery, Croix Rousse Hospital, Hospices Civils de Lyon (Hospital Group of Lyon), France. 8. Head and Neck Surgery, Centre François Baclesse, Caen, France. 9. Head and Neck Surgery, University Hospital of Nancy, France. 10. Head and Neck Surgery, Institut Universitaire de la Face et du Cou, Nice, France. 11. Head and Neck Surgery, University Hospital of Bordeaux, France. 12. Head and Neck Surgery, Tenon Hospital, Paris, France. 13. Head and Neck Surgery, University Hospital of Angers, France. 14. Radiation Oncology, Centre François Baclesse/ARCHADE, Caen, France. Electronic address: jthariat@gmail.com.
Abstract
BACKGROUND: Among patients with T0-2 N3 head and neck squamous cell carcinomas (HNSCC), those undergoing upfront neck dissection have better oncological outcomes. However, there is no consensual definition of disease resectability of N3 nodes, leading to major treatment attrition and interpretation biases between studies. We established a Delphi method-based consensus to define resectability and impact on decision-making for upfront neck dissection in N3 patients. METHODS: The Delphi method was designed as recommended by the French Haute Autorite de Sante among head and neck surgeons from university hospitals and cancer centers, using a 24-item questionnaire. Strong and relative agreements were subsequently established, and recommendations were written. The resulting recommendations were assessed by 30 independent surgeons. RESULTS: N3 nodes with intraparenchymal brain invasion, foramen invasion, skull base erosion, nodes requiring bilateral XIIth cranial nerve sacrifice, retropharyngeal N3 node or a node above the plan of soft palate are major contraindications to neck dissection. When neck dissection requires unilateral sacrifice of the IXth or Xth or XIIth cranial nerves or cervical nerve roots, upfront neck dissection may be performed, based on a case-by-case assessment of other patient and tumor estimates. CONCLUSION: Consensual contraindications to neck dissection in patients with T0-2 N3 HNSCC were defined among French head and neck surgeons as concerns skull base invasion, retropharyngeal nodes and bilateral XIIth cranial nerve sacrifice. This consensus should allow more reliable comparisons between surgical and non-surgical strategies in N3 patients.
BACKGROUND: Among patients with T0-2 N3 head and neck squamous cell carcinomas (HNSCC), those undergoing upfront neck dissection have better oncological outcomes. However, there is no consensual definition of disease resectability of N3 nodes, leading to major treatment attrition and interpretation biases between studies. We established a Delphi method-based consensus to define resectability and impact on decision-making for upfront neck dissection in N3 patients. METHODS: The Delphi method was designed as recommended by the French Haute Autorite de Sante among head and neck surgeons from university hospitals and cancer centers, using a 24-item questionnaire. Strong and relative agreements were subsequently established, and recommendations were written. The resulting recommendations were assessed by 30 independent surgeons. RESULTS: N3 nodes with intraparenchymal brain invasion, foramen invasion, skull base erosion, nodes requiring bilateral XIIth cranial nerve sacrifice, retropharyngeal N3 node or a node above the plan of soft palate are major contraindications to neck dissection. When neck dissection requires unilateral sacrifice of the IXth or Xth or XIIth cranial nerves or cervical nerve roots, upfront neck dissection may be performed, based on a case-by-case assessment of other patient and tumor estimates. CONCLUSION: Consensual contraindications to neck dissection in patients with T0-2 N3 HNSCC were defined among French head and neck surgeons as concerns skull base invasion, retropharyngeal nodes and bilateral XIIth cranial nerve sacrifice. This consensus should allow more reliable comparisons between surgical and non-surgical strategies in N3 patients.