The Laryngoscope V C 2010 The American Laryngological, Rhinological and Otological Society, Inc. Elective Neck Dissection During Salvage Surgery for Locally Recurrent Head and Neck Squamous Cell Carcinoma After Radiotherapy With Elective Nodal Irradiation Roi Dagan, MD; Christopher G. Morris, MS; Jessica M. Kirwan, MS; John W. Werning, MD; Mikhail Vaysberg, DO; Robert J. Amdur, MD; William M. Mendenhall, MD Objectives/Hypothesis: To define the role of elective neck dissection during salvage surgery for locally recurrent head and neck squamous cell carci- noma (SCCA) initially treated with elective nodal irradiation (ENI). Study Design: Retrospective chart review. Methods: We reviewed the medical records of patients treated with ENI at our institution from 1965 to 2006 for T1-4 N0 M0 SCCA of the orophar- ynx, hypopharynx, or larynx who developed an iso- lated local recurrence and remained N0. Fifty-seven patients were salvaged, 40 with neck dissection and 17 with neck observation. We then compared toxicity and actuarial outcomes between the two groups. Results were compared to the pertinent literature in a pooled analysis. Results: Four of 46 (9%) heminecks were found to have occult metastases in dissected specimens. The 5-year local-regional control rate was 75% for all patients. Neck dissection resulted in poorer outcomes compared with observation. In the dissected group, the 5-year local control, regional control, cause-spe- cific survival, and overall survival rates were 71%, 87%, 60%, and 45%, respectively, compared to 82%, 94%, 92%, and 56%, respectively, for the observed group. Toxicity was more likely with dissection. In the pooled analysis totaling 230 patients, the overall pathologic positive rate of neck-dissection specimens was 9.6%; the compiled data showed no improvement in outcomes when salvage included neck dissection. Conclusions: Routine elective neck dissection should not be included during salvage surgery for locally recurrent head and neck SCCA if initial radio- therapy includes ENI. The risk of occult neck disease is low, outcomes do not improve, and the likelihood of toxicity increases. Key Words: Neck dissection, salvage surgery, head and neck, squamous cell carcinoma, radiotherapy, elective nodal irradiation. Level of Evidence: 4. Laryngoscope, 120:945–952, 2010 INTRODUCTION The optimal management of the node-negative (N0) neck during salvage surgery for locally recurrent head and neck squamous cell carcinoma (SCCA) after initial treat- ment with radiotherapy (RT) is not known. Because the neck can be seeded at the time of local recurrence, it is believed there is a high likelihood of occult regional meta- static disease. 1 Therefore, it is common practice to include an elective neck dissection as part of the salvage procedure. Neck dissection after RT has been associated with decreased quality of life, increased operative time, and the potential for increased complications. 2 In patients who pres- ent N0, are treated with elective nodal irradiation (ENI), and subsequently remain N0 when they recur locally, the potential for occult regional disease may be low enough to justify omitting the elective neck dissection during surgical salvage. The following analysis aims to define the role of elective neck dissection in this setting by quantifying the risk of occult nodal disease based on the pathologic results of elective neck-dissection specimens, and by comparing outcomes and toxicity in patients salvaged with neck dissec- tion to those whose necks were observed. MATERIALS AND METHODS All patients included in this retrospective, institutional review board-approved outcomes study were treated with cura- tive-intent RT at the University of Florida for T1-4 N0 M0 head From the Departmentof Radiation Oncology (R.D., C.G.M., J.M.K., R.J.A., W.M.M.), and Department of Otolaryngology (J.W.W., M.V .), University of Florida, Gainesville, Florida, U.S.A. Editor’s Note: This Manuscript was accepted for publication November 16, 2009. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to William M. Mendenhall, 2000 SW Archer Rd., PO Box 100385, Gainesville, FL 32610-0385. E-mail: mendwm@ shands.ufl.edu DOI: 10.1002/lary.20854 Laryngoscope 120: May 2010 Dagan et al.: Neck Dissection for Recurrent SCCA 945