The Laryngoscope Lippincott Williams & Wilkins © 2008 The American Laryngological, Rhinological and Otological Society, Inc. Role of Planned Postchemoradiotherapy Selective Neck Dissection in the Multimodality Management of Head and Neck Cancer S. A. Reza Nouraei, MA(Cantab), MBBChir, MRCS; Tahwinder Upile, MBBS, FRCS; Chadwan Al-Yaghchi, MD; Mary Lei, FRCR; Guri S. Sandhu, MBBS, FRCS; Simon Stewart, MBBS, FRCR; Peter M. Clarke, MBBS, FRCS; Ann Sandison, MBBS, FRCPath Objective/Hypothesis: To assess the oncologic ef- ficacy and functional outcome of selective postchemora- diotherapy neck dissection for stage IV head and neck squamous cell carcinoma. Methods: Retrospective review of patients with N 2–3 cervical metastases at presentation who underwent planned neck dissection after complete biopsy-proven clearance of primary site mucosal disease with chemora- diotherapy between 2000 and 2006. Results: There were 31 males and 10 females. The average age at presentation was 57  9 years. The oro- pharynx was the most common primary site (n = 23; 56%). Forty-nine hemineck dissections were performed, including six bilateral and two revision procedures. Six- teen (39%) patients had residual viable postchemoradio- therapy neck disease. Patient weight did not deteriorate after neck dissection (P  .4). Two patients had persis- tently worsened postoperative swallowing. Ten patients required shoulder physiotherapy, of whom eight were treated with conservative measures. Five-year hemineck disease control and disease-specific survival rates were 92% and 64%, respectively. Presence of viable postchemo- radiotherapy neck disease was the only independent pre- dictor of regional control (P  .001; hazard ratio 0.00; 0.00 – 0.40) and disease-specific survival (P  .02; hazard ratio 0.23; 0.04 – 0.55). Surgery was twice more likely to confer therapeutic benefit than to cause a significant, albeit in most cases, transitory, complication. Conclusions: Neck dissection is a safe and effective procedure and a necessary component of the multimodality management of all head and neck cancer patients with N 2–3 disease. It should be performed soon after satisfac- tory demonstration of primary site disease clearance. Universal deployment of radical surgery appears unnec- essary and should, when possible, be abandoned in favor of more selective procedures to lessen morbidity. Key Words: Neck dissection, chemoradiotherapy, head and neck cancer. Laryngoscope, 118:797– 803, 2008 INTRODUCTION Chemoradiotherapy has gained increasing popularity over surgery in the primary management of advanced squamous cell carcinoma of the upper aerodigestive tract. 1 For those patients who present with N 2–3 disease in the neck and achieve complete clearance of primary site mu- cosal disease with chemoradiotherapy, optimal manage- ment of the neck remains controversial. On the one hand, the opinion about the optimal extent of neck dissection is divided, with some surgeons opting for a radical or a modified radical procedure as a matter of course, whereas others perform selective neck dissections for most patients and reserve more radical surgery for patients with exten- sive residual neck disease. 2,3 On the other hand, and more fundamentally, the continuing need for universal deploy- ment of postchemoradiotherapy neck dissection has been questioned. Given the therapeutic efficacy of chemoradio- therapy, whether neck dissection continues to confer sig- nificant disease control benefits and whether it therefore should continue to be offered to all postchemoradiotherapy patients with initial advanced neck disease has come un- der increasing scrutiny. 4–6 We undertook a review of our experience with planned predominantly selective neck dissection in patients with initial N 2–3 disease who achieved complete, biopsy-proven clearance of primary-site disease with chemoradiotherapy to determine its diagnostic and staging utility and assess From the Departments of Otolaryngology (S.A.R.N., T.U., C.A.-Y., G.S.S., P.M.C.), Clinical Oncology (M.L., S.S.), and Histopathology (A.S.), Charing Cross Hospital, London, U.K. Editor’s Note: This Manuscript was accepted for publication Decem- ber 19, 2007. Send correspondence to Dr. Reza Nouraei, Department of Otolar- yngology, Charing Cross Hospital, London, W6 8RF, UK. E-mail: RN@ cantab.net DOI: 10.1097/MLG.0b013e318165e33e Laryngoscope 118: May 2008 Nouraei et al.: Postchemoradiotherapy Selective Neck Dissection 797