What is the role of up-front neck dissection in locally advanced head and neck squamous cell carcinoma?

The place of neck dissection (whether performed before or after definitive chemoradiotherapy) in the treatment of advanced head and neck cancer continues to be debated, with wide institutional variability in practice. Prior to this recent randomized trial from the UK published in the NEJM (N Engl J Med. 2016 Apr 14;374(15):1444-54) that indirectly seeks to answer your question, the data that would be used to support up front dissection was almost entirely retrospective. While this NEJM study was not designed specifically to answer your question, I think there are lessons to be learned from the prospective data.

The debate revolves around a handful of central questions in my mind.

1) Does planned neck dissection, whether before or after chemo...

Upfront neck dissection should preferably be used as part of definitive surgery for both the neck and the primary tumor, especially when surgery is expected to result in very good tumor control rates and functional results, such as in small-medium T stage oropharyngeal cances. In the case of multiple necrotic nodes, likely HPV(+) OPC, the pt will require postop RT (if no ECE) or chemo-RT (if sig. ECE) based on randomized studies and NCCN recommendations. The data in the TORS literature suggests that while function after TORS in experienced hands is quite good, sequellae like dysphagia are significantly worsened if post-op RT is required and even more so if chemo-RT is required after surgery (See for example Fig 3 in Leonhardt FD et al, Head...