We would very much like to have a conclusive answer to the question of postoperative radiotherapy for positive nodes, but unfortunately this is not the case. In fact, nobody has the answer to this question.
Postoperative radiotherapy has been recommended in a large variety of situations: for all patients with positive nodes; only for patients with more than a certain number of positive nodes— the number being as variable as the authors that propose this approach; only for patients with positive nodes showing extracapsular extension; and also, for some combinations of the above.
In our experience, postoperative radiotherapy does not improve regional control or survival in previously untreated patients with cancer of the larynx undergoing surgical treatment—all patients in this series had functional neck dissection as part of the initial treatment. Several aspects of the previous statement should be emphasized: (1) This series includes only patients with cancer of the larynx, a special subset of head and neck cancer patients with particular characteristics. Extension of this statement to other tumor locations requires further studies. (2) Patients included in this study were N0 patients with occult disease and patients with palpable mobile nodes smaller than 2.5 cm. (3) All patients in our series were treated with the same functional approach, removing all lymph node regions except level I. (4) The study was performed retrospectively with a historical control from the same institution. Although this may be considered a weak point of the study, it must be remembered that the great majority of studies trying to assess the usefulness of postoperative radiotherapy are retrospective studies, and, up till now, no prospective trial has yet demonstrated a survival benefit derived from postoperative radiotherapy in head and neck cancer patients.
With this in mind, we can affirm that postoperative radiotherapy did not improve the outcome of our patients (survival and regional control) in any situation. Patients with positive nodes fared worse than those without nodes; and patients with extracapsular spread had an especially bad prognosis. However, this was not improved or modified by the addition of postoperative radiotherapy.
In conclusion, we do not use postoperative radiotherapy on a routine basis in pN+ patients with cancer of the larynx treated with functional neck dissection. Postoperative irradiation is reserved for large nodes requiring radical neck dissection and factors related to other clinical and surgical characteristics such as positive margins.
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