Management of the "violated Neck" in the era of chemoradiation

Objectives: To determine if patients who have undergone an open neck biopsy (a "violated" neck) have improved disease control and survival with completion neck dissection. Materials and Methods: Retrospective review of patients who underwent open cervical biopsy for diagnosis prior to definitive treatment between February 1997 and February 2010 at two academic tertiary referral centers. Results: Ninety-four patients met study criteria, with completion neck dissection performed in 53 patients (56%). The majority of patients (84%) had oropharyngeal tumors. Human papilloma virus (HPV) status was positive in 55 of 63 patients (87%). Chemotherapy was used more often in patients treated nonoperatively (88%) compared to patients who underwent neck dissection (49%; P <.001). Five-year disease-specific survival (DSS) was 84% for patients treated with neck dissection and 82% for nonoperative treatment (P =.5806), and disease-free survival (DFS) was 82% for patients treated with neck dissection and 70% for nonoperative treatment (P =.6047). Five-year DSS was 84% for patients with HPV-positive disease and 63% for HPV-negative disease (P =.0086), and DFS was 79% for HPV-positive disease and 50% for HPV-negative disease (P =.0004). Only advanced primary tumor (T3/T4) stage (hazard ratio [HR] = 8.8, P =.004) was associated with DSS, whereas advanced primary tumor stage (HR = 5.3, P =.008), N3 disease (HR = 5.6, P =.036), and HPV-positive disease (HR = 0.2, P =.032) were significant predictors of DFS, after controlling for all other variables. Conclusions: In the era of chemoradiation, completion neck dissection following an open cervical biopsy does not appear to provide a survival advantage. A high proportion of HPV-positive oropharyngeal tumors may explain the favorable outcomes observed.