Wertigkeit der geplanten Neck dissection nach primärer Radiochemotherapie oro- und hypopharyngealer Karzinome im Stadium IV
Aufgrund äquivalenter onkologischer Ergebnisse findet die primäre Radiochemothe-rapie bei der Behandlung ausgedehnter oropharyngealer und hypopharyngealer Kar-zinome eine im Vergleich zum chirurgischen Behandlungsansatz weltweit höhere Verbreitung. Trotz guter Ansprechraten im Bereich des Primärtumo...
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Due to equivalent oncologic result, primary radiochemotherapy is much more dis-tributed worldwide in the therapy of oropharyngeal and hypopharyngeal carcinomas compared to surgical treatment procedures. However, despite good response rates in the area of the primary tumor it is still not clear how to verify the posttherapeutic re-sponse of primary lymph node metastases with high security and which patients should undergo neck dissection with the purpose of definite staging together with curative intention. With this background the present doctoral thesis analyses prospectively a patient population that was treated in the context of a multicenter Germany-wide study pro-tocol (HART study protocol, study central: Prof. Dr. V. Budach, Charité, Berlin, Germany). The prospective analysis of the 29 patients included in the standardized study proto-col was performed with the intention of collecting first data on posttherapeutically persisting vital tumor cell aggregations by means of a standardized evaluation proto-col. The patients involved in the analysis suffered from oropharyngeal and hypo-pharyngeal carcinomas of stage IV were treated at the Department of Otolaryngol-ogy, Head & Neck Surgery, of the Philipps University of Marburg, Germany. An in-tensive histopathological examination of the neck dissection specimens was per-formed according to a previously validated classification of Barth, Marburg, Ger-many. For the first time the mentioned classification differentiates between five different stages of histomorphological findings of cervical lymph nodes after primary radio-chemotherapy. The stages II to IV contain vital tumor cells while the stages 0 and I are considered as being tumor-free lymph nodes without or with changes of the tis-sue. In 7/14 patients suffering from oropharyngeal carcinomas vital tumor cells could be detected in the neck dissection specimens corresponding to stages II to IV according to Barth’s classification. Vital tumor cells in the cervical lymph nodes were also found in 6/15 patients with hypopharyngeal carcinomas corresponding to stages II to IV of Barth’s classification. An analysis of the 7 patients with oropharyngeal cancer and vital tumor cells in the neck dissection specimens revealed that 1/7 patients had an N0 neck pretherapeutically, 5/7 patients had a pretherapeutic N2 neck and 1/7 had an N3 neck. Posttherapeutically one patient had an yN1 neck. In this case, however, the histological examination revealed a stage 1 according to Barth’s classification. None of the seven patients with histological residual metastases had a posttherapeu-tic yN+ neck. The corresponding analysis of the six patients with hyopharyngeal cancer and vital tumor cells in the neck dissection specimens revealed that 2/6 patients had prethera-peutic N1 necks, 3/6 patients had a pretherapeutic N2 neck and 1/6 had an N3 neck. Posttherapeutically two of the patients with hypopharyngeal carcinomas had an yN1 neck, however, with a postoperative stage 0 according to Barth’s classification. One of those six patients with vital tumor cells had an yN2a neck. Vital tumor cell aggre-gations were found in 5 patients who had a posttherapeutic yN0 neck and only one patient had an yN+ neck. So it can be summarized that vital tumor cells were de-tected in 7/7 patients with carcinomas of the oropharynx with yN0 neck and 5/6 pa-tients with carcinomas of the hypopharynx with yN0 neck. Those results confirm that planned neck dissection can still be recommended for pa-tients who even do not have persisting tumorous masses in the sense of yN0 neck af-ter primary radiochemotherapy. Generally it must of course be admitted that the own data and the published data is still too inhomogeneous. Further it is still not clear which is the optimal time of operative intervention. Thus general recommendations for the procedure in cases of posttherapeutic yN0 necks cannot be given. With the background of those diverse and extremely complex questions with regard to the optimal treatment concept for patients treated in multimodal study protocols the presented doctoral thesis gives a further data base as point of departure of future multicenter studies. It can be confirmed in this context that significant interdiscipli-nary efforts must be made in order to answer the enormous catalogue of questions related to this subject.