References

Table A: Incidence of nodal metastases ...

References

w1 Buckley JG, Feber T. Surgical treatment of cervical node metastases from squamous carcinoma of the upper aerodigestive tract: evaluation of the evidence for modifications of neck dissections. Head Neck 2001;23:907-15.

w2 Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer 1972;29:1447.

w3 Dische S, Saunders M, Barrett A, Harvey A Gibson D, Pamar M. A randomised multicentre trial of CHART versus conventional radiotherapy in head and neck cancer. Radiother Oncol 1997;44:123-36.

w4 Overgaard J, Sand Hansen H, Sapru W, et al. The DAHANCA 6&7 trial of 5 vs. 6 fractions per week of conventional radiotherapy of squamous-cell carcinoma of the head and neck: a randomised study of 1485 patients. Radiother Oncol 2001;58(suppl 1):S40.

w5 Horiot JC, Bontemps P, van den Bogaert W, Le Fur R, van den Weijngaert D, Bolla M, et al. Accelerated fractionation (AF) compared to conventional fractionation (CF) improves loco-regional control in the radiotherapy of advanced head and neck cancers: results of the EORTC 22851 randomized trial. Radiother Oncol 1997;44:111-21.

w6 Fu KK, Pajak TF, Trotti A, Jones CU, Spencer SA, Phillips TL, et al. A radiation therapy oncology group (RTOG) phase III randomized study to compare hyperfractionation and two variants of accelerated fractionation to standard fractionation radiotherapy for head and neck squamous cell carcinomas: first report of RTOG 9003. Int J Radiat Oncol Biol Phys 2000;48:7-16.

Box A: Neck dissections

Classic�removes levels 1-5, sternomastoid muscle, internal jugular vein, accessory nerve
Modified�as above but preserves

Type 1�Accessory nerve
Type 2�Accessory nerve, internal jugular vein
Type 3�Accessory nerve, internal jugular vein, sternomastoid muscle

Selective�removal of only selected lymph node groups and preservation of other structures
Extended�as classic procedure, but with the removal of additional lymph node groups or non-lymphatic structures such as overlying skin

Evidence shows that a modified neck dissection is oncologically safe in the N1 and N2 staged neck (see staging). There may be a role for selective neck dissection, but more information on oncological outcome is needed.^w1

Table A Incidence of nodal metastases by site and T stage of primary tumour^w2

Site	TX, T1, T2	T3, T4
Oral tongue	22	62
Floor of mouth	20	49
Tonsil fossae	71	80
Base of tongue	69	79
Nasopharynx	88	86
Supraglottis	41	62
Pyriform sinus	34	77
Glottis	5	20

Box B: Accelerated regimens

The continuous hyperfractionated accelerated radiotherapy from Mount Vernon Hospital in the United Kingdom incorporated both elements.^w3 They compared conventional radiotherapy over 6.5 weeks to the continuous hyperfractionated accelerated radiotherapy regimen of three fractions daily continuously including weekends for 12 days. There was no overall benefit in terms of locoregional control although late morbidity was reduced in the continuous hyperfractionated accelerated radiotherapy arm.

Treatment with more than one fraction daily or over the weekend is less convenient for the patient and has significant logistical implications for staffing and machine availability that make it difficult to introduce into routine clinical practice. A more pragmatic approach was taken by the Danish head and neck cancer group. Patients were treated with one extra fraction a week either on a Saturday or as a second fraction on a weekday.^w4 This reduced the overall treatment time by one week and has shown a 10% increase in survival specific to the disease over five years. Other strategies for altered fractionation include split course treatments and concurrent boost which have been investigated by the European organisation for research and treatment of cancer (EORTC).^w5 and the radiation therapy and oncology group (RTOG) in the United States. Preliminary results suggest that patients treated with hyperfractionation and accelerated fractionation with concomitant boost have better locoregional control than those treated with standard fractionation although there is no difference in survival.^w6

Figure A