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.