Neck management

In a systematic review of vestibule SCCs, the overall incidence of nodal disease varied from 4 to 40% between series (18). This heterogeneity explains the discrepancies noted between authors and their recommendations of surveillance, elective nodal dissection or prophylactic radiotherapy for the management of cN0 vestibule SCC (7,13). Scurry et al. published a meta-analysis of nasal cavity SCCs with and without prophylactic neck treatment, irrespective of the type of treatment of the primary tumour. They observed a 18.1% rate of regional recurrence, approaching the 20% cut-off, often cited as suggestive of consideration for elective nodal treatment (17). Other authors observed a significant association between tumour size or volume and regional control (22,23). In our series, the rate of regional recurrence was 13% despite the absence of prophylactic irradiation of the neck for N0 disease.
Some authors advocate neck dissection only for cases of suspected metastasis in early-stage lesions (7,9). Sentinel lymph node biopsy could be developed in this indication, to select patients requiring a neck dissection (25). Bouaouad et al. recommended treating lymph nodes systematically and bilaterally for locally-advanced tumours, either by neck dissection if cN+ or by RT if cN0, since they found better regional control when bilateral neck prophylactic treatment was performed (13). Treatment of the neck should at least include levels I, II and III, however, metastasis to the pre-auricular, facial and retropharyngeal lymph nodes are possible and should be considered (13,18).