Introduction Of Guest Of Honor by Paul H. Ward, MD

This year I have departed from the tradition of selecting as Guest of Honor someone older than myself. I couldn't find anyone older! It is with great pleasure that l introduce you to Dr Willard E. Fee,Jr, currently Professor and Chairman of Otolaryngology-Head and Neck Surgery at Stanford. He is one of the current chairmen that I have had the opportunity to help train. Dr Fee completed his residency at UCLA in 1974. He joined the faculty at Stanford and progressed up through the ranks to his current position. Since You all know him well from his many accomplishments, I will cite only a few. He is a member of the American Board of Otolaryngology, former Secretary and past President of the American Society for Head and Neck Surgery, currently Secretary of the American Section of the Collegium Oto-Rhino-Laryngologie Sacrum Amicitiae, and instigator and past President of the Paul H. Ward Medical Society. In selecting Bill, I recognize all of my extended academic family and their trainees. Bill is the epitome of a leader, scholar, and teacher, a superior surgeon, and a role model. It is truly a unique opportunity to have him as the American Laryngological Association Guest of Honor. He will speak on the subject "Cancer Has No Rules."

Thank you, Paul, fellow members and guests, ladies and gentlemen. It is indeed an honor to stand before you this morning, particularly to be honored by someone who has been so influential in my entire life. I must say that I had several minutes, or hours or days perhaps, to think about what I might want to say to you, and rather than giving a philosophical talk about the state of affairs in medicine, which I actually think are quite interesting, I thought I would talk about a subject for which I have no data and for which there is no data that exists, and for which I think some data needs to be generated, and it has to do with neck dissection. Now, when I say cancer does not behave by rules, it seems to me it's not predictable, it's not logical, it's not a very nice disease, it's smarter than I am (and I'm a doctor), it's smarter than most ministers, it's smarter than faith healers, it's creative, it's energetic, it's beguiling, and it's capricious. It is parasitic, ugly, and nasty, and that's why it's called cancer.

Now, budget cuts -this is the only budget cut that I have seen in the last 4 years that was meaningful. I rather like it because they look a little bit like myself, and earlier in the business meeting there was a slant towards one of our new members who did not have much hair, as opposed to a newly inducted member who had a full head, like Paul Ward, which I have been envious of all my life. Budget cuts are like neck dissections, or I guess I should say, neck dissections are like budget cuts: everybody has an idea of how to do it.

It goes back to, I suppose, to George Crile in 1906, when he presented his data in JAMA on 96 cases of less than a radical neck dissection, compared to 36 cases of a radical neck dissection. Only 12 of those 36 had greater than 3-year follow-up, and because the freedom from disease was 19% for less than radical and 75% for radical, I am not so sure those numbers are statistically significant. It was recommended that only a radical neck dissection should be done, and there was, as you might imagine in the audience, some greater discussion about how radical that was.

Remember that Halsted was around at that time, and Halsted was doing these incredible radical operations for carcinoma of the breast, and I think Crile came along to say that - well, I don't want to be outdone by Halsted, and so I can't pick on the breast, I better pick on the neck, and indeed he did. What people were operating on then generally was carcinoma of the lip and carcinoma of the tongue, and that's all they talked about. Well, we know that with carcinoma of the lip you almost never need to do a neck dissection. So a mortality of 8% was interesting. Remember, they had no intubation at that time, no antibiotics, no blood transfusions, and no sphygnomanometers; they weren't even doing blood pressures when Crile first reported this. It's wonderful, it's amazing, that he only had an 8% mortality. Everything was done as a two-stage procedure. The tongue was done first. Three weeks later, after the tongue healed, the neck was done. It's interesting.

This is not meant to be an exhaustive history of the neck, because I don't have time, but there are some important people in the field of neck dissection, and Hayes Martin certainly was one of those. He recommended no prophylactic treatment of the neck ever be done for any reason at any time, because the mortality of doing a neck dissection was greater than the mortality of the disease state for which you were doing the neck dissection. I thought that was interesting. And isn't it interesting in his 1941 article that when all primary sites are considered, radiation is "undoubtedly more useful than surgery for treatment of cervical metastases." I'm glad that philosophy didn't last into the 1970s and 1980s -certainly not at UCLA. Look at his mortality, doing neck dissections under local anesthesia: only 1.5 %, but general anesthesia was 14.3%.

However, if you were going to treat the neck for whatever reasons surgically, then you needed to do a neck dissection, and when we talk about neck dissection in the 1940s and 1950s, that was considered a radical neck dissection. Brown and McDowell, two plastic surgeons from Philadelphia, came along and said this wait-and-see method that was promulgated by Martin and the Memorial Group was not a very good idea. It wasn't a very good idea because operable neck masses could become inoperable while waiting for those two stages to occur. That is, complete regression of the local lesion from either radiation or healing after an operation. So they were sort of the first people to publicly come out and say, wait-and-see is not good; don't do that.

However, it took almost 40 years for Vandenbrouk to randomize 75 patients to elective versus therapeutic neck dissection. That is a prospective randomized study, of which there are not many, sadly, in our field, that showed no survival difference in these groups. However, two patients in the wait-and-see, that is, the therapeutic neck dissection, group could not undergo surgery due to poor health and "acute nodal growth." Pointing out what Brown and McDowell had foreseen some 30 years before, that with the wait-and-see attitude you are going to lose a few people along the line. I must say in my own career that in those patients who for whatever reason I had not done a neck dissection I have lost people, even with regular follow-up, going front NO to N+ - surgically resectable but, sadly, surgically incurable. Fortunately rare, but nonetheless, it does happen.

Then in the 1960s Suarez and Bocca introduced the concept in the English literature of conservation with comprehensive neck dissection. They performed a complete cervical lymphadenectomy, doing what became known as a functional neck dissection, and showed that the recurrence rates in the neck were the same as if you had done a radical neck dissection. Now that occurred shortly before I began my training. Functional neck dissection didn't really catch on with great vigor here in the United States until the mid-1970s, after my training.

It took almost - not quite - 40 years, as it did for the issue of elective versus therapeutic neck dissection, but took about 30 years before someone did a prospective randomized study comparing radical neck dissection versus functional neck dissection. They did not use any patients with fixed nodes. Everything was less than N3 - a very short 1 -year follow-up - and they found that the mortality in both groups was identical. This was the German-Swiss Combined Head and Neck Study Group. As far as I know, this is the first randomized prospective study of this issue showing that functional neck dissection carries the same beneficial effect as radical neck dissection if one excludes large fixed neck nodes.

Then in the 1970s Emanuel Skolnik from Chicago introduced the concept of sparing the spinal accessory nerve. He demonstrated that you could spare this spinal accessory nerve in almost everybody. He looked at 25 elective neck dissections and 26 therapeutic neck dissections and serially sectioned the entire posterior triangle in those 51 patients and found that no nodes were positive. Therefore, he concluded that you could almost always save the spinal accessory nerve. However, he must have forgotten his own data, because in 1967 he had 4% who had positive posterior triangle nodes when he was making the case for saving the spinal accessory nerve. I am sure that the Chicago data caught on. I remember the meeting when he presented some of this data, and there were some rumblings in the audience and out in the coffee room. But to make a long story short, it was slow to catch on, and the concept of almost routinely saving the spinal accessory nerve probably didn't catch on in the United States until the mid-1980s and following.

In the late 1980s emerged another new concept in neck dissection, and that is called the supraomohyoid neck dissection. There are no anatomical barriers to spread beyond this, but it consisted of a cervical lymphadenectomy of the submental triangle, submandibular triangle, and the upper and middle superior cervical and middle cervical chain lymph nodes. There has not been a prospective randomized study to suggest that selective neck dissection is truly beneficial. It does assume a logical cancer, and as I mentioned to you in the first slide, there is nothing to suggest that this disease is logical. We know that from 40% to 60% of metastases to the neck (depending upon what kind of cancer you are studying) will have skip areas. That is, they will bypass the first echelon of nodes and go to the second and perhaps even tertiary echelon of the nodes, and in fact there are patients that have primaries, skip the neck nodes completely, and end up with pulmonary metastases, albeit those are uncommon. There is no logical behavior to cancer. It was largely an argumentum ad hominem that caught on because two very powerful and very excellent head and neck cancer institutions, Memorial and M. D. Anderson, about this concept at the same time.

So there seemed to be some competition between the two great cancer centers in our field. It seems to me that this ignores historical data. I mean by that if we go back and look at the work of Lindberg from M. D. Anderson, who categorized where nodes were. In nasopharynx cancer 147 of 169 patients were positive, and if you add up these numbers you will find out how many patients had numbers in the ipsilateral posterior triangle and in the contralateral posterior triangle. Certainly, for nasopharynx cancer if you have to operate for neck disease you wouldn't consider not removing the posterior triangle. If we look at base of tongue, I agree that there are few patients who have disease in the posterior triangle.

But if I said to you I have something in my pocket that will increase your survival 5% to 10% and cost you very little in terms of morbidity and actual cost, would you do it, I think the answer to that is you probably would. Tonsillar fossa - 14 of 106 patients had positive posterior neck nodes, this is 1969 data. Hypopharynx - again, a little bit more than 10%. Supraglottic larynx - a little bit less than 10%. Leemans, in his studies from Amsterdam, assessed 71 neck dissections and did an exhaustive study. I suggest that you read his work. It's, probably never to be done again, as it was a huge amount of work. Cutting nodes into three slices and doing an amazing amount of work in different studies, he has contributed significantly. He found that 19% of lymph nodes were actually found in the posterior triangle, and of positive lymph nodes, 7% were in the posterior triangle. If you look at the work of Schuller from 1980, you will find that he had 9 patients in that group of various head and neck sites where disease was isolated to the posterior triangle. It does happen that disease hits into the posterior triangle.

These are what I would consider the four major articles to look at, because they all look at the same thing. That is, they talk about neck recurrences when the primary is controlled, and that is the important thing. We can't just look at neck recurrences. We have got to look at neck recurrences when the primary is controlled, because then it becomes a meaningful figure. Spiro started it from Memorial in 1988, when he talked about 131 patients with supraomohyoid neck dissections. When these patients were pathologically N0, 5% recurred in the neck. When they were pathologically N+, clinically N0, 15% recurred in the neck. When they were clinically positive and pathologically positive, 29% recurred in the neck when the primary was controlled. When Medina was at M. D. Anderson, he looked at 234 patients. When the patients were pathologically N0, 6% recurred in the neck. When they were pathologically N+, 15% recurred in the neck. Leemans, on the other hand, doing a comprehensive modified radical neck dissection in 565 patients, had a recurrence rate of 2.6% for pathologic N0 and 9.7% for pathologic N+.

What's interesting about this data is this is the same institution (M. D. Anderson), so one would think that the surgery was at least consistently done between the two study groups. In 132 modified radical neck dissections where the 11th nerve was spared, they had obviously no pathologic N0, because these were all N1 and N2 positive necks. They had an 8% recurrence rate, and when they did a radical neck dissection, they had a 12% recurrence rate.

I suggest to you that the historical data would suggest that a comprehensive neck dissection is going to give you the lowest recurrence rate in the neck. I went to my statisticians and gave them all the different variables that might occur and said, assuming a 10% difference between a comprehensive and a selective neck dissection, how many patients am I going to need to do before I can prove statistically significant difference'? They said 660 patients. That is probably a 6-year study multi-institutional group - probably a $10 million piece of work. Eventually, I am sure, someone will do it. The problem is it will probably be when I'm long gone. Now here is what my mentor told me, which was one of the 10 commandments of Paul Ward: "radical-early, conservative-late." I think if he had considered all that has happened subsequent to his training, he might adopt this philosophy: comprehensive-early, selective-rarely.

Thank you, Mr President. I am very grateful for the honor and privilege of having the podium and for being honored as your guest. I certainly accept it on behalf of all the former residents who had the privilege of training under you.