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Is there a role for elective neck dissection with salvage laryngectomy? A decision-analysis model

Authors

  • Ohad Hilly MD,

    Corresponding author
    1. Department of Otolaryngology–Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel
    • Send correspondence to Ohad Hilly, MD, Department of Otolaryngology–Head and Neck Surgery, Rabin Medical Center, 39 Jabotinski St., Petach Tikva, Israel 49100. E-mail: hillyo@clalit.org.il

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    • Ohad Hilly, MD, and Sagit Stern, MD, contributed equally to this work.

  • Sagit Stern MD,

    1. Department of Otolaryngology–Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel
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    • Ohad Hilly, MD, and Sagit Stern, MD, contributed equally to this work.

  • Einav Horowitz MD,

    1. Israeli Center for Technology Assessment in Health Care, The Gertner Institute, Tel Hashomer, Israel
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  • Moshe Leshno MD, PhD,

    1. Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
    2. Faculty of Management, Tel Aviv University, Tel Aviv, Israel
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  • Raphael Feinmesser MD

    1. Department of Otolaryngology–Head and Neck Surgery, Rabin Medical Center, Petach Tikva, Israel
    2. Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

Objectives/Hypothesis

Elective neck dissection for the clinically negative neck is often a matter of debate. A decision-analysis model that was published in 1994 established the widely accepted principle that neck dissection is warranted when the risk for occult metastases is higher than 20%. The aim of the present study was to build a specific and up-to-date decision-analysis model to determine the need for elective neck dissection during salvage laryngectomy after chemoradiation failure and to identify the variables that effect the decision.

Study Design

Decision-analysis model.

Methods

A decision-analysis model was performed to compare the outcome of patients after salvage total laryngectomy with and without an elective neck dissection. Probabilities and expected utilities were derived from available literature to construct the model. Monte Carlo simulation and sensitivity analysis were used to calculate our models' outcomes and to identify the variables that influence the model most, respectively.

Results

When calculating our model results with published data, we found that elective neck dissection is not warranted during salvage total laryngectomy. Optimal decision was found to be sensitive by two variables: 1) the probability for cure with neck dissection, and 2) the probability for regional-only recurrence after salvage laryngectomy without neck dissection. In multiway sensitivity analysis, only when cure rate with neck dissection exceeded 82%, adding neck dissection was the preferred decision. In practice, cure rates for patients after salvage total laryngectomy are around 50% to 65%.

Conclusions

Based on our decision-analysis model, we do not recommend routine elective neck dissection during salvage total laryngectomy after failure of chemoradiation.

Level of Evidence

NA. Laryngoscope, 123:2706–2711, 2013

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