Histopathologic validation of the sentinel node concept in oral and oropharyngeal squamous cell carcinoma

Radioactive nanosized colloids and indocyanine green identify the same sentinel lymph nodes in oral squamous cell carcinoma

PURPOSE

Near-infrared fluorescence imaging using indocyanine green (ICG) combined with radioactive markers has the potential to improve sentinel lymph-node (SLN) mapping in oral squamous cell carcinoma (OSCC). This study aimed to evaluate the ability of 99mTc and ICG in identifying the sentinel lymph nodes in patients with early stage OSCC.

METHODS

Data were collected prospectively, and a retrospective analysis of 15 patients with early stage OSCC and a cN0 neck was performed. All patients received peritumoral injection of 99mTc the day before surgery and ICG was administered intraoperatively. Intentionally, the application of the two different tracers were done by two different physicians with varying degrees of experience. The number of identified lymph nodes positive for 99mTc and ICG, the overlap or possible discrepancies of both methods, and the time until fluorescence signals of ICG were detected were noted.

RESULTS

In all patients, a 100% agreement in sentinel lymph-node identification was achieved, regardless of both the exact location of the peritumoral injection and the experience of the injecting surgeon. Time until ICG accumulation in the sentinel lymph node was consistently found to be between 1 and 3 min.

CONCLUSION

ICG constitutes a viable and useful addition to 99mTc for intraoperative sentinel lymph-node detection in this study.

Ultrasound-guided contrast-enhanced sentinel node biopsy of the head and neck in a porcine model

Objective

To test the feasibility of contrast-enhanced ultrasound (CEUS)–guided sentinel lymph node biopsy (SNB) of the head and neck in a porcine model.

Study Design and Setting

In this prospective, non-randomized study, methylene blue and Sonazoid were injected into the lateral tongue or floor of mouth (FOM) of four swine. Real-time CEUS was used to identify contrast in the lymphatic channels flowing to the sentinel lymph node (SLN). Endoscopic or open SNB was performed. Neck dissection was then performed, and the residual nodal packet was examined for remaining contrast-enhancing or blue dye–stained nodes.

Results

In all eight procedures, the SLN was visualized with ultrasound and blue dye. Seven procedures identified a single SLN, and one identified two SLNs. Subsequent neck dissections revealed no other nodes containing methylene blue or contrast in the nodal specimen or operative bed.

Conclusion/Significance

CEUS-guided SNB of the head and neck in swine is feasible, with success comparable to blue dye–guided SNB. This technique may offer several advantages over traditional techniques, and warrants further study.

The role of OCT4 immunohistochemistry in evaluation of retroperitoneal lymph node dissections: a pilot study

We investigated the role of OCT4 immunohistochemical staining in detecting germ cell tumor lymph node metastases. Retroperitoneal lymph node dissection is important for staging and treatment of testicular germ cell tumors, and OCT4 is sensitive and specific for pluripotent testicular germ cell tumors; however, micrometastases, particularly from seminoma, can be difficult to detect. We examined 262 lymph nodes in 45 retroperitoneal lymph node dissection specimens from germ cell tumor patients. Specimens were categorized as postchemotherapy and untreated retroperitoneal lymph node dissection with or without clinical suspicion, based on lymphadenopathy or elevated serum germ cell tumor markers. Sections were stained with anti-OCT4 antibody. Twenty-one additional positive lymph nodes in 12 cases were detected to harbor scattered seminoma cells, singly and in small clusters, from 256 previously considered benign in: untreated retroperitoneal lymph node dissection with clinical suspicion (13% increase), postchemotherapy retroperitoneal lymph node dissection (7%), and untreated retroperitoneal lymph node dissection without suspicion (4%). However, no patient with an entirely negative dissection specimen was reclassified as positive. OCT4 immunohistochemistry detected scattered seminoma cells and small clusters of seminoma cells in lymph nodes previously considered to be benign for an overall increase of 8%, greatest in the setting of untreated retroperitoneal lymph node dissection with clinical suspicion. However, immunohistochemistry did not convert any entirely negative specimen to positive. Future studies will be useful to determine whether the small volume of disease detected by immunohistochemistry has the same impact as routinely detected lymph node metastases.

Long term results of sentinel lymph node biopsy in early oral squamous cell carcinoma

The objective of the study was to evaluate the long term results of the sentinel node (SN) biopsy technique in the management of the clinically negative (N0) neck in patients with early oral squamous cell carcinoma (T1-T2). Patients with positive SN underwent neck dissection. A sentinel lymph node (SLN) biopsy was performed on 31 consecutive patients. Six of the 31 patients were upstaged by the results of the SLN biopsy. The SLN biopsy allowed the identification of node metastasis in 100% of the cases with a sensitivity of 100%, specificity of 100%, and negative predictive value of 100%. There was a mean follow-up of 59 months. The neck control rate was 100% in the SLN negative group and two SLN positive patients developed subsequent neck disease (neck control rate of 88%). One SLN patient presented at the follow-up with a second primary tumor, 18 months later treated successfully by chemoradiotherapy. The overall survival rate was 100% in both groups. The promising reported short-term results have been sustained by long term follow-up. Patients with negative SLN achieved an excellent neck control rate. The neck control rate in SN negative patients was superior to that in SLN positive patients, but not statistically different.

Visualization of the sentinel node in early-stage oral cancer: limited value of late static lymphoscintigraphy

OBJECTIVE

Various lymphoscintigraphic imaging protocols exist for sentinel node (SN) identification in early-stage oral cancer. This study aimed to evaluate the clinical value of performing additional late lymphoscintigraphic imaging.

METHODS

We retrospectively analysed early (directly following injection of 99mTc-Nanocoll) and late (2-4 h after injection) imaging results of 60 early-stage (T1-T2, cN0) oral cancer patients scheduled for SN procedure. Lymphoscintigraphic results of late imaging were categorized into: (a) no visualization of additional hotspots considered to be SNs; (b) additional hotspots visualized that are considered to be SNs and (c) hotspots visualized only during late imaging. Histopathological results of the harvested SNs were related to the corresponding hotspot.

RESULTS

In all patients (n=60) lymphoscintigraphy was able to visualize a hotspot that was identified as an SN. In 51/60 (85%) patients, early imaging was able to visualize at least one hotspot, whereas in 9/60 (15%) patients, mostly with oral cavity tumours other than mobile tongue and floor-of-mouth tumours, only late imaging was able to visualize hotspots. In 14/51 (27%) patients, late imaging resulted in additionally visualized hotspots marked as SNs, resulting in a more extensive surgical procedure. These additionally removed SNs appeared to be of no clinical relevance, as all SNs identified during early imaging correctly predicted whether the neck was positive or negative for cancer.

CONCLUSION

Results of this study indicate that additional late lymphoscintigraphic imaging should be performed only in selected cases.

Sentinel node biopsy for oral and oropharyngeal squamous cell carcinoma in the previously treated neck

In patients with early stage oral or oropharyngeal squamous cell carcinoma (OSCC) sentinel node biopsy (SNB) is a reliable method to detect occult disease in the neck. However, patients with a history of surgery or radiotherapy in the neck may have aberrant lymphatic drainage caused by disruption of lymphatic channels. Therefore, treatment of the same levels at risk as in the primary setting may not be appropriate. The aim of our prospective observational study was to evaluate the clinical application of SNB in previously treated OSCC. Between 2003 and 2010 twenty-two patients were included. Lymph node mapping consisted of preoperative lymphoscintigraphy, SPECT/CT, intraoperative use of gamma-probe and patent blue. Endpoints were the sentinel node (SN) detection rate, unexpected lymphatic drainage patterns, negative predictive value and regional tumor control. 4/22 (18%) Patients were previously treated only on the contralateral site. The SN detection rate was 100% and unexpected drainage was found in 1/4 patients. The other 18 patients had ipsi- or bilateral previous neck treatment and a SN detection rate of 83%. The upstaging rate was 7% and 67% had unexpected lymphatic drainage patterns. The median follow-up was 22 months. Regional tumor control and negative predictive value were 100%. SNB in previously treated OSCC patients is feasible. SN detection is reliable and regional tumor control after staging by SNB is excellent. Moreover, SNB renders an assessment of the individual lymphatic drainage pattern, compensating for a potential variability after previous treatment of the neck.

T1-T2 Squamous Cell Carcinoma of the Uvula

Objective. No specific epidemiology data are available for carcinoma of the uvula. This study aims to analyze the epidemiological characteristics and treatment outcomes of carcinoma of the uvula at the authors’ institution.

Study Design. Case series with chart review.

Setting. Service of ENT–Head and Neck Surgery, University Hospital Complex of Santiago de Compostela (CHUS), Spain.

Subjects and Methods. Retrospective epidemiological study of 21 male patients, mean age 57.52 years, diagnosed with squamous cell carcinoma of the uvula in the CHUS between January 1990 and June 2009.

Results. Most patients presented with odynophagia and exophytic lesions microscopically consistent with moderately differentiated squamous cell carcinoma. Despite the size of the lesions (T1 and T2), more than half of the patients had lymph node metastases at diagnosis. More than 90.0% of patients with lesions larger than 1 cm presented with lymph node metastases. Although more than 70.0% of patients underwent a neck dissection in the first year after diagnosis, only 25.0% were free of metastatic disease. Recurrences occurred at a mean of 14 months from baseline in more than 50.0% of cases. Of the patients, 52.4% died, with a median survival of 38.15 months after diagnosis. The overall 5-year survival was 39.0%. According to tumor size, 5-year survival was 53.0% for T1 and 27.0% for T2.

Conclusion. According to the data, clinical features of carcinoma of the uvula correspond with aggressive tumors, with rapid onset and a major negative impact regardless of tumor size at diagnosis. Early stage patients benefit significantly from surgical treatments with neck dissections.

Neck restaging with sentinel node biopsy in T1-T2N0 oral and oropharyngeal cancer: Why and how?

Objective: To evaluate the lack of accuracy in neck staging with the classical technique (i.e., neck dissection and routine histopathology) with the sentinel node (SN) biopsy in oral and oropharyngeal T1-T2N0 cancer.

Study Design: Cross-sectional study with planned data collection.

Setting: Tertiary center care.

Subjects and Methods: In 50 consecutive patients, the pathological stage of sentinel node (pSN) was established after analyzing SN biopsies (n = 148) using serial sectioning and immunohistochemistry. Systematic selective neck dissection was performed. The pN stage was established with routine histopathologic analysis of both the non-SN (n = 1075) and the 148 SN biopsies.

Results: The sensitivity and negative predictive value of pSN staging were 100 percent. Conversely, if one considers pSN staging procedure as the reference test for micro- and macro-metastasis diagnosis, the sensitivity of the classical pN staging procedure was 50 percent (9/1; 95% CI 26.9-73.1) and its negative predictive value was 78 percent (95% CI 61.9-88.8). Fifteen patients (30%) were upstaged, including nine cases from pN0 to pSN ≥ 1 and six cases from pN1 to pSN2. Two of the pN0-pSN1 upstaged patients died with relapsed neck disease.

Conclusion: The SN biopsy technique appeared to be the best staging method in cN0 patients and provided evidence that routinely undiagnosed lymph node invasion may have clinical significance.

Non-sentinel node tumor invasion in oropharyngeal and oral cancer: risk of misdiagnosis of metastasis

CONCLUSION

The existence of patients with positive non-sentinel node indicates a risk of misdiagnosis of metastasis in oropharyngeal and oral cancer.

OBJECTIVES

We attempted to confirm the usefulness of sentinel lymph node biopsy (SLNB) in oropharyngeal and oral cavity cancer to detect clinically occult metastases.

PATIENTS AND METHODS

Twenty-two patients with a mean age of 57 (SD=13) years were studied prospectively. All presented T1-T3 squamous cell carcinoma (SCC) of the oropharynx or oral cavity, and were cN0 on palpation and CT. A preoperative (24 h) lymphoscintigraphy was performed with 99mTc-labelled sulfur colloid injected around the primary tumor. Subsequently, we proceeded with tumor exeresis and detection of SLN following the procedures described in a previous paper.

RESULTS

We detected a total of 32 SLNs in 21 of 22 patients. Ipsilateral neck node location was observed in 18 patients and bilateral in 3. We observed 10 patients with true positive SLNs (3 patients had micrometastases), indicating occult metastases. We harvested a total of 454 nodes in our selective neck dissections, 19 of which presented metastatic invasion. We identified four patients with positive non-sentinel nodes.

The sentinel node concept in endometrial cancer: histopathologic validation by serial section and immunohistochemistry

BACKGROUND

The sentinel node (SN) is defined as the first node in the lymphatic system that drains a tumor site. If the SN is not metastatic, then all other nodes should also be disease-free. We used serial sections and immunohistochemical (IHC) staining to examine both SN and non-sentinel nodes (non-SNs).

PATIENTS AND METHODS

Twenty-three patients (median age 69 years) with early endometrial cancer underwent a laparoscopic SN procedure based on a combined detection method, followed by complete laparoscopic pelvic lymphadenectomy. If the SN was free of metastasis by both hematoxylin and eosin (H&E) and IHC staining, all non-SNs were also examined by the combined staining method.

RESULTS

SNs were identified in 19 patients (82.6%). A total of 47 SNs were removed (mean 2.5). Ten SNs (21.3%) from five patients (26.3%) were found to be metastatic at the final histologic assessment. In 14 patients, no metastatic SN involvement was detected by H&E and IHC staining. In these 14 patients, 120 non-SNs were examined by serial sectioning and IHC, and none were found to be metastatic.

CONCLUSION

The SN procedure appears to reliably predict the metastatic status of the regional lymphatic basin in patients with early endometrial cancer.

Sentinel lymph nodes in cancer of the oral cavity: is central step-sectioning enough?

BACKGROUND

Extended histopathologic work-up has increased the detection of micrometastasis in sentinel lymph nodes in malignant melanoma and breast cancer. The aim of this study was to examine if (A) step-sectioning of the central 1000 microM at 250 microM levels with immunostaining were accurate when compared with (B) step-sectioning and immunostaining of the entire sentinel lymph node at 250 microM levels.

METHODS

Forty patients with T1/T2 cN0 oral cancer were enrolled. Three patients were excluded. In one patient no sentinel lymph node was identified. The remaining two had unidentified sentinel lymph nodes due to lymphoscintigraphic and surgical sampling error. The central 1000 microM of 147 sentinel lymph nodes were step-sectioned in 250-microm intervals and stained with hematoxylin and eosin and CK-KL1. All lymph nodes were recorded as negative or positive for macrometastases or micrometastases. After inclusion of the last patient the residual tissue of the lymph nodes was totally step-sectioned at 250-microm intervals and re-classified. The tumor deposits were divided into macrometastases and micrometastases and ITC.

RESULTS

Method (A) upstaged 17 lymph nodes and 11 patients compared with method (B), which upstaged 22 lymph nodes and 11 patients. Seven of the patients with positive lymph nodes did not change stage. However, four lymph nodes changed from micrometastases to macrometastases. One patient changed from a micrometastasis to four micrometastases. One pN2c patient with bilateral micrometastases did not change stage, but an additional ipsilateral lymph node with a micrometastasis was identified.

CONCLUSION

Larger tumor deposits and more metastases are identified by more extensive sectioning of the sentinel lymph nodes. None of the patients was false-negative due to histopathologic sampling error, but the results indicate that central step-sectioning of the central 1000 microM cannot completely be relied upon for accurate staging of the patients.

High-Risk Cutaneous Squamous Cell Carcinoma without Palpable Lymphadenopathy: Is There a Therapeutic Role for Elective Neck Dissection?

PURPOSE

The beneficial role of elective neck dissection (END) in the management of high-risk cutaneous squamous cell carcinoma (CSCC) of the head and neck remains unproven. Some surgical specialists suggest that END may be beneficial for patients with clinically node-negative (N0) high-risk CSCC, but there are few data to support this claim. We reviewed the available literature regarding the use of END in the management of both CSCC and head and neck SCC (HNSCC).

METHODOLOGY

The available medical literature pertaining to END in both CSCC and HNSCC was reviewed using PubMed and Ovid Medline searches.

RESULTS

Many surgical specialists recommend that END be routinely performed in patients with N0 HNSCC when the risk of occult metastases is estimated to exceed 20%; however, patients who undergo END have no proven survival benefit over those who are initially staged as N0 and undergo therapeutic neck dissection (TND) after the development of apparent regional disease. There is a lack of data regarding the proper management of regional nodal basins in patients with N0 CSCC. In the absence of evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of patients with N0 high-risk CSCC of the head and neck.

CONCLUSIONS

Appropriate work-up for occult nodal disease may occasionally be warranted in patients with high-risk CSCC. END may play a role in only a very limited number of patients with high-risk CSCC.

Sentinel lymph node biopsy in squamous cell carcinomas of the lips and the oral cavity—A single center experience

BACKGROUND AND OBJECTIVES

Despite the availability of initial data on sentinel lymph node biopsy (SLNB) in OSCC, its value in clinical practice remains unclear. The aim of this study is to evaluate the feasibility and potential of SLNB as a reliable staging procedure in early stage SCC of the lips and the oral mucosa.

METHODS

From 2001 to 2004, 40 patients with early stage SCC of the lips and oral cavity were enrolled. The main inclusion criteria were: cN0 category by MRI and ultrasound, tumor category T1-T2, for certain sites also T3. Patients with positive SLN underwent MRND and/or radiation. Patients with negative SLN were monitored monthly.

RESULTS

In eight patients, the SLN were positive. Two patients with negative SLN subsequently developed nodal disease (5% false negatives). Twenty-one patients have a follow-up longer than 24 months. Five patients died (one from nodal disease, one from local recurrence, and three from unrelated causes). One patient developed a second primary tumor, the remaining patients are free of disease.

CONCLUSIONS

SLNB may contribute to more targeted lymph node dissection strategies. Further studies will have to ensure the safety of this procedure in comparison to selective neck dissection.

Head and Neck Squamous Cell Carcinoma: Sentinel Node or Selective Neck Dissection

Improved knowledge about the metastatic behavior of mucosal squamous cell cancer of the head and neck made it possible to reduce the extension of elective and even therapeutic neck dissections by sparing selected levels, thereby reducing morbidity. The diagnostic question of when to treat a clinically negative neck to avoid unnecessary overtreatment, even through selective neck dissections, might be answered with sentinel lymph node biopsy. A thorough and sophisticated evaluation of this technique is necessary when defining suited patients.

Impact of the type of imaging modality on target volumes delineation and dose distribution in pharyngo-laryngeal squamous cell carcinoma: comparison between pre- and per-treatment studies

BACKGROUND AND PURPOSE

It has been shown that the use of pre-treatment FDG-PET impacted on the GTV delineation of pharyngo-laryngeal tumors. The goals of this study were to evaluate (1) the impact of FDG-PET GTV on dose distribution, and (2) the impact of per-treatment re-imaging on target volume delineation and dose distribution.

MATERIALS AND METHODS

Eighteen patients with squamous cell carcinoma of the oropharynx or larynx/hypopharynx were treated with curative intent by forward planning IMRT. Prior to treatment and on average after a dose of 46 Gy, all patients underwent contrast-enhanced CT, MRI and FDG-PET. After coregistration, GTVs were delineated manually on CT and MRI and automatically on FDG-PET. From these volumes, CTVs and PTVs were derived using consistent guidelines. Planning was performed using conformal radiotherapy.

RESULTS

GTVs, CTVs and PTVs based on pre-treatment FDG-PET were significantly smaller than those based on pre-treatment CT. Such difference in target volumes (TV) translated into a significant reduction in the irradiated volumes (reduction of 13 and 18% of the V50 and V95, respectively), Dmean to ipsilateral parotids (30.7 and 38.6% for FDG-PET and CT based plans, respectively) and to controlateral parotids (11.2 and 14.4% for FDG-PET and CT based plans, respectively). TVs based on per-treatment CT or MRI were also significantly smaller compared to those delineated from pre-treatment CT. Volumes delineated with MRI were significantly smaller than those delineated with CT. Due to radiotherapy-induced peri-tumoral inflammation, automatic delineation of FDG-PET GTV could not be performed. Such reductions in TVs translated into a reduction of the irradiated volumes compared to pre-treatment CT planning (reduction for V50 of 19 and 32%, and for V95 of 22 and 40%, for CT and MRI, respectively); Dmean to the ipsilateral parotids were also reduced (ipsilateral parotid Dmean of 20.4% for CT and of 20.1% for MRI compared to 24.7% for pre-treatment CT).

CONCLUSIONS

The use of pre-treatment FDG-PET and per-treatment CT or MRI significantly impacts on the delineation of TVs in pharyngo-laryngeal SCC, translating into more normal tissue sparing after conformal radiotherapy planning.

Elective and therapeutic selective neck dissection

Selective neck dissection is a modification of the more comprehensive modified radical or radical neck dissection that is designed to remove only those nodal levels considered to be at risk for harboring nodal metastases. The role of selective neck dissection continues to evolve: while initially designed as a staging and diagnostic procedure for patients without clinical evidence of nodal disease, a growing body of literature suggests that selective neck dissection has a therapeutic role in patients with clinical and histologic evidence of nodal metastases. The rationale behind selective neck dissection, its application in the clinically negative but histologically node-positive neck and the extended application of selective neck dissection in patients with clinical evidence of nodal disease are discussed.

Sentinel node biopsy and head and neck tumors—Where do we stand today?

BACKGROUND

Sentinel lymph node sampling may be studied profitably in series of patients with 1 tumor type, such as breast carcinoma, in 1 anatomic locale. The present work analyzes the efficacy of sentinel node sampling in a pathologically diverse group of lesions from an anatomically diverse region such as the head and neck; however, there are risks conflating the findings in different tumors with radically different behaviors, in the process producing muddled data. This report reviews the head and neck experience with sentinel sampling and concludes that certain tumor types that have a known propensity for aggressive behavior are the best candidates for trials employing sentinel node sampling; candidates include many cutaneous melanomas of the head and neck, oropharyngeal squamous carcinomas, and selected thyroid carcinomas. Despite the growing popularity of sentinel node sampling in a variety of regions of the body, however, at this juncture this technique remains an investigational procedure, pending demonstration of a tangible improvement in patient outcome through its use. It is recommended that studies of the efficacy of this technique strive, whenever possible, to segregate results of different tumor types in different head and neck locales from one another so as to produce more focused findings for discrete types of malignancies, and not group together tumor types that may in reality exhibit different biological behaviors.

Management of the N0 neck--reference or preference

For patients with squamous cell carcinoma of the upper aerodigestive tract, appropriate management of the regional lymph nodes is an important and often controversial issue that has significant influence on survival. Over the years radical treatment either by surgery or radiotherapy contributed to improvement in prognosis. Recently, a more conservative approach has achieved a similar level of cancer control with less morbidity. This review considers the issues of selection of patients for treatment of the neck, choice of modality and extent of therapy, treatment of the contralateral neck, management of recurrence and influence of the site and status of the primary lesion.