A case report of ansa cervicalis to spinal accessory transposition graft: a new surgical technique to prevent shoulder dysfunction

Introduction and importance

The spinal accessory nerve is at risk when performing neck dissections for head and neck cancers. Injury to this nerve can result in shoulder syndrome, which can be challenging to manage. Various nerve repair or grafting methods are available to prevent this condition. A safe, simple, and cost-effective option is the ansa cervicalis to spinal accessory transposition graft.

Case presentation

A 60-year-old Afro-Trinidadian female presented to the Outpatient clinic for evaluation of a scalp lesion and a large neck mass for a duration of one year. Preoperative tissue biopsies confirmed she had squamous cell cancer with metastatic spread to the cervical nodes. The patient underwent surgical excision of the scalp lesion and left neck dissection with the sacrifice of the sternocleidomastoid and the left spinal accessory nerve due to tumour involvement. During the procedure, the ansa cervicalis was successfully joined to the distal remainder of the spinal accessory nerve. After the surgery, the patient fully recovered and achieved a good quality of life during the 24-month follow-up.

Clinical discussion

This is the first reported case of using the ansa cervicalis to reinnervate the trapezius muscle through the spinal accessory nerve. This procedure aims to prevent pain, muscle wasting, and adhesive capsulitis. A quality-of-life questionnaire and adequate range of motion proved the success of this procedure, demonstrating that this option provides practical, functional, and aesthetic benefits for patients.

Conclusion

The ansa cervicalis to spinal accessory transposition nerve graft is a valuable option for reinnervation. This case report highlights the effectiveness of this single-stage procedure in preventing shoulder syndrome.

Exploring the use of rehabilitation in individuals with head and neck cancer undergoing treatment: a scoping review

Explore the use, characteristics, feasibility, and functional outcomes of rehabilitation interventions used for individuals with head and neck cancer (HNC) during treatment.

Searches were conducted in four databases from Jan 2011 to Dec 31, 2022. Included studies had to include adults with HNC undergoing treatment, a rehabilitation intervention, an assessment of functional outcome(s) addressed by the International Classification of Functioning Framework (ICF) and be published in English language. Title and abstract screening, full-text review, and data extraction were completed independently, in duplicate. Descriptive statistics and a qualitative synthesis summarized findings.

Twenty-seven studies were included in this review. The majority of studies were randomized controlled trials (70%). Most individuals represented in the included studies were males (92% of all participants) between 50 and 60 years of age. Interventions led by a speech language pathologist (33%) were most commonly described. Sixteen studies (59%) described primary outcomes that fit the ICF "impairment" domain.

We identified few studies that explored the use, feasibility, and effectiveness of rehabilitation interventions for individuals with HNC during treatment. Future research should assess the effectiveness of rehabilitation interventions on functional outcomes beyond the ICF body function and structure domain.

Sentinel lymph node biopsy versus elective neck dissection in management of the clinically negative (cN0) neck in patients with oral squamous cell carcinoma: A systematic review and meta-analysis

Oral squamous cell carcinoma (OSCC) is the most prevalent type of head and neck cancer, and lymph node metastasis is a crucial prognostic factor that has a direct correlation with the survival rate. The standard procedure for managing clinically negative (cN0) neck in OSCC patients is elective neck dissection (END), but it can lead to various complications that affect the patient's quality of life. Therefore, medical professionals are exploring the use of the sentinel lymph node biopsy (SLNB) to manage cN0 neck in OSCC patients. The aim of this systematic review and meta-analysis was to compare the overall survival (OS) and disease-free survival (DFS) of patients undergoing SLNB and END in the surgical management of early cN0 neck in OSCC patients. To conduct this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to report the systematic reviews. The study included all comparative clinical studies, including randomized clinical trials (RCTs), clinical perspective studies, and retrospective studies that compared END to SLNB for early cN0 neck in OSCC patients. The hazard ratio (HR) and risk ratio (RR) with 95% confidence interval (CI) were calculated using comprehensive meta-analysis. The primary outcome variables were OS, DFS, and disease-specific survival (DSS). The secondary outcome variable was the nodal recurrence rate without local or distant metastasis. The GRADE system was used to assess the evidence's certainty. The meta-analysis included 12 clinical studies, comprising three RCTs and seven non-RCTs. The results showed no statistically significant difference between END and SLNB concerning OS (HR = 0.993, CI: 0.814 to 1.211, P = 0.947, low-quality evidence), DFS (HR = 0.705, CI: 0.408 to 1.29, P = 0.21, low-quality evidence), and nodal recurrence (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). Additionally, SLNB was non-inferior to END regarding DSS (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). In conclusion, this research affirms the safety and precision of SLNB as a means to stage cN0 OSCC patients, with outcomes that are comparable to END in terms of survival and nodal recurrence. Nevertheless, it's crucial to acknowledge that the quality of evidence in this study was relatively low. Therefore, additional RCTs comparing END to SLNB are warranted to validate these results and offer more robust guidance for managing cN0 OSCC patients.

Prognostic factors and treatment considerations of submandibular gland carcinomas: A population-based study

OBJECTIVES

The therapeutic regimen of submandibular gland carcinoma (SGC) has not reached consensus, especially for the neck treatment of patients with cN0.

MATERIALS AND METHODS

Patients with SGC were identified from the medical database of Shanghai Ninth People's Hospital. Kaplan-Meier analysis, univariate and multivariate Cox regression were employed to evaluate the survival and independent prognostic factors.

RESULTS

Two hundred and fifteen patients with SGC were retrospectively reviewed. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 71.5% and 77.8%, respectively. Multivariate analysis revealed that histological grade, cT classification, cN classification, and perineural invasion (PNI) were independent prognostic factors for DFS, while histological grade, cT classification, cN classification, and age were those for OS. The neck dissection showed no significant survival benefit for patients with cN0. Lung was the most common site of distant metastasis (16.7%).

CONCLUSIONS

Histological grade, cT classification, cN classification, age, and PNI were independent prognostic factors of patient with SGC, which should be the main considerations for making therapeutic regimens. Our study also verifies the neck dissection of patient with cN0 is unnecessary, and postoperative radiotherapy (PORT) is vital for patients with pN+.

Quality of life and shoulder function among oral cancer patients treated with selective neck dissection: A cross-sectional study

BACKGROUND

There is no doubt about the oncologic effectiveness of neck dissections (NDs). But the quality of life (QoL) of patients with oral cancer and the morbidity associated with ND like shoulder dysfunction remain uncertain. The present study aimed to assess the postoperative ND-related QoL and shoulder function of oral cancer patients who underwent selective neck dissection (SND).

METHODS

A cross-sectional study was conducted by using a self-administered, ND-related QoL questionnaire and arm abduction test (AAT) in 128 patients who had undergone only SND (up to Level IV) for oral cancer.

RESULTS

Out of the 128 patients, 94 (73.8%) patients had better QoL, and 34 (26.2%) patients had worse QoL. Fifty-one (39.84%) participants were able to abduct up to or more than 150° but less than 180° (Score 3) followed by 31 (24.22%) participants who could abduct up to or more than 90° but not less than 150° (Score 2). Strong positive correlations ( r = 1.000) were observed between the ND QoL scores and the AAT scores. It was found to be statistically significant ( P = 0.000).

CONCLUSION

SND, being a more conservative approach sparing the spinal accessory nerve, could still limit the QoL and could affect the shoulder function to a certain extent.

Comparison of Preoperative DOI Estimation in Oral Tongue Cancer With cN0 Disease

OBJECTIVE

To understand the accuracy of pre- and intraoperative estimation of tumor depth of invasion (DOI).

STUDY DESIGN

A retrospective case-control study.

SETTING

Patients who presented at 1 institution with oral tongue squamous cell carcinoma that underwent oncologic resection between 2017 and 2019 were identified.

METHODS

Patients that met the inclusion criteria were included. Patients with nodal, distant, or recurrent disease, prior history of head and neck cancer, or preoperative tumor assessment and/or final histopathology that did not include DOI were excluded. Preoperative DOI estimation and technique and pathology reports were obtained. Our primary outcome was the sensitivity and specificity of DOI estimation modalities including full-thickness biopsy (FTB), manual palpation (MP), punch biopsy (PB), and intraoperative ultrasound (IOUS).

RESULTS

Tumor DOI was assessed quantitatively preoperatively in 40 patients by FTB (n = 19, 48%), MP (n = 17, 42%), or PB (n = 4, 10%). Additionally, 19 patients underwent IOUS to assess DOI. The sensitivities of FTB, MP, and IOUS for DOI ≥ 4 mm were 83% (confidence interval [CI]: 44%-97%), 83% (CI: 55%-95%), and 90% (CI: 60%-98%), respectively, and the specificities were 85% (CI: 58%-96%), 60% (CI: 23%-88%), and 78% (CI: 45%-94%).

CONCLUSION

Our study demonstrated that DOI assessment tools measured had similar sensitivity and specificity in stratifying patients with DOI ≥4 mm, with no statistically superior diagnostic test. Our results support the need for additional research into nodal disease prediction and continued refinement of ND decisions with respect to DOI.

Prevalence and Patterns of Nodal Metastasis Among Oral Cavity Cancer Patients: A Prospective Observational Study

Introduction

Lip and oral cavity cancer remains the most common cancer among Indian males and third most common cause of cancer-related deaths in India. Cervical lymph node metastasis is one of the most important prognostic factors in oral cavity cancer. The aim of present study was to estimate the prevalence of nodal involvement and analyse patterns of nodal metastasis in oral cavity cancer patients.

Methods

This prospective observational study was conducted between January 2019 and June 2020. Patients of oral cavity squamous cell carcinoma undergoing surgery with simultaneous neck dissection were included. Data pertaining to the clinical profile, treatment and histology details were collected and analysed.

Results

A total of 63 patients were included in present study. Out of 63 patients, unilateral neck dissection was performed in 47 (75%), while 16 (25%) underwent bilateral neck dissection. Overall clinical and pathological nodal positivity rates were 75% and 52%, respectively. Level I (48%) followed by IIa (20%) were most commonly involved stations. Combined involvement of level IV and V was seen in only 5%, and no skip metastasis was reported in level IV and V.

Conclusion

Level I and II are the most commonly involved stations in oral cavity squamous cell carcinoma (SCC). Oral SCC has a predictable nodal spread pattern with no skip metastasis to level IV/V noted in present study. There is a need for good quality randomised control trials to optimise the treatment protocols in clinically node-positive patients with respect to level IIB and V dissection.

Lymph node metastasis in level IIb in oropharyngeal squamous cell carcinoma: a multicentric, longitudinal, retrospective analysis

INTRODUCTION

Nowadays, 70% of patients in Europe and the USA are affected by a p16 + , potentially HPV driven oropharyngeal squamous cell carcinoma. However, despite the improved survival rate in this group, the quality-of-life remains low in cases which neck dissection took place. In this vein, in recent years, some surgeons have considered to avoid dissection of level IIB, proposing a supra-selective non-IIb neck dissection.

MATERIALS AND METHODS

A retrospective, longitudinal, multicentric study was conducted, including patients with pathologically confirmed primary HPV + or HPV - OPSCC who went through surgical treatment for the primary lesion and neck dissection.

RESULTS

141 patients were included. Among them, 99 (70.2%) were male and 42 (29.8%) were female. The mean age was 62 ± 9 years (range 36-81). The most frequent anatomical location was the tonsil in 63 (44.7%) of patients. The most common approach was the classic transoral oropharyngectomy in 51 (36.2%) patients. Immunohistochemistry for p16 was positive in 62 (44%) patients. One-hundred and five (74.5%) patients received a unilateral ND, and a 36 (25.5%) a bilateral ND. Of those, a 12.8% (18/141) of patients were level IIb LN + . According to our results, level IIb ND should be considered in patients underwent therapeutic ND with positive LN metastasis in level IIa (OR = 9.83; 95% CI 3.463-27.917) or III (OR = 6.25; 95% CI 2.158-18.143), advanced (T3/T4) oropharyngeal primary tumors (OR = 3.38; 95% CI 1.366-8.405), and patients with ENE (OR = 6.56; 95% CI 2.182-19.770), regardless of p16 status.

CONCLUSIONS

According to our results, level IIb ND should be considered in patients who underwent therapeutic ND with positive LN metastasis in level IIa or III, advanced oropharyngeal primary tumors, and patients with ENE, independently of p16 status. Prospective data are necessary to definitively ensure the safety of omitting ipsilateral or contralateral level IIb ND in cN - patients with early stage disease.

Patients of stage I oral cancer with pathologically low‐risk feature managed by primary tumor resection alone: Impact of depth of invasion and a nomogram analysis

Objectives

To evaluate the importance of depth of invasion (DOI) in patients with pathologically low‐risk feature stage I oral squamous cell carcinoma (OSCC) managed by primary tumor resection alone.

Methods

Patients with stage I OSCC, at pathologically low risk, underwent primary tumor resection without neck dissection were enrolled retrospectively between 2007 and 2015. Low risk was defined as the absence of positive or close margins, lymphovascular invasion, perineural invasion, worst pattern of invasion‐5, and poor differentiation in histologic grade. The primary endpoints included overall survival (OS), cancer specific survival (CSS), local recurrence free survival (LRFS), and regional recurrence free survival (RRFS). A nomogram based on the DOI was established for predicting RRFS.

Results

A total of 198 patients were enrolled in this study. DOI was the only prognosticator to achieve statistical significance in all primary endpoints according to univariate analysis. Patients with DOI <3 mm tumor showed better five‐year OS, CSS, LRFS, and RRFS than those with DOI ≥3 mm tumor. The concordance index of the nomogram model without DOI was 0.684, which could increase to 0.733 when DOI was included in the calculation.

Conclusion

Patients with pathologically low‐risk stage I OSCC correlate with a higher chance in occult neck metastasis if increasing DOI (≥3 mm) is noticed. Indeed, the chance of occult neck metastasis is significantly higher in this group (14% vs. 2%) than in those with DOI <3 mm. Elective neck dissection is advised if DOI is ≥3 mm to achieve better clinical outcomes.

Level of Evidence

4.

Extent of Neck Dissection and Cervical Lymph Node Involvement in Oral Squamous Cell Carcinoma

Introduction

Tumor resection combined with neck dissection (ND) or radiotherapy are established methods for the treatment of patients with oral squamous cell carcinoma (OSCC). However, the extent of ND can lead to postoperative complications. Therefore, for the first time, this study aims to identify lymph node involvement in OSCC performed in a bilateral systematic approach based on oncologic board meetings relying on presurgical magnetic resonance imaging (MRI) and computed tomography (CT).

Materials and Methods

In a retrospective single-center study, patients with primary OSCC resection and systematic ND performed in 4 different manners (MRND III bilateral, MRND III left and SND right, MRND III right, SND left, and SND bilateral) were examined. Lymph node involvement allocated to levels was evaluated depending on primary localization and T-stage.

Results

A total of 177 consecutive patients (mean age 63.64; 92 female, male 85) were enrolled in this study. A total of 38.98% showed cervical lymph node involvement, and metastases were found in levels 1–4. The distribution of positive lymph node metastases (n=190 LNs) was 39.47% in level 1, 38.95% in level 2, 10.53% in level 3, and 11.05% in level 4.

Discussion

In a cohort of OSCC patients with systematic bilateral ND, levels 1 and 2 had positive lymph node involvement, and no lymph node involvement was seen at level 5. Without any clinical or imaging suspicion, ND expanding 5-level MRND should be avoided regardless of the primary tumor localization, T-stage and intraoperative proof of cervical metastases.

State of Rehabilitation Research in the Head and Neck Cancer Population: Functional Impact vs. Impairment-Focused Outcomes

PURPOSE OF REVIEW

Management of head and neck cancer (HNC) typically involves a morbid combination of surgery, radiation, and systemic therapy. As the number of HNC survivors grows, there is growing interest in rehabilitation strategies to manage HNC-related comorbidity. In this review, we summarize the current state of HNC rehabilitation research.

RECENT FINDINGS

We have organized our review using the World Health Organization's International Classification of Function (ICF) model of impairment, activity, and participation. Specifically, we describe the current research on rehabilitation strategies to prevent and treat impairments including dysphagia, xerostomia, dysgeusia, dysosmia, odynophagia, trismus, first bite syndrome, dysarthria, dysphonia, lymphedema, shoulder syndrome, cervicalgia, cervical dystonia and dropped head syndrome, deconditioning, and fatigue. We also discuss the broader impact of HNC-related impairment by exploring the state of rehabilitation literature on activity, participation, psychosocial distress, and suicidality in HNC survivors. We demonstrate that research in HNC rehabilitation continues to focus primarily on impairment-driven interventions. There remains a dearth of HNC rehabilitation studies directly examining the impact of rehabilitation interventions on outcomes related to activity and participation. More high-quality interventional studies and reviews are needed to guide prevention and treatment of functional loss in HNC survivors.

The Role of IONM in Reducing the Occurrence of Shoulder Syndrome Following Lateral Neck Dissection for Thyroid Cancer

Lateral neck dissection (LND) leads to a significant morbidity involving accessory nerve injury. Modified radical neck dissection (MRND) aims at preservation of the accessory nerve, but patients often present with negative functional outcomes after surgery. The role of neuromonitoring (IONM) in the prevention of shoulder syndrome has not yet been defined in comparison to nerve visualization only. We retrospectively analyzed 56 thyroid cancer patients who underwent MRND over a period of six years (2015–2020) in a high-volume institution. Demographic variables, type of surgical procedure, removed lymph nodes and the metastatic node ratio, pathology, adoption of IONM and shoulder functional outcome were investigated. The mean number of lymph nodes removed was 15.61, with a metastatic node ratio of 0.2745. IONM was used in 41.07% of patients, with a prevalence of 68% in the period 2017–2020. IONM adoption showed an effect on post-operative shoulder function. There were no effects in 89.29% of cases, and temporary and permanent effects in 8.93% and 1.79%, respectively. Confidence intervals and two-sample tests for equality of proportions were used when applicable. Expertise in high-volume centres and IONM during MRND seem to be correlated with a reduced prevalence of accessory nerve lesions and limited functional impairments. These results need to be confirmed by larger prospective randomized controlled trials.

Sentinel lymph node biopsy versus elective neck dissection in squamous cell carcinoma of the oral cavity with a clinically N0 neck: Systematic review and meta-analysis of prospective studies

Sentinel lymph node biopsy (SLNB) is an emerging strategy for managing early-stage oral squamous cell carcinoma (SCC) with a clinically N0 (cN0) neck. However, the role of SLNB in this scenario is debatable. Herein, relevant literature was systematically reviewed, and a meta-analysis was performed to evaluate the potential dividends of SLNB compared to elective neck dissection (END) for these patients. The meta-analysis, including six prospective studies, showed comparable results of the two management strategies in terms of regional recurrence (risk ratio [RR] = 0.99; 95% confidence interval [CI], 0.58-1.70), 5-year disease-free survival (RR = 0.99; 95% CI, 0.87-1.11), and 5-year overall survival (RR = 1.01; 95% CI, 0.90-1.13). Fewer adverse events occurred in the SLNB arm than in the END arm (RR = 0.12; 95% CI, 0.02-0.70). Overall, SLNB results in as favorable an oncologic prognosis for patients with cN0 oral SCC as END, while significantly lessening side effects and unnecessary surgeries.

Is the Depth of Invasion a Marker for Elective Neck Dissection in Early Oral Squamous Cell Carcinoma?

Objective

The depth of invasion (DOI) is considered an independent risk factor for occult lymph node metastasis in oral cavity squamous cell carcinoma (OCSCC). It is used to decide whether an elective neck dissection (END) is indicated in the case of a clinically negative neck for early stage carcinoma (pT1/pT2). However, there is no consensus on the cut-off value of the DOI for performing an END. The aim of this study was to determine a cut-off value for clinical decision making on END, by assessing the association of the DOI and the risk of occult lymph node metastasis in early OCSCC.

Methods

A retrospective cohort study was conducted at the Erasmus MC, University Medical Centre Rotterdam, The Netherlands. Patients surgically treated for pT1/pT2 OCSCC between 2006 and 2012 were included. For all cases, the DOI was measured according to the 8^th edition of the American Joint Committee on Cancer guideline. Patient characteristics, tumor characteristics (pTN, differentiation grade, perineural invasion, and lymphovascular invasion), treatment modality (END or watchful waiting), and 5-year follow-up (local recurrence, regional recurrence, and distant metastasis) were obtained from patient files.

Results

A total of 222 patients were included, 117 pT1 and 105 pT2. Occult lymph node metastasis was found in 39 of the 166 patients who received END. Univariate logistic regression analysis showed DOI to be a significant predictor for occult lymph node metastasis (odds ratio (OR) = 1.3 per mm DOI; 95% CI: 1.1-1.5, p = 0.001). At a DOI of 4.3 mm the risk of occult lymph node metastasis was >20% (all subsites combined).

Conclusion

The DOI is a significant predictor for occult lymph node metastasis in early stage oral carcinoma. A NPV of 81% was found at a DOI cut-off value of 4 mm. Therefore, an END should be performed if the DOI is >4 mm.

Spinal Accessory and Suprascapular Nerve Injury After Human Bite

ABSTRACT

This is a unique clinical case of spinal accessory and suprascapular nerve injury related to a human bite not yet described elsewhere. The case emphasizes the importance of considering local trauma of the posterior triangle of the neck in case of shoulder weakness with electrophysiologic evidence of combined spinal accessory and suprascapular nerve injury.

Neurovascular Complications After Neck Dissection: a Prospective Analysis at a Tertiary Care Centre in South India

Owing to high incidence of oral cancers in India, neck dissection is the most commonly performed procedure in any head and neck oncology setup. This surgery is particularly prone to various neurovascular complications due to intricate anatomy of neck, but the exact incidence has been studied less especially in Indian subcontinent. A prospective observational study was done on 105 patients of oral cancer who underwent neck dissection at Regional Cancer Centre, Trivandrum, and various short-term and long-term neurovascular complications were recorded. There was high temporary praxia of marginal mandibular and greater auricular nerve of 32.5% and 36.1%, respectively, immediate post-operative period which reduced significantly during 6 months. Eight patients had long-term shoulder abduction difficulty. There were isolated cases of IJV thrombosis and phrenic nerve paralysis. Despite our best intentions, complications arise due to complex anatomy of the neck, but if surgeon remains cognisant of the potential complications, their impact on patients' health, pocket and hospital resources can be minimized.

A Novel RNA-Seq-Based Model for Preoperative Prediction of Lymph Node Metastasis in Oral Squamous Cell Carcinoma

Objective

To develop and validate a novel RNA-seq-based nomogram for preoperative prediction of lymph node metastasis (LNM) for patients with oral squamous cell carcinoma (OSCC).

Methods

RNA-seq data for 276 OSCC patients (including 157 samples with LNM and 119 without LNM) were downloaded from TCGA database. Differential expression analysis was performed between LNM and non-LNM of OSCC. These samples were divided into a training set and a test set by a ratio of 9 : 1 while the relative proportion of the non-LNM and LNM groups was kept balanced within each dataset. Based on clinical features and seven candidate RNAs, we established a prediction model of LNM for OSCC using logistic regression analysis. Tenfold crossvalidation was utilized to examine the accuracy of the nomogram. Decision curve analysis was performed to evaluate the clinical utility of the nomogram.

Results

A total of 139 differentially expressed RNAs were identified between LNM and non-LNM of OSCC. Seven candidate RNAs were screened based on FPKM values, including NEURL1, AL162581.1 (miscRNA), AP002336.2 (lncRNA), CCBE1, CORO6, RDH12, and AC129492.6 (pseudogene). Logistic regression analysis revealed that the clinical N stage (p < 0.001) was an important factor to predict LNM. Moreover, three RNAs including RDH12 (p value < 0.05), CCBE1 (p value < 0.01), and AL162581.1 (p value < 0.05) could be predictive biomarkers for LNM in OSCC patients. The average accuracy rate of the model was 0.7661, indicating a good performance of the model.

Conclusion

Our findings constructed an RNA-seq-based nomogram combined with clinicopathology, which could potentially provide clinicians with a useful tool for preoperative prediction of LNM and be tailored for individualized therapy in patients with OSCC.

Variability in Recommendations for Cervical Lymph Node Pathology for Staging of Canine Oral Neoplasia: A Survey Study

There is no clear guideline regarding the indication for routine lymph node extirpation and pathologic evaluation during staging of canine oral tumors, despite a relatively high reported nodal metastatic rate for select tumor types. It is particularly unclear if clinicians recommend removal of lymph nodes only when there is confirmation of metastasis, defined as the N+ neck, or if elective neck dissection (END) is routinely recommended to confirm the true pathologic metastatic status of lymph nodes in the clinical N0 neck (no evidence of metastasis on clinical staging with diagnostic imaging or cytology). When clinicians are recommending END as a staging tool to confirm nodal status, there is also ambiguity regarding the surgical extent for subsequent histopathologic evaluation. The objective of this cross-sectional survey study was to determine the current recommendations given by practicing specialists regarding lymph node removal for dogs with oral tumors. Overall, 87 responses were obtained from 49 private practices (56%) and 38 academic institutions (44%). Respondents identified as oncologists (44%, N = 38), soft tissue surgeons (40%, N = 35), and dentists (16%, N = 14). Regardless of tumor type and stage, extirpation and histopathology were most commonly recommended in the clinical N+ neck only. The recommendation to routinely perform END in the N0 neck was significantly associated with tumor type. Bilateral removal of the mandibular and retropharyngeal lymph nodes was recommended more often for oral malignant melanoma (OMM) than for oral squamous cell carcinoma (OSCC; p ≤ 0.0039) or for oral fibrosarcoma (OFSA; p ≤ 0.0007). The likelihood of recommending END increased with increasing tumor size. Academic clinicians were significantly (p < 0.01) more likely to recommend END compared to private practitioners for canine T1-T3 OMM, T3 OSCC, T2 OFSA, and MCT. This study highlights the variability in recommendations for lymph node pathology for dogs with oral tumors. While tumor type and size influenced the decision to pursue END, it was not routinely recommended, even for tumor types with a known propensity for metastasis. Prospective studies are warranted to determine the potential diagnostic and therapeutic value of END in the N0 neck in veterinary patients such that a consensus approach can be made.

Depth of invasion in early stage oral cavity squamous cell carcinoma: The optimal cut-off value for elective neck dissection

OBJECTIVES

Depth of invasion (DOI) is the most important predictor for lymph node metastasis (LNM) in early stage (T1-T2) oral cancer. The aim of this study is to validate the cut-off value of 4 mm on which the decision to perform an Elective Neck Dissection (END) is made.

MATERIALS AND METHODS

We performed a retrospective study in patients with pathologically proven early stage oral cavity squamous cell carcinoma (OCSCC) without clinical or radiological signs of LNM, who were treated between 2013 and 2018. An END was performed when DOI was ≥ 4 mm and a watchful waiting protocol was applied in patients with DOI < 4 mm.

RESULTS

Three hundred patients were included. END was performed in 77% of patients with DOI ≥ 4 mm, of which 36% had occult LNM (pN+). Patients in the watchful waiting group (48%) developed a regional recurrence in 5.2% for DOI < 4 mm and 24.1% for DOI ≥ 4 mm. For DOI ≥ 4 mm, regional recurrence free survival was higher for patients who were treated with END compared to watchful waiting (p = 0.002). A Receiver-Operator-Curve -analysis showed that a DOI cut-off value of 4.0 mm was the optimal threshold for the prediction of occult LNM (95.1% sensitivity, 52.9% specificity).

CONCLUSION

A DOI of ≥ 4 mm is an accurate cut-off value for performing an END in early stage OCSCC. END results in higher survival rates and lower regional recurrence rates in patients with DOI ≥ 4 mm.

Lymphoscintigraphy for Sentinel Node Mapping in Head and Neck Cancer

The aim of this comprehensive review is to describe and analyze the role of the sentinel node mapping in head and neck cancers. For this purpose, head and neck neoplasms have been categorized in cutaneous malignancies and neoplasms of the upper aerodigestive tract. A concise description of lymphatic drainage will be the "prelude" for each section, as well as the description of the injection techniques, when specific. Concisely, the attention has been focused on detection rate of the sentinel node by lymphoscintigraphy for each cancer, and for those patients in which the sentinel lymph node has been identified, true-positives rates, false-negative rates, and overall accuracy has been pointed out. Overall, in cutaneous neoplasms of the head and neck, the detection rate is higher than 90%, however the false-negative rate is still an issue, in particular in melanoma, inducing the need for newer developments. In fact, new tracers and techniques are already available, while prospective multicenter trials exploring the outcome impact are needed in the near future. For the upper aerodigestive tract and in particular oral cavity and oropharynx, sentinel lymph node identification by lymphoscintigraphy allows avoiding unnecessary neck dissection and/or node irradiation. Even in this case, the main limit remains the risk of false-negative rates. While, for patients affected by laryngeal and hypopharyngeal cancers the data seem very limited and, although the feasibility has been demonstrated, performances of this lymphoscintigraphy still need to be confirmed by multicenter studies.

Should a neck dissection be performed on patients with cN0 adenoid cystic carcinoma? A REFCOR propensity score matching study

BACKGROUND

Patterns of nodal involvement in adenoid cystic carcinoma (ACC) of the head and neck have not been sufficiently assessed to guide a decision of prophylactic neck dissection (ND). The objective of this study is to analyse the influence of ND on event-free survival (EFS) for patients with cN0 ACC.

PATIENTS AND METHODS

A multicentre prospective study was conducted between 2009 and 2018. Patients presenting cN0 non-metastatic ACC on any site, and who received surgery on the tumour, were included. EFS was the main judgement criterion. A comparative survival analysis between the groups that received a ND versus those that did not was performed, using a propensity score. Analyses were carried out using the R software.

RESULTS

Between 2009 and 2018, 322 patients with cN0 ACC were included, out of which 58% were female. The average age was 53 years. Tumours were in minor salivary glands in 58% of cases, and 52% had T3/T4 stages. ND was performed on 46% of patients. Out of them, seven had histological lymph node invasion, out of which six had tumour infiltration in the mucosa of oral cavity. After propensity score, the median EFS for N0 patients with ND was 72 months (95% Confidence Interval (CI) [48-81]), compared to 73 months (95% CI [52-85]) for patients without ND (HR = 1.33; 95% CI [0.82-2.16]; p = 0.2).

CONCLUSION

ND of cN0 patients does not provide any benefit on EFS, which suggests that its application on such patients is not necessary.

Do patients benefit from physiotherapy for shoulder dysfunction following neck dissection? A systematic review

OBJECTIVE

Accessory nerve palsy affects a proportion of patients following neck dissection, and results in shoulder dysfunction and regional pain. This project aimed to establish the evidence supporting post-operative physiotherapy for the shoulder following neck dissection.

METHOD

A systematic review was conducted of prospective trials investigating the efficacy of rehabilitation for shoulder or upper limb dysfunction and pain following any type of neck dissection.

RESULTS

A total of 820 papers were identified; through a staged review process, 7 trials were found that fulfilled the inclusion criteria. These included three randomised, controlled trials and four non-randomised studies. Five out of the seven trials demonstrated a statistically significant benefit of physiotherapy.

CONCLUSION

Current evidence shows a benefit from physiotherapy in patients with shoulder dysfunction following neck dissection. Some evidence suggests progressive resistance is superior to other types of physiotherapy. Long-term benefit and cost efficacy have not been studied.

The necessity of IIb dissection in T1-T2N0M0 oral squamous cell carcinoma: protocol for a randomized controlled trial

Background

There is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, “shoulder syndrome” appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1–2N0M0 oral squamous cell carcinoma (OSCC).

Methods

We designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression–free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant–Murley scale to measure shoulder function.

Discussion

Currently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1–T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800019128. Registered on 26 October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3683-y) contains supplementary material, which is available to authorized users.

[Sentinel lymph node biopsy in head and neck oncology]

Sentinel lymph node biopsy (SLNB) has been initially developed for melanoma and breast cancers. Its application in head and neck cancers is recent, probably due to the complexity of the lymphatic drainage, the proximity between the primary tumor and the lymph nodes and the critical anatomical structures (such as the facial nerve). In onco-dermatology, SLNB is validated in head and neck surgery for melanoma with Breslow thickness up to 1mm or ulceration, Merkel carcinoma and high-risk squamous cell carcinoma. Considering the malignancies of the upper aerodigestive tract, the feasibility and oncologic safety of SLNB are now established for T1-T2N0 oral and oropharyngeal squamous cell carcinomas. Thus, it could allow patients with negative sentinel nodes to avoid an unnecessary neck dissection, leading to a decrease of morbidity with an quality of life improvement. For some primary locations (e.g., anterior floor of the mouth) with high proximity between tumor and lymph nodes, it is recommended to remove the tumor before the SLNB so as to improve the detection. New techniques of detection are currently being developed with intra-operative procedures and new tracers (such as tilmanocept), leading to a better accuracy of detection and, probably, new indications.

Identifying Gaps in Research on Rehabilitation for Patients With Head and Neck Cancer: A Scoping Review

OBJECTIVES

Examine the amount and nature of research activity in head and neck cancer (HNC) rehabilitation; highlight publication trends, including information about the authors, settings, and study designs; and identify gaps in the existing literature.

DATA SOURCES

Eligible studies were identified using PubMed, Embase, and CINAHL databases.

STUDY SELECTION

Inclusion criteria included human subjects, English language, publication between 1/1/1990 and 4/30/2017, HNC patients at any timepoint in disease, and evaluation of rehabilitation outcomes as described by the International Classification of Functioning, Disability and Health (ICF) framework. Exclusion criteria included intervention or outcome not specific to rehabilitation or the HNC population, and protocols or abstracts without corresponding full manuscripts.

DATA EXTRACTION

An established 6-step scoping review framework was utilized to develop the review protocol. A 3-level review was then performed. Data on eligible studies were collected using a Research Electronic Data Capture (REDCap) tool.

DATA SYNTHESIS

Among 2201 publications, 258 met inclusion criteria. Publication rate increased by 390% over the study timeframe. Most studies were observational (n=150). Few were interventional (n=35). The most common interventions focused on chewing or swallowing (n=14), followed by exercise (n=10). Most primary outcome measures fit the ICF definition of impairment; fewer fit the definitions of activity limitation or participation restriction.

CONCLUSIONS

Although research volume in HNC rehabilitation is increasing, the literature is dominated by small (≤100 patients), outpatient-based observational studies involving chewing or swallowing-related impairments. More prospective studies in multidisciplinary domains across the cancer care continuum are needed. There is particular need for interventional studies and prospective observational studies. Future studies should evaluate clinically-relevant activity limitations and participation restrictions. Rehabilitation professionals have an important role in the design of future HNC rehabilitation research.

Elective Neck Dissection Versus Wait-and-Watch Policy for Oral Cavity Squamous Cell Carcinoma in Early Stage: A Systematic Review and Meta-Analysis Based on Survival Data

PURPOSE

Whether elective neck dissection (END) should be adopted for patients with clinically early-stage (cT1-2N0M0) oral cavity squamous cell carcinoma (OCSCC) remains debated. The aim of this systematic review was to compare the survival benefit of END with that of the wait-and-watch policy (WW) for patients with early-stage OCSCC based on survival data.

MATERIALS AND METHODS

According to the inclusion criteria, an exhaustive search for eligible studies was conducted. The study inclusion and data extraction were performed by 2 reviewers independently. The risk of bias was assessed in duplicate using the Risk Of Bias In Nonrandomized Studies of Interventions instrument. The hazard ratio (HR) of the time-to-event data was extracted or estimated. RevMan 5.3 and STATA 15.1 were adopted for data synthesis.

RESULTS

Of the 35 studies that were included, only 5 were assessed as having a low risk of bias. Results of the meta-analyses showed END could significantly decrease neck recurrence (relative risk = 0.45; confidence interval [CI], 0.35-0.59; P < .00001) and improve disease-free survival (HR = 0.55; CI, 0.42-0.71; P < .00001), overall survival (HR = 0.75; CI, 0.64-0.86; P < .0001), and disease-specific survival (HR = 0.76; CI, 0.61-0.94; P = .01) compared with WW for patients with cT1-2N0. The subgroup analysis showed that END could decrease neck recurrence (P < .00001) and improve disease-free survival (P = .001) for patients with early-stage tongue cancer and that supraomohyoid neck dissection could decrease neck recurrence (P = .02). For patients with cT1N0, END could significantly decrease the proportion with neck recurrence (P = .0008) and improve disease-free survival (P = .0003), but the difference between overall survival and disease-specific survival did not achieve significance.

CONCLUSIONS

END can decrease recurrence and improve survival time for patients with early-stage OCSCC. More high-quality studies are needed to make a solid conclusion, especially for patients with cT1N0M0.

Pectoralis major myocutaneous flap in salvage reconstruction following free flap failure in head and neck cancer surgery

Objective

This study aimed to compare the results of the pectoralis major myocutaneous (PMM) flap in primary and salvage head and neck cancer surgery.

Methods

A total of 160 patients were enrolled in this study. The salvage group consisted of 30 patients who received immediate PMM flap surgery following free flap failure. In the primary group, the PMM flap was primarily chosen for 130 patients. Related information was collected and analysed. The University of Washington (UW)-Quality of Life questionnaire, version 4, was mailed to every patient.

Results

Partial necrosis was significantly lower in the primary group (n = 13, 10.0%) than in the salvage group (n = 7, 23.3%). Surgical site infection was found in 10 (7.8%) patients in the primary group and in six (20.0%) patients in the salvage group. The mean composite quality of life scores were 66.8 ± 20.5 and 66.2 ± 22.1 in the two groups, respectively. Differences in scores for domains of activity, mood, and anxiety were significant. Disease-specific survival and recurrence-free survival rates were not different between the two groups.

Conclusion

PMM flap salvage reconstruction has a higher complication rate and poorer functional results, but similar survival prognosis, compared with primary surgery.

Association of neck dissection with survival for early stage N0 tongue cancer: A SEER population-based study

The management of the node negative neck in patients with tongue cancer remains a complex and controversial issue, especially in those with early stage tumors. Patients with negative cervical lymph nodes generally have a good prognosis. However, in patients without neck dissection, neck recurrences may occur after excision of the primary tumor due to occult cervical metastases. It often results in poor salvage therapy options and short survival. We used Surveillance, Epidemiology, and End Results data from 2004 to 2013 to investigate the association of neck dissection with survival among early stage tongue cancer patients with negative lymph node metastasis. A total of 4274 eligible patients were subdivided into 2 groups according to their neck management strategies: neck dissection and observation. Univariate and multivariate Cox proportional hazards regression models were used to determine the independent factors of survival. The Kaplan-Meier method was employed for survival analysis. In the overall cohort, patients who underwent neck dissection had better survival than those who were managed with observation in both tongue cancer specific survival and overall survival. After adjusting for confounding variables, neck dissection strategy remains an independent prognostic factor for better survival. When stratifying the patients according to age, gender, race, marital status, histologic grade, stage and radiotherapy, patients in the neck dissection group had significantly better survival than those in the observation group. Neck dissection may improve survival for early stage tongue cancer patients with negative lymph node metastasis. These results may assist clinicians in selecting the most appropriate neck management strategy for individual patients.

Factors influencing neck and shoulder function after oral oncology treatment: a five-year prospective cohort study in 113 patients

BACKGROUND

The aim of this study was to identify factors influencing shoulder and/or neck function in patients up to five years after treatment.

MATERIALS AND METHODS

Lateral flexion of the neck, ipsilateral forward flexion, and abduction of the shoulder were measured. Potential factors were entered into a linear mixed model analysis to create a multivariate model for describing the results.

RESULTS

Predicted neck and shoulder function was negatively influenced by higher age before intervention. Contralateral flexion of the neck was lower for patients undergoing surgery and radiotherapy compared to surgery. Ipsilateral flexion of the neck is influenced by a higher age at baseline. Ipsilateral shoulder abduction is lower for female gender, bone graft/flap reconstruction, and more extensive neck dissection. Ipsilateral forward flexion of the shoulder is lower for bone graft/flap reconstruction and better for patients with a T2 tumor in comparison to T3 and T4 tumors, as predicted.

CONCLUSION

By our five-year follow-up outcomes of this study, neck and/or shoulder impairments can be found for high-risk patients by physiotherapists.

Sentinel lymph node biopsy for early stage tongue cancer-a 14-year single-centre experience

This study was performed to report the usage of sentinel lymph node biopsy (SLNB) in clinical stage I or II tongue cancer patients with cN0 necks seen over a 14-year period. Data were collected prospectively, and a retrospective analysis was performed of 41 patients with early stage oral squamous cell carcinoma of the tongue and a cN0 neck. Sentinel lymph node (SLN)-positive patients underwent elective neck dissection, whereas SLN-negative patients were kept under careful observation. Seven of the 41 (17%) patients enrolled in the study were found to have occult metastases. The patients were followed up for a mean duration of 92 months (range 60-144 months). The neck recurrence rate for SLN-positive patients was 0% and for SLN-negative patients was 3%. The authors recommend the routine use of SLNB in patients with early stage oral squamous cell carcinoma of the tongue and a cN0 neck. Furthermore, special focus should be placed on isolated tumour cells, as their presence is of high clinical relevance.

Oral cancers: Current status

Oral cancer is a global disease. Despite a well elucidated tumour progression model, these cancers present late. Attempts at early detection by way of adjunctive diagnostic technologies and screening have not lived up to expectations in spite initial promise. Surgery is the mainstay of treatment. Treatment intensification by way of adjuvant radiation/chemo radiation is warranted for those with high risk features. Recent studies have explored intensification in those with intermediate risk factors in an attempt to improve outcomes. There has been generation of recent robust evidence that has influenced the need and extent of neck dissection. Neoadjuvant chemotherapy (NACT) may have a potential role in organ preservation and borderline resectable oral cancers. Recurrent tumours should be offered surgery whenever feasible while the addition of biological agents to chemotherapy gives best results in the palliative settings.

Elective Neck Dissection Versus Observation in Squamous Cell Carcinoma of Oral Cavity With Clinically N0 Neck: A Systematic Review and Meta-Analysis of Prospective Studies

PURPOSE

To assess the possible benefits of elective neck dissection (END) in patients with squamous cell carcinoma (SCC) of the oral cavity and clinically N0 neck.

MATERIALS AND METHODS

Medline, Embase, the China National Knowledge Infrastructure, and the Wan Fang Database were systematically searched. A meta-analysis was performed to evaluate the possible benefits of END to such patients.

RESULTS

Six prospective studies involving 865 patients fulfilled the inclusion criteria. Meta-analysis of all included studies showed that END substantially lowered the risk of regional recurrences (risk ratio [RR] = 0.27; 95% confidence interval [CI], 0.21-0.36) in the fixed-effect model compared with observation only. Three of the 6 included studies showed that the specific death rate related to regional recurrences was lower in the END group than in the observation group in the fixed-effect model (RR = 0.35; 95% CI, 0.19-0.65). The mean metastasis rate of occult cervical lymph node was 30.27% (standard deviation, 9.42%). When the fixed-effect model was applied, 4 of the 6 included studies showed less recurrence in the END group compared with the observation group (RR = 0.53; 95% CI, 0.44-0.64).

CONCLUSIONS

END substantially decreases recurrences and deaths related to regional recurrences in early-stage SCC of the oral cavity with clinically N0 neck, especially SCC of the oral tongue and floor of the mouth, which is necessary for such patients.

Shoulder Morbidity in Patients after Head and Neck Reconstruction with the Pedicled Supraclavicular Island Flap

Supplemental Digital Content is available in the text.

Background:

The pedicled supraclavicular artery island flap (SCAIF) for reconstruction of the head and neck has been shown to be a pliable alternative to established pedicled flaps, such as the pectoralis major myocutaneous flap. Because there are limited published data regarding shoulder morbidity after SCAIF procedure, we aimed to investigate it with 2 established questionnaires for the upper extremity [Constant-Murley score and Disabilities of the Arm, Shoulder and Hand Outcome Measure (DASH) score].

Methods:

The authors designed and implemented a retrospective cohort study of patients who received a defect reconstruction by SCAIF. Analyzed parameters were demographics, comorbidities, donor-site morbidity and shoulder morbidity in terms of range of motion, pain, strength, and daily activities evaluated and compared between the donor site and contralateral arm.

Results:

Of the 61 consecutively performed head and neck reconstructions with SCAIF, 20 met inclusion criteria (curative intended treatment, head and neck squamous cell cancer, follow-up time more than 4 months). Mean follow-up was 17.3 months (±10.4 months) ranging from 4–35 months. Donor-site complication rate was low with 5% major (surgical revision) and 30% minor complications (conservative management). Overall Constant-Murley-Score (P = 0.334), pain (P = 0.150), overall range of motion (P = 0.861), and strength of the extremity (P = 0.638) of the shoulder receiving a SCAIF showed no significant differences to the contralateral extremity. Mean of Disabilities of the Arm, Shoulder and Hand Outcome Measure score was 32.5 (±28.6).

Conclusion:

The results of the present study suggest very low shoulder morbidity in patients after SCAIF procedure with no significant functional impairment of the donor shoulder compared with the contralateral side.

Functional outcomes and quality of life after a 6-month early intervention program for oral cancer survivors: a single-arm clinical trial

Background

Advanced treatment of oral cancer increases survival rates; however, it also increases the risk of developing shoulder dysfunction, dysphagia, oral dysfunction, donor site morbidity and psychological issues. This single-arm preliminary pilot study aims to explore the effects of a six-month early intervention program following reconstructive surgery in oral cancer survivors.

Methods

A total of 65 participants were analyzed following reconstructive surgery. Outcome measurements were taken during the first visit, and at one, three and six months after reconstructive surgery.

Results

Scapular muscle strength and shoulder range of motion progressively improved during the 6-month follow-up. The mean Disability of the Arms, Shoulder and Hand (DASH) score showed significant improvement at 1 month (p < .001). Health related QoL showed significant differences between baseline and 6-months post-surgery scores on global health and on most of the function and symptom scales. The predicted return-to-work rate was 80% at one year after the operation. Return-to-work rate differs in different vocational types, with a higher rate of return in the skilled or semi-skilled (87.5%) and self-employed (86.7%).

Conclusions

We suggest that early integrated intervention program with a follow-up of at least six months following reconstructive surgery may help develop and identify intervention guidelines and goals in the initial six months of treatment following neck dissection in oral cancer survivors.

Intraoperative cardiac arrest etiologies in head and neck surgery: A comprehensive review

BACKGROUND

The etiologies of intraoperative cardiac arrest within otolaryngology are not well understood as they are rare events.

METHODS

A comprehensive review of the etiologies and corresponding pathophysiologic neural mechanisms of intraoperative cardiac arrest in otolaryngologic surgery are examined.

RESULTS

The occurrence of this rare complication has been described in a range of head and neck procedures, including but not limited to suspension laryngoscopy and oncologic resections in the neck, maxilla and thyroid. Three anatomically distinct pathways leading to intraoperative cardiac arrest are described: direct vagal stimulation, the trigeminocardiac reflex and the baroreceptor reflex. All three share the final common pathway of parasympathetic signaling to the sinoatrial node via the cardiac fibers of the vagus nerve.

CONCLUSION

With a firm understanding of the mechanistic underpinning of this rare phenomenon, otolaryngologic surgeons can be better prepared for its occurrence.

Diagnostic value of sentinel lymph node biopsy for cT1/T2N0 tongue squamous cell carcinoma: a meta-analysis

The aim of this study was to systematically evaluate the diagnostic value of the sentinel lymph node biopsy (SLNB) for cT1/T2N0 tongue squamous cell carcinoma (TSCC) patients. A comprehensive and systematic literature review was performed by searching the Embase and PubMed databases for English language articles published up to December 2016. The pooled overall sentinel lymph node (SLN) detection rate, sensitivity and negative predictive value (NPV) were used to evaluate the diagnostic value of SLNB which used neck dissection or follow-up as a reference test. The Q test and I ² statistic were used to assess the heterogeneity across the studies. Subgroup analyses were performed in consideration of higher contribution of different clinical characteristics on the SLNB diagnostic value. Begg's linear regression and Egger's regression tests were conducted to evaluate the publication bias. Thirty-five studies (with 1084 patients) were included. The pooled SLN detection rate was 98% (95% CI 97-100%). The pooled overall sensitivity and NPV of SLNB were 0.92 (95% CI 0.88-0.95) and 0.96 (95% CI 0.94-0.97), respectively. The subgroup analyses demonstrated that higher extracted number of patients (n ≥ 30) from the included studies achieved a more stable NPV than lower number of patients. SLNB can effectively predict the status of regional lymph nodes in cT1/T2N0 TSCC patients. With high sensitivity and NPV, SLNB can guide the treatment of SLNB-positive patients with neck dissections and those with negative SLNBs with follow-ups in order to avoid unnecessary surgical morbidity.

Sensitivity and Specificity of Cetuximab-IRDye800CW to Identify Regional Metastatic Disease in Head and Neck Cancer

Purpose: Comprehensive cervical lymphadenectomy can be associated with significant morbidity and poor quality of life. This study evaluated the sensitivity and specificity of cetuximab-IRDye800CW to identify metastatic disease in patients with head and neck cancer.Experimental Design: Consenting patients scheduled for curative resection were enrolled in a clinical trial to evaluate the safety and specificity of cetuximab-IRDye800CW. Patients (n = 12) received escalating doses of the study drug. Where indicated, cervical lymphadenectomy accompanied primary tumor resection, which occurred 3 to 7 days following intravenous infusion of cetuximab-IRDye800CW. All 471 dissected lymph nodes were imaged with a closed-field, near-infrared imaging device during gross processing of the fresh specimens. Intraoperative imaging of exposed neck levels was performed with an open-field fluorescence imaging device. Blinded assessments of the fluorescence data were compared to histopathology to calculate sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV).Results: Of the 35 nodes diagnosed pathologically positive, 34 were correctly identified with fluorescence imaging, yielding a sensitivity of 97.2%. Of the 435 pathologically negative nodes, 401 were correctly assessed using fluorescence imaging, yielding a specificity of 92.7%. The NPV was determined to be 99.7%, and the PPV was 50.7%. When 37 fluorescently false-positive nodes were sectioned deeper (1 mm) into their respective blocks, metastatic cancer was found in 8.1% of the recut nodal specimens, which altered staging in two of those cases.Conclusions: Fluorescence imaging of lymph nodes after systemic cetuximab-IRDye800CW administration demonstrated high sensitivity and was capable of identifying additional positive nodes on deep sectioning. Clin Cancer Res; 23(16); 4744-52. ©2017 AACR.

A nomogram for predicting the risk of neck node metastasis in pathologically node-negative oral cavity carcinoma

OBJECTIVE

To generate a nomogram for predicting the risk of neck node metastasis in pathologically node-negative patients using a combination of variables comprising of protein expression, ultrastructural alterations and clinicopathological parameters.

MATERIALS AND METHODS

Surgically removed oral tumours (n = 103) were analysed for the expression of desmosomal and hemidesmosomal assembly proteins by immunohistochemistry and ultrastructural alterations by transmission electron microscopy (TEM). Protein expression, ultrastructural alterations and clinicopathological variables were used to construct nomogram from the training set in 75 patients. Clinical utility of the nomogram was validated in a discrete set of 28 patients.

RESULTS

Univariate and multivariate analyses were performed on the training set, and obtained significant variables comprising of integrin β4 expression (p = .027), number of hemidesmosomes (p = .027)/desmosomes (p = .046), tumour differentiation grade (p = .033) and tumour thickness (p = .024) were used for construction of the nomogram. The area under the curve was calculated for both training 0.821 (95% CI 0.725-0.918) and validation sets 0.880 (95% CI 0.743-1.000). The nomogram demonstrated a predictive accuracy of 73.3% and 78.6% with the sensitivity of 81.4% and 83.3% in the training and validation sets, respectively.

CONCLUSIONS

The nomogram constructed on postsurgical tumour samples will be a value addition to histopathology for the detection of neck node metastasis in pathologically node-negative patients.

Regional recurrence in early stage I-II oral tongue cancer: a single institutional study and review of the literature

CONCLUSIONS

There is a high propensity for locoregional and isolated regional failure in stage II patients, even though treated with combined therapy. In stage I patients the risk of isolated regional failure was moderate, at levels below 10%.

BACKGROUND

The neck treatment of early stages of oral tongue squamous cell carcinoma (OTSCC) are still debatable, considering that previous studies have produced diverting results. The purpose of this study is to report on the outcome of patients with stages I-II, with special respect to regional outcome.

MATERIALS AND METHODS

All patients treated for OTSCC at Karolinska University Hospital between 2008-2014 were included. Patient demographics, intention of treatment, treatment modality, time of follow-up and status at follow-up, recurrence, and place of recurrence were recorded.

RESULTS

Of 230 patients, 149 presented within stages I and II. Of those, 105 were electively treated to the neck. In stage I, the risk of presence of disease in the neck specimen was four out of 63 (6%), whereas 17 out of 41 (41%) were positive in stage II patients. The overall risk of isolated regional failure at any time in stage I patients was six out of 89 and in stage II 25 out of 60.

Fracture of the Clavicle following Radical Neck Dissection and Reconstruction Using Pectoralis Major Myocutaneous Flap Accompanied by Postoperative Radiotherapy

Fracture of the clavicle following radical neck dissection (RND) and/or radiotherapy is a rare complication. Several causes of fracture of the clavicle after treatment of head and neck cancer were postulated in previous reports. We present a case of fracture of the clavicle after treatment of squamous cell carcinoma of the tongue. An 81-year-old Japanese woman underwent RND, subtotal glossectomy, reconstruction using a pectoralis major myocutaneous flap (PMMCF), and postoperative radiotherapy (50.4 Gy). One month after the primary treatment, fracture of the clavicle occurred. It was thought that muscular dynamic factor and reduction of blood supply in the clavicle associated with RND and PMMCF were the causes of the fracture. We have to recognize the occurrence of this complication and try to reduce the factors related to the complication.