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Deuß E, Kürten CHL, Meyer M, Buhr CR, Künzel J, Ernst B, Mattheis S, Lang S, Hussain T. [Nodal metastasis and value of neck dissection in T1/2 oropharyngeal and hypopharyngeal carcinomas]. Laryngorhinootologie 2024. [PMID: 38830380 DOI: 10.1055/a-2291-9979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Due to heterogeneous data, the indication for elective neck dissection (END) in patients with squamous cell carcinoma of the hypopharynx and oropharynx (HPSCC and OPSCC) in stages T1/2N0 is somewhat unclear. Therefore, in this multicenter study, we performed detailed analysis of the metastatic behavior of HPSCC and OPSCC. MATERIAL AND METHODS The nodal metastatic patterns of 262 HPSCC and OPSCC patients who had undergone surgery was retrospectively investigated. In addition, recurrence-free and overall survival were recorded. Furthermore, a systematic literature review on the topic was completed. RESULTS In patients with HPSCC, a discrepancy between clinical and pathologic N status was recorded in 62.1% of patients vs. 52.4% for p16- OPSCC, and 43.6% for p16+ OPSCC. The occult metastasis rate in cT1/2cN0 primary tumors was 38.9% for HPSCC vs. 17.8% (p16- OPSCC) and 11.1% (p16+ OPSCC). Contralateral metastases occurred in 22.2% of cases for HPSCC at stages cT1/2cN0, compared to only 9.1% for p16- OPSCC, and 0% for p16+ OPSCC patients.Patients with p16+ OPSCC had better recurrence-free and overall survival than p16- OPSCC and HPSCC patients. A direct association between patient survival and the extent of neck surgical therapy could not be demonstrated in our patients. CONCLUSION Patients with HPSCC are at risk for bilateral neck metastases from stage cT1/2cN0, justifying bilateral END. Patients with T1/2 OPSCC present with occult metastases ipsilaterally in >20% of cases; however, the risk for contralateral occult metastasis is <10%. Hence, in strictly lateralized cT1/2CN0 tumors, omission of contralateral END may be considered.
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Affiliation(s)
- Eric Deuß
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Essen, Germany
| | - Cornelius H L Kürten
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Essen, Germany
| | - Moritz Meyer
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Essen, Germany
| | - Christoph Raphael Buhr
- Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Julian Künzel
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Benjamin Ernst
- Klinik für Hals-Nasen-Ohrenheilkunde, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Stefan Mattheis
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Essen, Germany
| | - Stephan Lang
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Essen, Germany
| | - Timon Hussain
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Essen, Germany
- Klinik für Hals-, Nasen-, Ohrenheilkunde, Klinikum rechts der Isar der Technischen Universität München, München, Germany
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Goldschmidt S, Stewart N, Ober C, Bell C, Wolf-Ringwall A, Kent M, Lawrence J. Contrast-enhanced and indirect computed tomography lymphangiography accurately identifies the cervical lymphocenter at risk for metastasis in pet dogs with spontaneously occurring oral neoplasia. PLoS One 2023; 18:e0282500. [PMID: 36862650 PMCID: PMC9980747 DOI: 10.1371/journal.pone.0282500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/16/2023] [Indexed: 03/03/2023] Open
Abstract
For dogs with oral tumors, cervical lymph node (LN) metastasis alters treatment and prognosis. It is therefore prudent to make an accurate determination of the clinical presence (cN+ neck) or absence (cN0 neck) of metastasis prior to treatment. Currently, surgical LN extirpation with histopathology is the gold standard for a diagnosis of metastasis. Yet, recommendations to perform elective neck dissection (END) for staging are rare due to morbidity. Sentinel lymph node (SLN) mapping with indirect computed tomography lymphangiography (ICTL) followed by targeted biopsy (SLNB) is an alternative option to END. In this prospective study, SLN mapping followed by bilateral END of all mandibular LNs (MLNs) and medial retropharyngeal LNs (MRLNs) was performed in 39 dogs with spontaneously occurring oral neoplasia. A SLN was identified by ICTL in 38 (97%) dogs. Lymphatic drainage patterns were variable although most often the SLN was identified as a single ipsilateral MLN. In the 13 dogs (33%) with histopathologically confirmed LN metastasis, ICTL correctly identified the draining lymphocentrum in all (100%). Metastasis was confined to the SLN in 11 dogs (85%); 2 dogs (15%) had metastasis beyond the SLN ipsilaterally. Contrast enhanced CT features had good accuracy in predicting metastasis, with short axis measurements less than 10.5 mm most predictive. ICTL imaging features alone were unable to predict metastasis. Cytologic or histopathologic SLN sampling is recommended prior to treatment to inform clinical decision-making. This is the largest study to show potential clinical utility of minimally invasive ICTL for cervical LN evaluation in canine oral tumors.
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Affiliation(s)
- Stephanie Goldschmidt
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St Paul, Minnesota, United States of America
- * E-mail:
| | | | - Christopher Ober
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St Paul, Minnesota, United States of America
| | - Cynthia Bell
- Specialty Oral pathology for Animals, Geneseo, Illinois, United States of America
| | - Amber Wolf-Ringwall
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St Paul, Minnesota, United States of America
| | - Michael Kent
- Department of Surgical and Radiologic Sciences, School of Veterinary Medicine, University of California Davis, Davis, California, United States of America
| | - Jessica Lawrence
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St Paul, Minnesota, United States of America
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Miyamoto S, Nakayama M, Kano K, Tsutsumi S, Momiyama K, Matsuki T, Yamashita T. Novel color fluorescence imaging for sentinel lymph node detection in oral and oropharyngeal cancer. Asia Pac J Clin Oncol 2023; 19:250-256. [PMID: 35871767 DOI: 10.1111/ajco.13815] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/06/2022] [Accepted: 06/18/2022] [Indexed: 01/20/2023]
Abstract
AIM Fluorescence imaging (FI) using indocyanine green (ICG) is a noteworthy alternative technique for sentinel lymph node (SLN) detection without radiation exposure in oral cavity and oropharynx cancer. However, conventional FI is monochrome, so the visibility is limited. This study assessed whether color FI using the HyperEye Medical System (HEMS) is feasible as an alternative for SLN detection. METHODS Patients with previously untreated cT1-2N0 oral or oropharyngeal cancer who were to undergo primary tumor resection and elective neck dissection (END) in our hospital were enrolled from November 2012 to March 2016. The patients underwent SLN detection for biopsy via the HEMS following the injection of ICG solution around the primary lesion before neck dissection. The visibility and the diagnostic accuracy of the imaging were evaluated. RESULTS SLNs were visualized in all eight cases; however, transcutaneous fluorescence detection was not observed in all cases. Utilizing color mode imaging simplified harvest by clearly discriminating SLNs from surrounding structures, while the monochrome mode proved to be more sensitive for detection. Two cases showed occult metastases on both sentinel and regional nodes. The identification and false negative rates were 100% and 0%, respectively. There were no complications incurred due to this method. CONCLUSION Our results suggest that color FI with the HEMS allows for the accurate and safe harvest of SLNs with a preparatory skin incision. Although there is room for improvement of sensitivity, this easy-to-handle procedure might provide the potential to expand the role of the ICG method for SLN detection in head and neck cancer.
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Affiliation(s)
- Shunsuke Miyamoto
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Meijin Nakayama
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan.,Department of Otorhinolaryngology-Head and Neck Surgery, Yokohama City University, Yokohama, Japan
| | - Koichi Kano
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shohei Tsutsumi
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kaho Momiyama
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takashi Matsuki
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Taku Yamashita
- Department of Otorhinolaryngology-Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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Wan J, Oblak ML, Ram AS, McKenna C, Singh A, Nykamp S. Evaluating the Feasibility and Efficacy of a Dual-Modality Nanoparticle Contrast Agent (Nanotrast-CF800) for Image-Guided Sentinel Lymph Node Mapping in the Oral Cavity of Healthy Dogs. Front Vet Sci 2021; 8:721003. [PMID: 34631851 PMCID: PMC8494771 DOI: 10.3389/fvets.2021.721003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 08/27/2021] [Indexed: 01/08/2023] Open
Abstract
A combination of pre and intraoperative sentinel lymph node (SLN) mapping techniques have been suggested to optimize SLN detection. A novel liposomal nanoparticle, Nanotrast-CF800 (CF800), utilizes computed tomography lymphography (CTL) and near infrared fluorescence imaging (NIRF) for image-guided surgery and SLN mapping. This novel tracer agent has not been evaluated in companion animals. The objective of this study was to evaluate the feasibility and efficacy of CF800 for SLN mapping in the oral cavity of healthy dogs and to report any local adverse effects. Six healthy adult purpose-bred research dogs randomly received either 1 mL (group 1) or 2 mL (group 2) of CF800 injected into the submucosa at the level of the right canine maxillary tooth. CTL and percutaneous NIRF were performed at 1, 3, and 10 min, then 1, 2, 4, 7, and 10 days post-injection (p.i). Overall, both CTL and NIRF identified SLNs in all dogs. The overall peak mean contrast enhancement of the SLNs was 73.98 HU (range 63.45-86.27 HU) at 2 days p.i. Peak fluorescence of the SLN occurred at 1 day p.i. The agent was retained within the SLN for at least 7 days for CTL and 4 days for percutaneous NIRF. No adverse effects were observed. Local administration of CF800 was simple and feasible for the detection of SLNs using CTL+NIRF in the head and neck of healthy dogs and was not associated with significant local adverse events.
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Affiliation(s)
- Jennifer Wan
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Michelle L. Oblak
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Ann S. Ram
- Department of Biomedical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Charly McKenna
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
- Department of Biomedical Sciences, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Ameet Singh
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Stephanie Nykamp
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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5
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Zhou Y, Yu T, Rui X, Jin T, Huang Z, Huang Z. Effectiveness of diffusion-weighted imaging in predicting cervical lymph node metastasis in head and neck malignancies. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 131:122-129.e2. [DOI: 10.1016/j.oooo.2020.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/11/2020] [Accepted: 06/28/2020] [Indexed: 01/18/2023]
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Garrel R, Poissonnet G, Moyà Plana A, Fakhry N, Dolivet G, Lallemant B, Sarini J, Vergez S, Guelfucci B, Choussy O, Bastit V, Richard F, Costes V, Landais P, Perriard F, Daures JP, de Verbizier D, Favier V, de Boutray M. Equivalence Randomized Trial to Compare Treatment on the Basis of Sentinel Node Biopsy Versus Neck Node Dissection in Operable T1-T2N0 Oral and Oropharyngeal Cancer. J Clin Oncol 2020; 38:4010-4018. [PMID: 33052754 DOI: 10.1200/jco.20.01661] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Sentinel node (SN) biopsy is accurate in operable oral and oropharyngeal cT1-T2N0 cancer (OC), but, to our knowledge, the oncologic equivalence of SN biopsy and neck lymph node dissection (ND; standard treatment) has never been evaluated. METHODS In this phase III multicenter trial, 307 patients with OC were randomly assigned to (1) the ND arm or (2) the SN arm (experimental arm: biopsy alone if negative, or followed by ND if positive, during primary tumor surgery). The primary outcome was neck node recurrence-free survival (RFS) at 2 years. Secondary outcomes were 5-year neck node RFS, 2- and 5-year disease-specific survival (DSS), and overall survival (OS). Other outcomes were hospital stay length, neck and shoulder morbidity, and number of physiotherapy prescriptions during the 2 years after surgery. RESULTS Data on 279 patients (139 ND and 140 SN) could be analyzed. Neck node RFS was 89.6% (95% CI, 0.83% to 0.94%) at 2 years in the ND arm and 90.7% (95% CI, 0.84% to 0.95%) in the SN arm, confirming the equivalence with P < .01. The 5-year RFS and the 2- and 5-year DSS and OS were not significantly different between arms. The median hospital stay length was 8 days in the ND arm and 7 days in the SN arm (P < .01). The functional outcomes were significantly worse in the ND arm until 6 months after surgery. CONCLUSION This study demonstrated the oncologic equivalence of the SN and ND approaches, with lower morbidity in the SN arm during the first 6 months after surgery, thus establishing SN as the standard of care in OC.
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Affiliation(s)
- Renaud Garrel
- Head Neck Surgery Department, Montpellier University Hospital Center, Montpellier, France
| | - Gilles Poissonnet
- Head Neck Surgery Department, Antoine Lacassagne Center, Nice, France
| | - Antoine Moyà Plana
- Head Neck Surgery Department, Institut Gustave Roussy, Villejuif, France
| | - Nicolas Fakhry
- Head Neck Surgery Department, Marseille University Hospital Center, Marseille, France
| | - Gilles Dolivet
- Head Neck Surgery Department, Alexis Vautrin Center, Vandœuvre-lès-Nancy, France
| | - Benjamin Lallemant
- Head Neck Surgery Department, Nîmes University Hospital Center, Nîmes, France
| | - Jérôme Sarini
- Head Neck Surgery Department, Toulouse Oncopole, Toulouse, France
| | - Sebastien Vergez
- Head Neck Surgery Department, Toulouse Oncopole, Toulouse, France
| | - Bruno Guelfucci
- Head Neck Surgery Department, Toulon Hospital Center, Toulon, France
| | - Olivier Choussy
- Head Neck Surgery Department, Curie Institute, Paris, France
| | - Vianney Bastit
- Head Neck Surgery Department, François Baclesse Center, Caen, France
| | - Fanny Richard
- Head Neck Surgery Department, Montpellier University Hospital Center, Montpellier, France
| | - Valérie Costes
- Pathology Department, Montpellier University Hospital Center, Montpellier, France
| | - Paul Landais
- Clinical Research University Institute, UPRES EA 2415, Montpellier, France
| | - Françoise Perriard
- Clinical Research University Institute, UPRES EA 2415, Montpellier, France
| | - Jean Pierre Daures
- Clinical Research University Institute, UPRES EA 2415, Montpellier, France
| | - Delphine de Verbizier
- Nuclear Medicine Department, Montpellier University Hospital Center, Montpellier, France
| | - Valentin Favier
- Head Neck Surgery Department, Montpellier University Hospital Center, Montpellier, France
| | - Marie de Boutray
- Head Neck Surgery Department, Montpellier University Hospital Center, Montpellier, France
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7
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Araki K, Tomifuji M, Shiotani A, Hirano S, Yokoyama J, Tsukahara K, Homma A, Yoshimoto S, Hasegawa Y. Minimally invasive surgery for laryngopharyngeal cancer: Multicenter feasibility study of a combination strategy involving transoral surgery and real‐time indocyanine green fluorescence‐navigated sentinel node navigation surgery. Head Neck 2019; 42:254-261. [DOI: 10.1002/hed.25993] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/03/2019] [Accepted: 10/09/2019] [Indexed: 02/05/2023] Open
Affiliation(s)
- Koji Araki
- Department of Otolaryngology—Head and Neck SurgeryNational Defense Medical College Tokorozawa Japan
| | - Masayuki Tomifuji
- Department of Otolaryngology—Head and Neck SurgeryNational Defense Medical College Tokorozawa Japan
| | - Akihiro Shiotani
- Department of Otolaryngology—Head and Neck SurgeryNational Defense Medical College Tokorozawa Japan
| | - Shigeru Hirano
- Department of Otolaryngology—Head and Neck SurgeryKyoto Prefectural University of Medicine Kyoto Japan
| | - Junkichi Yokoyama
- Department of Otolaryngology—Head and Neck SurgeryEdogawa Hospital Tokyo Japan
| | - Kiyoaki Tsukahara
- Department of Otorhinolaryngology—Head and Neck SurgeryTokyo Medical University Tokyo Japan
| | - Akihiro Homma
- Department of Otolaryngology—Head and Neck Surgery, Faculty of Medicine and Graduate School of MedicineHokkaido University Sapporo Japan
| | - Seichi Yoshimoto
- Department of Head and Neck SurgeryNational Cancer Center Hospital Tokyo Japan
| | - Yasuhisa Hasegawa
- Department of Head and Neck Surgery and OtolaryngologyAsahi University Hospital Gifu Japan
- Department of Head and Neck SurgeryAichi Cancer Center Hospital Nagoya Japan
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Garau LM, Muccioli S, Caponi L, Maccauro M, Manca G. Sentinel lymph node biopsy in oral–oropharyngeal squamous cell carcinoma: standards, new technical procedures, and clinical advances. Clin Transl Imaging 2019. [DOI: 10.1007/s40336-019-00338-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Koyfman SA, Ismaila N, Crook D, D'Cruz A, Rodriguez CP, Sher DJ, Silbermins D, Sturgis EM, Tsue TT, Weiss J, Yom SS, Holsinger FC. Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline. J Clin Oncol 2019; 37:1753-1774. [PMID: 30811281 DOI: 10.1200/jco.18.01921] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx. METHODS ASCO convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2018. Outcomes of interest included survival, regional disease control, neck recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical scenarios were devised; three for oral cavity cancer and three for oropharynx cancer, and recommendations were generated for each one. RECOMMENDATIONS For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended. Consensus was reached and recommendations were made for all six clinical scenarios. Additional information is available at www.asco.org/head-neck-cancer-guidelines .
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Affiliation(s)
| | | | - Doug Crook
- 3 Patient representative, Indianapolis, IN
| | | | | | | | | | | | | | - Jared Weiss
- 10 University of North Carolina, Chapel Hill, NC
| | - Sue S Yom
- 11 University of California, San Francisco, San Francisco, CA
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Garrel R, Poissonnet G, Temam S, Dolivet G, Fakhry N, de Raucourt D. Review of sentinel node procedure in cN0 head and neck squamous cell carcinomas. Guidelines from the French evaluation cooperative subgroup of GETTEC. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 134:89-93. [DOI: 10.1016/j.anorl.2016.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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11
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Liu M, Wang SJ, Yang X, Peng H. Diagnostic Efficacy of Sentinel Lymph Node Biopsy in Early Oral Squamous Cell Carcinoma: A Meta-Analysis of 66 Studies. PLoS One 2017; 12:e0170322. [PMID: 28107500 PMCID: PMC5249063 DOI: 10.1371/journal.pone.0170322] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 01/03/2017] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES The diagnostic efficacy of sentinel lymph node biopsy(SLNB) in early oral squamous cell carcinoma(OSCC) still remains controversial. This meta-analysis was conducted to assess the diagnostic value of SLNB in clinically neck-negative T1-2 OSCC. METHODS A systematic literature search for relevant literature published up to September 11, 2016 was conducted in PubMed, Embase, Web of Science, Cochrane Library and ClinicalTrials, and the reference lists of eligible studies were examined. Data from different studies were pooled to estimate the summary sentinel lymph node(SLN) identification rate, sensitivity, negative predictive value. Summary receiver operator characteristic curve(SROC) was plotted and area under the SROC curve (AUC) was calculated to evaluate the overall diagnostic efficacy. Threshold effect was assessed with use of the spearman correlation coefficient. Between-study heterogeneity was tested using the Q tests and the I2 statistics. Subgroup analyses were conducted in view of the greater effect of different study characteristics on diagnostic efficacy of SLN. Deeks' funnel plot asymmetry test was performed to evaluate publication bias. Sensitivity analysis was evaluated through omitting studies one by one and comparing the pooled results of random-effects model and fixed-effects model. All analyses were performed using Review Manager (version 5.3.5), Meta-DiSc (version 1.4), Comprehensive Meta Analysis (version 2.0) and STATA (version 12). RESULTS 66 studies comprising 3566 patients with cT1-2N0 OSCC were included in this meta-analysis. The pooled SLN identification rate was 96.3%(95% CI: 95.3%-97.0%). The pooled sensitivity was 0.87 (95% CI: 0.85-0.89), pooled negative predictive value was 0.94 (95% CI: 0.93-0.95), and AUC was 0.98 (95% CI: 0.97-0.99). Subgroup analyses indicated that SLN assessment with immunohistochemistry(IHC) achieved a significantly higher sensitivity than without IHC. CONCLUSIONS This meta-analysis suggests that SLNB has a high diagnostic accuracy in cT1-2N0 oral squamous cell carcinoma, and is an ideal alternative to elective neck dissection. Furthermore, the use of IHC can significantly improve SLNB diagnostic sensitivity for early OSCC.
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Affiliation(s)
- Muyuan Liu
- Department of Head and Neck, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Steven J. Wang
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tucson, Arizona, United States of America
| | - Xihong Yang
- Department of Head and Neck, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Hanwei Peng
- Department of Head and Neck, Cancer Hospital of Shantou University Medical College, Shantou, China
- * E-mail:
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Christensen A, Juhl K, Charabi B, Mortensen J, Kiss K, Kjær A, von Buchwald C. Feasibility of Real-Time Near-Infrared Fluorescence Tracer Imaging in Sentinel Node Biopsy for Oral Cavity Cancer Patients. Ann Surg Oncol 2016; 23:565-72. [PMID: 26467454 PMCID: PMC4718950 DOI: 10.1245/s10434-015-4883-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Indexed: 01/08/2023]
Abstract
Background
Sentinel node biopsy (SNB) is an established method in oral squamous cell carcinoma (OSCC) for staging the cN0 neck and to select patients who will benefit from a neck dissection. Near-infrared fluorescence (NIRF) imaging has the potential to improve the SNB procedure by facilitating intraoperative visual identification of the sentinel lymph node (SN). The purpose of this study was to evaluate the feasibility of fluorescence tracer imaging for SN detection in conjunction with conventional radio-guided technique. Methods
Prospective study of patients with primary OSCC planned for tumor resection and SNB. Thirty patients were injected peritumorally with a bimodal tracer (ICG-99mTc-Nanocoll) followed by lymphoscintigraphy and SPECT/CT to define the SNs and their anatomical location preoperatively. SNs were detected intraoperatively with a hand-held gamma-probe and a hand-held NIRF camera. Results In 29 of 30 subjects (97%), all preoperatively defined SNs could be identified intraoperatively using a combination of radioactive and fluorescence guidance. A total of 94 SNs (mean 3, range 1–5) that were both radioactive and fluorescent ex vivo were harvested. Eleven of 94 SNs (12%) could only be identified in vivo using NIRF imaging, and the majority of those were located in level 1 close to the primary tumor. Conclusions A combined fluorescent and radioactive tracer for SNB is feasible, and the additional use of NIRF imaging may improve the accuracy of SN identification in oral cancer patients. Intraoperative fluorescence guidance seems of particular value when SNs are located in close proximity to the injection site.
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Affiliation(s)
- Anders Christensen
- />Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- />Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Karina Juhl
- />Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Charabi
- />Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jann Mortensen
- />Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Katalin Kiss
- />Department of Pathology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andreas Kjær
- />Department of Clinical Physiology, Nuclear Medicine & PET and Cluster for Molecular Imaging, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Christian von Buchwald
- />Department of Otolaryngology, Head & Neck Surgery and Audiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Miura K, Hirakawa H, Uemura H, Yoshimoto S, Shiotani A, Sugasawa M, Homma A, Yokoyama J, Tsukahara K, Yoshizaki T, Yatabe Y, Matsuo K, Ohkura Y, Kosuda S, Hasegawa Y. Sentinel node biopsy for oral cancer: A prospective multicenter Phase II trial. Auris Nasus Larynx 2016; 44:319-326. [PMID: 27496008 DOI: 10.1016/j.anl.2016.07.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/30/2016] [Accepted: 07/12/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A recent study identified a survival benefit with prophylactic neck dissection (ND) at the time of primary surgery as compared with watchful waiting followed by therapeutic neck dissection for nodal relapse, in patients with cN0 oral squamous cell carcinoma (OSCC). Alternative management of cN0 neck cancer is recommended to minimize the adverse effects of ND, indicating the need for sentinel node biopsy (SNB) and limited neck dissection. We conducted a multicenter Phase II study to examine the feasibility of SNB for clinically N0 OSCC. METHODS Previously untreated N0 OSCC patients (n=57) with clinical late-T2 or T3 tumors were enrolled across 10 institutions. SNB navigated with multislice frozen section analysis of sentinel nodes (SNs) and SNB supported sentinel node lymphatic basin dissection (SN basin dissection) were performed in a one-stage procedure. The endpoint was to investigate the rate of false-negative metastases after SN basin dissection and SNB alone. RESULTS Most tumors were late-T2 lesions (n=50; 87.7%). SNs were identified in all patients. A total of 196 SNs were detected. Among these SNs, 35 (17.8%) were positive for metastasis (9 in level I, 12 in level II, 12 in level III, 1 in level V and 2 in the contralateral region of the neck). The false-negative rate of SNB supported by SN basin dissection and SNB alone was 4.5% and 9.1%, respectively. The concordance of the SN status in intraoperative frozen sections with the permanent histopathology was 97.4% (191/196). The sensitivity and specificity of intraoperative pathological evaluation were 85.7% (30/35) and 100% (30/30), respectively. The 3-year overall survival (OS) and disease-free survival was 89.5% and 82.5%, respectively. The OS of SN-negative patients was significantly longer than that of SN-positive patients (P=0.047). CONCLUSION The current study verified that SN basin dissection was a useful back-up procedure for SNB performed as a one-stage procedure, showing a low false-negative rate. SNB alone is an appropriate staging method for patients with clinical N0 staging, and a reliable procedure to determine the appropriate levels for neck dissection.
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Affiliation(s)
- Kouki Miura
- Department of Head and Neck Oncology and Surgery, International University of Health and Welfare, Mita Hospital, Tokyo 108-8329, Japan
| | - Hitoshi Hirakawa
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya 464-8681, Japan; Department of Otorhinolaryngology, Head and Neck Surgery, Graduate School of Medicine, University of the Ryukyus, 903-0213 Okinawa, Japan
| | - Hirokazu Uemura
- Department of Otolaryngology-Head and Neck Surgery, Nara Medical University, Kashihara 634-8521, Japan
| | - Seiichi Yoshimoto
- Department of Head and Neck Oncology, National Cancer Center Hospital, Tokyo 104-0045, Japan
| | - Akihiro Shiotani
- Department of Otolaryngology-Head and Neck Surgery, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Masashi Sugasawa
- Department of Head and Neck Surgery, Saitama Medical University International Medical Center, Saitama 350-1298, Japan
| | - Akihiro Homma
- Department of Otolaryngology, Head and Neck Surgery, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan
| | - Junkichi Yokoyama
- Department of Otolaryngology, Head and Neck Surgery, Moriyama Memorial Hospital, Tokyo 134-0088, Japan
| | - Kiyoaki Tsukahara
- Department of Otolaryngology - Head and Neck Surgery, Tokyo Medical University Hospital, Tokyo 160-0022, Japan
| | - Tomokazu Yoshizaki
- Division of Otolaryngology, Head and Neck Surgery, Graduate School of Medical Science, Kanazawa University 920-0942, Kanazawa, Japan
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya 464-8681, Japan
| | - Keitaro Matsuo
- Division of Molecular Medicine, Aichi Cancer Center Research Institute, Nagoya 464-8681, Japan
| | - Yasuo Ohkura
- Department of Pathology, Kyorin University School of Medicine, Tokyo 181-8612, Japan
| | - Shigeru Kosuda
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University School of Medicine, Maebashi 371-8511, Japan
| | - Yasuhisa Hasegawa
- Department of Head and Neck Surgery, Aichi Cancer Center Hospital, Nagoya 464-8681, Japan.
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14
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Mermod M, Bongiovanni M, Petrova TV, Dubikovskaya EA, Simon C, Tolstonog G, Monnier Y. Correlation between podoplanin expression and extracapsular spread in squamous cell carcinoma of the oral cavity using subjective immunoreactivity scores and semiquantitative image analysis. Head Neck 2016; 39:98-108. [PMID: 27437903 DOI: 10.1002/hed.24537] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The correlation between podoplanin expression and extracapsular spread in head and neck squamous cell carcinoma (HNSCC) has never been reported. The purpose of this study was to assess the predictive value of podoplanin expression for this parameter. METHODS Subjective immunoreactivity scores and semiquantitative image analysis of podoplanin expression were performed in 67 patients with primary oral squamous cell carcinoma and in their corresponding lymph nodes. Neck classification showed 34 cases (51%) of pN0 and 33 cases (49%) of pN+. Correlation between the levels of podoplanin expression and the histopathological data was established. RESULTS In lymph nodes, a high level of podoplanin expression correlated with the presence of extracapsular spread by multivariate analysis (p = .03). A strong correlation between subjective and semiquantitative image analysis was observed (r = 0.77; p < .001). CONCLUSION A high level of podoplanin expression in lymph node metastases of oral squamous cell carcinoma is independently associated with extracapsular spread. © 2016 Wiley Periodicals, Head Neck 39: 98-108, 2017.
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Affiliation(s)
- Maxime Mermod
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Massimo Bongiovanni
- Institute of Pathology, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Tatiana V Petrova
- Department of Fundamental Oncology, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Elena A Dubikovskaya
- Laboratory of Bioorganic Chemistry and Molecular Imaging (LBCMI), Institute of Chemical Sciences and Engineering (ISIC), École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Christian Simon
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Genrich Tolstonog
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Yan Monnier
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory, CHUV and University of Lausanne, Lausanne, Switzerland
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Demir D. The Role of Sentinel Lymph Node Biopsy in Head and Neck Cancers and Its Application Areas. Turk Arch Otorhinolaryngol 2016; 54:35-38. [PMID: 29392013 DOI: 10.5152/tao.2016.1129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/04/2015] [Indexed: 02/05/2023] Open
Abstract
The management of the clinically N0 neck in patients with head and neck cancers still remains controversial. Elective neck dissection is traditionally recommended when the subside of the head and neck, such as the oral cavity and supraglottic area, confers at least a 15-20% risk of lymphatic spread. However, elective neck dissection may cause an increase in patient morbidity and mortality rates. The emergence of sentinel lymph biopsy provides the possibility of accurate pathological staging of the cervical node with a less invasive procedure. The present review will summarize the role of sentinel lymph node biopsy and its application areas when evaluating occult metastases in patients with head and neck cancers.
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Affiliation(s)
- Deniz Demir
- Department of Otorhinolaryngology, Sakarya University School of Medicine, Sakarya, Turkey
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16
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Mermod M, Bongiovanni M, Petrova TV, Dubikovskaya EA, Simon C, Tolstonog G, Monnier Y. Prediction of occult lymph node metastasis in squamous cell carcinoma of the oral cavity and the oropharynx using peritumoral Prospero homeobox protein 1 lymphatic nuclear quantification. Head Neck 2016; 38:1407-15. [DOI: 10.1002/hed.24452] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 01/15/2016] [Accepted: 02/08/2016] [Indexed: 02/05/2023] Open
Affiliation(s)
- Maxime Mermod
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory; CHUV and University of Lausanne; Lausanne Switzerland
| | - Massimo Bongiovanni
- Institute of Pathology; CHUV and University of Lausanne; Lausanne Switzerland
| | - Tatiana V. Petrova
- Department of Fundamental Oncology; CHUV and University of Lausanne; Lausanne Switzerland
| | - Elena A. Dubikovskaya
- Laboratory of Bioorganic Chemistry and Molecular Imaging (LBCMI), Institute of Chemical Sciences and Engineering (ISIC); École Polytechnique Fédérale de Lausanne (EPFL); Lausanne Switzerland
| | - Christian Simon
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory; CHUV and University of Lausanne; Lausanne Switzerland
| | - Genrich Tolstonog
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory; CHUV and University of Lausanne; Lausanne Switzerland
| | - Yan Monnier
- Department of Otolaryngology - Head and Neck Surgery, Head and Neck Tumor Laboratory; CHUV and University of Lausanne; Lausanne Switzerland
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Sentinel lymph node biopsy for eyelid and conjunctival tumors: what is the evidence? Int Ophthalmol Clin 2015; 55:123-36. [PMID: 25436498 DOI: 10.1097/iio.0000000000000051] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Rosso KJ, Nathanson SD. Techniques that accurately identify the sentinel lymph node in cancer. World J Surg Proced 2015; 5:14-26. [DOI: 10.5412/wjsp.v5.i1.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/30/2014] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Sentinel lymph node (SLN) biopsy has become the gold standard for patients with melanoma and breast cancer but it’s clinical application in other solid tumor types such as cancers of the esophagus, stomach, colon and rectum, head and neck, penis, uterine cervix and endometrium has been somewhat limited. Commonly used mapping techniques utilizing the combination of radiocolloid and blue dye may result in reduced SLN detection and increased false negative rates when applied to cancers with more complex lymphatic drainage patterns. Novel localization techniques including near infrared fluorescence, high resolution imaging and molecular targeted agents have been developed to address the limitations of conventional SLN detection practices in many solid tumor types. This article reviews the indications, techniques and detection rates for SLN biopsy in several different solid tumor types as well as the promising novel techniques created to address the contemporary limitations of this procedure.
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Tausch C, Baege A, Rageth C. Mapping lymph nodes in cancer management - role of (99m)Tc-tilmanocept injection. Onco Targets Ther 2014; 7:1151-8. [PMID: 25028560 PMCID: PMC4077853 DOI: 10.2147/ott.s50394] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Two decades ago, lymphatic mapping of sentinel lymph nodes (SLN) was introduced into surgical cancer management and was termed sentinel node navigated surgery. Although this technique is now routinely performed in the management of breast cancer and malignant melanoma, it is still under investigation for use in other cancers. The radioisotope technetium (99mTc) and vital blue dyes are among the most widely used enhancers for SLN mapping, although near-infrared fluorescence imaging of indocyanine green is also becoming more commonly used. 99mTc-tilmanocept is a new synthetic radioisotope with a relatively small molecular size that was specifically developed for lymphatic mapping. Because of its small size, 99mTc-tilmanocept quickly migrates from its site of injection and rapidly accumulates in the SLN. The mannose moieties of 99mTc-tilmanosept facilitate its binding to mannose receptors (CD206) expressed in reticuloendothelial cells of the SLN. This binding prevents transit to second-echelon lymph nodes. In Phase III trials of breast cancer and malignant melanoma, and Phase II trials of other malignancies, 99mTc-tilmanocept had superior identification rates and sensitivity compared with blue dye. Trials comparing 99mTc-tilmanocept with other 99mTc-based agents are required before it can be routinely used in clinical settings.
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20
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Araki K, Mizokami D, Tomifuji M, Yamashita T, Ohnuki K, Umeda IO, Fujii H, Kosuda S, Shiotani A. Novel Indocyanine Green-Phytate Colloid Technique for Sentinel Node Detection in Head and Neck: Mouse Study. Otolaryngol Head Neck Surg 2014; 151:279-85. [PMID: 24732687 DOI: 10.1177/0194599814530409] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/14/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Sentinel node navigation surgery using real-time, near-infrared imaging with indocyanine green is becoming popular by allowing head and neck surgeons to avoid unnecessary neck dissection. The major drawback of this method is its quick migration through the lymphatics, limiting the diagnostic time window and undesirable detection of downstream nodes. We resolved this problem by mixing indocyanine green (ICG) with phytate colloid to retard its migration and demonstrated its feasibility in a nude mouse study. STUDY DESIGN Experimental prospective animal study. SETTINGS Animal laboratory. SUBJECTS AND METHODS Indocyanine green at 3 concentrations was tested to determine the optimal concentration for sentinel lymph node detection in a mouse model. Effect of indocyanine green with phytate colloid mixture solutions was also analyzed. Indocyanine green or mixture solution at different mixing ratios were injected into the tongue of nude mice and near-infrared fluorescence images were captured sequentially for up to 48 hours. The brightness of fluorescence in the sentinel lymph node and lymph nodes further downstream were assessed. RESULTS Indocyanine green concentration >50 μg/mL did not improve sentinel lymph node detection. The addition of phytate colloid to indocyanine green extended the period when sentinel lymph node was detectable. Second echelon lymph nodes were not imaged in mice injected with the mixture, while these were visualized in mice injected with indocyanine green alone. CONCLUSION This novel technique of ICG-phytate colloid mixture allows prolonged diagnostic time window, prevention of downstream subsequent nodes detection, and improved accuracy for the detection of true sentinel lymph nodes.
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Affiliation(s)
- Koji Araki
- Department of Otolaryngology-Head & Neck Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Daisuke Mizokami
- Department of Otolaryngology-Head & Neck Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Masayuki Tomifuji
- Department of Otolaryngology-Head & Neck Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Taku Yamashita
- Department of Otolaryngology-Head & Neck Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kazunobu Ohnuki
- Functional Imaging Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Izumi O Umeda
- Functional Imaging Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Hirofumi Fujii
- Functional Imaging Division, Research Center for Innovative Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Shigeru Kosuda
- Department of Radiology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Akihiro Shiotani
- Department of Otolaryngology-Head & Neck Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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