Application value of a hybrid tracer during sentinel lymph node biopsy for head and neck malignancies: A systematic review and meta-analysis

To address the limitations of conventional sentinel lymph node biopsy (SLNB), a novel hybrid tracer (indocyanine green [ICG]-99mTc-nanocolloid) has been developed. This meta-analysis aimed to compare the differences between the novel hybrid tracer and conventional methods using ICG or radioisotope (RI) for SLNB in head and neck malignancies. This study was registered in the International Prospective Register of Systematic Reviews (CRD42023409127). PubMed, Embase, Web of Science, and the Cochrane Library were systematically searched. This study included raw data on the number of sentinel lymph nodes (SLNs) identified using different modalities during surgery for head and neck malignancies. The identification rate of SLNs was the main outcome of interest. Prognostic data and complication rate cannot be deduced from this article. The heterogeneity test (I2) determined the use of a fixed- or random-effects model for the pooled risk ratio (RR). Overall, 1275 studies were screened, of which 11 met the inclusion criteria for the meta-analysis. In SLN identification of head and neck malignancies, ICG-99mTc-nanocolloid was superior to ICG or RI. In the subgroup analyses, the detection rates of ICG and RI tracers in SLNB were comparable, regardless of the device, tumor type, or tumor stage. In conclusion, in SLN identification of head and neck malignancies, the use of ICG-99mTc-nanocolloid is superior to the single technique of ICG or RI. This study suggests that Hospitals using ICG or RI may find it beneficial to change their practice to ICG-99mTc-nanocolloid, especially in the head and neck area, owing to its superior effectiveness.

Sentinel lymph node biopsies in early stage oral and oropharyngeal carcinoma: a retrospective single-centre experience

The aim of this retrospective study was to analyse a consecutive series of patients with oral and oropharyngeal carcinoma who had had sentinel lymph node biopsy (SLNB) at our hospital during 2008-2017. A total of 70 patients with clinically and radiologically confirmed primary oral (n=67) or oropharyngeal (n=3) carcinoma, with no signs of metastatic lymph nodes preoperatively (clinically N0) were included. Patients' clinical and personal data, characteristics of the tumours, sentinel lymph node (SLN) status and outcomes were recorded. Eight patients had invaded SLN. Two patients with clear sentinel lymph node biopsies had recurrences in the cervical lymph nodes with no new primary tumour as origin. The negative predictive value (NPV) and sensitivity for SLNB were 97% and 80%, respectively. The depth of invasion was an individual predictor for cervical lymph node metastasis (p=0.043). Single photo emission computed tomography (SPECT) detected fewer SLN in patients with invaded lymph nodes than in patients with clear lymph nodes (p=0.018). Our data support the use of SLNB as a minimally invasive method for staging the cervical lymph nodes among patients with cN0 oral and oropharyngeal carcinoma. Our results further confirm that greater depth of invasion is associated with cervical lymph node metastases.

Systematic analysis of genes involved in oral cancer metastasis to lymph nodes

Oral cancer remains a deadly disease worldwide. Lymph node metastasis and invasion is one of the causes of death from oral cancer. Elucidating the mechanism of oral cancer lymph node metastasis and identifying critical regulatory genes are important for the treatment of this disease. This study aimed to identify differentially expressed genes (gene signature) and pathways that contribute to oral cancer metastasis to lymph nodes. The GSE70604-associated study compared gene profiles in lymph nodes with metastasis of oral cancer to those of normal lymph nodes. The GSE2280-associated study compared gene profiles in primary tumor of oral cancer with lymph node metastasis to those in tumors without lymph node metastasis. There are 28 common differentially expressed genes (DEGs) showing consistent changes in both datasets in overlapping analysis. GO biological process and KEGG pathway analysis of these 28 DEGs identified the gene signature CCND1, JUN and SPP1, which are categorized as key regulatory genes involved in the focal adhesion pathway. Silencing expression of CCND1, JUN and SPP1 in the human oral cancer cell line OECM-1 confirmed that those genes play essential roles in oral cancer cell invasion. Analysis of clinical samples of oral cancer found a strong correlation of these genes with short survival, especially JUN expression associated with metastasis. Our study identified a unique gene signature - CCND1, JUN and SPP1 - which may be involved in oral cancer lymph node metastasis.

Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with high risk human papillomavirus related squamous cell cancer

PURPOSE

Diagnostic tonsillectomy is rarely an oncologic operation owing to close or positive margins. The standard of care is for further treatment to the primary site, typically with adjuvant radiotherapy.

METHODS

14 patients with close or positive margins following a diagnostic tonsillectomy underwent transoral robotic surgery (TORS) and lateral oropharyngectomy; five patients with the longest follow-up had their excision specimens examined with a step serial sectioning technique (SSS).

RESULTS

Conventional histopathological examination of the TORS resection specimens did not demonstrate residual carcinoma in 13 patients, confirmed by examination using SSS in 5 patients. There were no post-operative complications or long-term functional deficit. Seven patients received surgery alone with 100% overall and disease specific survival, respectively (median follow-up 27.5 months; range 5.2-50.4).

CONCLUSIONS

This prospective study suggests that TORS lateral oropharyngectomy alone is an oncologically safe treatment when close or positive margins are identified on diagnostic tonsillectomy in HPV-positive SCC.

The Role of Sentinel Lymph Node Biopsy in Head and Neck Cancers and Its Application Areas

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.

Sentinel node biopsy using indocyanine green in oral/oropharyngeal cancer

BACKGROUNDS

Radioactive tracer-based detection has been proposed as a standard procedure in identifying sentinel nodes for cN0 oral/oropharyngeal carcinoma. However, access to radioactive isotopes may be limited in some surgical centers, and there is potential risk of the radioactive tracers to the operators. This study was designed to evaluate the feasibility of near-infrared fluorescence imaging with indocyanine green combined with blue dye mapping in sentinel node biopsy for cN0 oral/oropharyngeal carcinoma.

METHODS

Twenty-six cases of previously untreated oral/oropharyngeal carcinoma staged cT1-2N0M0 were enrolled in this study. One milliliter of indocyanine green (5 mg/ml) and 1.5 ml of methylene blue (1 mg/ml) were injected sequentially around the primary tumor in a four-quadrant pattern before skin incision. After elevation of the platysma flap and posterior retraction of the sternocleidomastoid muscle, fluorescence images were taken with a near-infrared detector, with special attention paid to any blue-dyed lymph nodes. Lymph nodes identified first with fluorescent hot spots with or without blue dye were defined as sentinel nodes, and they were harvested and sent for pathologic study.

RESULTS

Sentinel nodes were successfully harvested in all 26 cases. The number of sentinel nodes (SNs) per case varied from 1 to 9, with an average of 3.4. Routine pathology demonstrated occult metastasis exclusively in SNs in four cases (15.4 %). No tracer-associated side effects occurred in this series.

CONCLUSIONS

Near-infrared imaging using indocyanine green combined with methylene blue mapping is a feasible and reliable new method for SN biopsy in cN0 oral/oropharyngeal carcinoma.

On the horizon: Optical imaging for cutaneous squamous cell carcinoma

BACKGROUND

Surgical resection with negative margins remains the standard of care for high-risk cutaneous squamous cell carcinoma (SCC). However, surgical management is often limited by poor intraoperative tumor visualization and inability to detect occult nodal metastasis. The inability to intraoperatively detect microscopic disease can lead to additional surgery, tumor recurrence, and decreased survival.

METHODS

A comprehensive literature review was conducted to identify studies incorporating optical imaging technology in the management of cutaneous SCC (January 1, 2000-December 1, 2014).

RESULTS

Several innovative optical imaging techniques, Raman spectroscopy, confocal microscopy, and fluorescence imaging, have been developed for intraoperative surgical guidance. Fifty-seven studies review the ability of these techniques to improve cutaneous SCC localization at the gross and microscopic level.

CONCLUSION

Significant advances have been achieved with real-time optical imaging strategies for intraoperative cutaneous SCC margin assessment and tumor detection. Optical imaging holds promise in improving the percentage of negative surgical margins and in the early detection of micrometastatic disease. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2204-E2213, 2016.

An innovative multimodality approach for sentinel node mapping and biopsy in head and neck malignancies

PURPOSE

Recent innovations such as preoperative SPECT/CT, intraoperative imaging using portable devices and a hybrid tracer were evaluated in a multimodality approach for sentinel node (SN) mapping and biopsy in head and neck malignancies.

MATERIAL AND METHODS

The evaluation included 25 consecutive patients with head and neck malignancies (16 melanomas and 9 oral cavity squamous cell carcinomas). Patients were peritumorally injected with the hybrid tracer ICG-(99m)Tc-nanocolloid. SNs were initially identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT/CT) 2 hours after tracer administration. During surgery a portable gamma camera in combination with a near-infrared fluorescence camera was used in addition to a handheld gamma ray detection probe to locate the SNs.

RESULTS

In all patients the use of conventional lymphoscintigraphy, SPECT/CT and the additional help of the portable gamma camera in one case were able to depict a total of 67 SNs (55 of them visualized on planar images, 11 additional on SPECT/CT and 1 additional with the portable gamma camera). A total of 67 of the preoperatively defined SNs together with 22 additional SNs were removed intraoperatively; 12 out of the 22 additional SNs found during operation were located in the vicinity of the injection site in anatomical areas such as the periauricular or submental regions. The other 10 additional SNs were found by radioguided post-resection control of the excision SN site.

CONCLUSION

In the present series 26% additional SNs were found using the multimodal approach, that incorporates SPECT/CT and intraoperative imaging to the conventional procedure. This approach appears to be useful in malignancies located close to the area of lymphatic drainage such as the periauricular area and the oral cavity.

Freehand SPECT-guided sentinel lymph node biopsy in early oral squamous cell carcinoma

BACKGROUND

In oral squamous cell carcinoma (OSCC), cervical lymph node status is the most important prognostic factor. Compared to elective neck dissection, reduced morbidity and better quality of life was demonstrated for sentinel lymph node biopsy, which is controversial because of the reduced detection rate of sentinel lymph nodes in close proximity to the injection site (also known as the shine-through phenomenon).

METHODS

We report the case of a 44-year-old woman with a biopsy-proven early OSCC of the anterior floor of the mouth, who received SLNB guided with freehand single-photon emission CT (fhSPECT), a system for the 3D visualization of radioactivity in the body.

RESULTS

One level III sentinel lymph node and 1 level I sentinel lymph node, in close proximity to the injection site, were detected and dissected. The level I sentinel lymph node contained a metastasis.

CONCLUSION

Using fhSPECT, the issue outlined was overcome, and the precise histopathological lymph node status (pN1; 1 of 49) was determined.

A prospective evaluation of the clinical, histologic, and therapeutic variables associated with incidental perineural invasion in cutaneous squamous cell carcinoma

BACKGROUND

The prognosis and management of incidental perineural invasion (PNI) in patients with cutaneous squamous cell carcinoma (CSCC) has not been well defined.

OBJECTIVE

We sought to investigate the clinical, histologic, and treatment characteristics associated with incidental PNI, histologic PNI extending beyond the tumor bulk, in patients with CSCC.

METHODS

We conducted a multicenter prospective analysis of patients with CSCC undergoing Mohs micrographic surgery.

RESULTS

The incidence of PNI was 4.6% in 753 CSCC cases. PNI was significantly associated with tumors of the head and neck (P = .039), larger tumor diameter (P < .001), presence of clinically palpable lymphadenopathy (P = .012), and recurrent (P < .001) and painful (P < .001) tumors. Further, PNI was significantly associated with poor tumor differentiation (P < .001), greater tumor thickness (P < .001), a greater number of Mohs stages (P < .001), and larger estimated maximum Mohs margin (P < .001) required to clear the tumor.

LIMITATIONS

The low numbers of patients demonstrating incidental PNI limits this study.

CONCLUSIONS

The association of incidental PNI with clinicopathological indicators of poor prognosis suggests that incidental PNI may serve as a marker to improve the precision in the prognostic assessment of patients with CSCC.

Use of a novel receptor-targeted (CD206) radiotracer, 99mTc-tilmanocept, and SPECT/CT for sentinel lymph node detection in oral cavity squamous cell carcinoma: initial institutional report in an ongoing phase 3 study

IMPORTANCE

Sentinel lymph node biopsy has been proposed as an alternative to up-front elective neck dissection (END) for determination of pathologic nodal status in patients undergoing surgical treatment for oral cavity squamous cell carcinoma (OSCC) with clinically negative neck (cN0). Sentinel lymph node biopsy using current standard tracer agents and imaging adjuncts such as radiolabeled sulfur-colloid and planar lymphoscintigraphy (LS), however, is associated with several drawbacks.

OBJECTIVE

To assess the preliminary utility of technetium Tc 99m (99mTc)-tilmanocept, a novel molecular imaging agent for sentinel lymph node (SLN) mapping, in OSCC.

DESIGN, SETTING, AND PARTICIPANTS

Prospective, nonrandomized, single-arm, part of an ongoing phase 3 clinical trial. Patients had previously untreated, clinically and radiographically node-negative OSCC (T1-4aN0M0) at an academic tertiary referral center.

INTERVENTIONS

Patients received a single dose of 50 µg 99mTc-tilmanocept injected peritumorally followed by dynamic planar LS and fused single-photon emission computed tomography/computed tomography (SPECT/CT) prior to surgery. Surgical intervention consisted of excision of the primary tumor and radioguided SLN dissection followed by planned END. The excised lymph nodes (SLNs and non-SLNs) underwent histopathologic evaluation for presence of metastatic disease.

MAIN OUTCOMES AND MEASURES

False-negative rate and negative predictive value of SLNB using 99mTc-tilmanocept and comparison of planar LS with SPECT/CT in SLN localization.

RESULTS

Twelve of 20 patients (60%) had metastatic neck disease on pathologic examination. All 12 had at least 1 SLN positive for metastases. No patients had a positive END node who did not have at least 1 positive SLN. These data yield a false-negative rate of 0% and negative predictive value of 100% using 99mTc-tilmanocept in this setting. Dynamic planar LS and SPECT/CT revealed a mean (range) number of hot spots per patient of 2.9 (1-7) and 3.7 (1-12), respectively. Compared with planar LS, SPECT/CT identified additional putative SLNs in 11 of 20 cases (55%).

CONCLUSIONS AND RELEVANCE

The high negative predictive value and low false-negative rate in identification of occult metastases shows 99mTc-tilmanocept to be a promising agent in SLN identification in patients with OSCC. Use of SPECT/CT improves preoperative SLN localization including delineation of SLN locations near the primary tumor when compared with planar LS imaging.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00911326.

Concomitant radio- and fluorescence-guided sentinel lymph node biopsy in squamous cell carcinoma of the oral cavity using ICG-(99m)Tc-nanocolloid

PURPOSE

For oral cavity malignancies, sentinel lymph node (SLN) mapping is performed by injecting a radiocolloid around the primary tumour followed by lymphoscintigraphy. Surgically, SLNs can then be localized using a handheld gamma ray detection probe. The aim of this study was to evaluate the added value of intraoperative fluorescence imaging to the conventional radioguided procedure. For this we used indocyanine green (ICG)-(99m)Tc-nanocolloid, a hybrid tracer that is both radioactive and fluorescent.

METHODS

Fourteen patients with oral cavity squamous cell carcinoma were peritumourally injected with ICG-(99m)Tc-nanocolloid. SLNs were preoperatively identified with lymphoscintigraphy followed by single photon emission computed tomography (SPECT)/CT for anatomical localization. During surgery, SLNs were detected with a handheld gamma ray detection probe and a handheld near-infrared fluorescence camera. Pre-incision and post-excision imaging with a portable gamma camera was performed to confirm complete removal of all SLNs.

RESULTS

SLNs were preoperatively identified using the radioactive signature of ICG-(99m)Tc-nanocolloid. Intraoperatively, 43 SLNs could be localized and excised with combined radio- and fluorescence guidance. Additionally, in four patients, an SLN located close to the primary injection site (in three patients this SLN was located in level I) could only be intraoperatively localized using fluorescence imaging. Pathological analysis of the SLNs revealed a metastasis in one patient.

CONCLUSION

Combined preoperative SLN identification and intraoperative radio- and fluorescence guidance during SLN biopsies for oral cavity cancer proved feasible using ICG-(99m)Tc-nanocolloid. The addition of fluorescence imaging was shown to be of particular value when SLNs were located in close proximity to the primary tumour.

Sentinel lymph node biopsy for T1/T2 oral cavity squamous cell carcinoma--a prospective case series

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an established technique in breast and melanoma surgery and is gaining acceptance in the management of oral cavity squamous cell carcinoma. We report a single institution's experience of SLNB between 2006 and 2010.

METHODS

Prospective consecutive cohort study of 59 patients recruited between 2006 and 2010. All patients underwent SLNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with step-serial sectioning and immunohistochemistry. Endpoints included: overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS).

RESULTS

A total of 59 patients (36 male and 23 female) were operated on. Of these, 42 patients (71%) were pT1 and 17 patients (29%) were pT2. In two patients the sentinel node was not identified and proceeded to elective neck dissection. A total of 150 nodes were harvested from the remaining 57 patients of which 21 nodes were positive in 17 patients; three patients had positive contralateral nodes. The 2-year OS, DSS, LRFS, and RRFS for the SLNB negative patients were 97.5, 100, 95.8, and 95.8% and for the SLNB positive patients 68.2, 81.8, 83.9, and 100% respectively. Only OS and DSS approached statistical significance with P values of 0.07 and 0.06.

CONCLUSIONS

SLNB is a safe and accurate diagnostic technique for staging the neck with a negative predictive value in our series of 97.5%. Furthermore, in our series three patients (5%) had positive contralateral neck drainage that would have been missed by conventional ipsilateral neck dissection.

Comparison and evaluation of the current staging of cutaneous carcinomas

BACKGROUND

Recently the "Union for International Cancer Control" (UICC) and the "American Joint Committee on Cancer" (AJCC) changed their TNM (tumor, node, metastasis) classification of cutaneous carcinomas.

METHODS

We compared these classifications, tested their practicability with 615 prospectively collected, unselected, primary cutaneous squamous cell carcinomas, and introduced additional classification criteria.

RESULTS

Neither classification contains information about prognosis. Non-metastasizing types of cutaneous carcinoma should be excluded. The vermilion border of the lower lip and the eyelids should be included. Both systems have been improved, but in part they are irreproducible. The AJCC has introduced six "high-risk features" to differentiate between T1 and T2. However, this does not seem reasonable. Only rare cases are classified as T4. Both systems have different N classifications. A clinical cT classification based on tumor size 2 cm seems reasonable but not sufficient. It should be complemented by a postoperative p (pathologic) T classification based on tumor thickness: "no risk"≤ 2 mm thickness (0% risk of metastasis), "low risk" > 2 mm to 6 mm thickness (4% risk of metastasis), and "high risk" > 6 mm thickness (16% risk of metastasis). Immune suppression, poor differentiation/desmoplasia, and the ear as tumor site are additional risk factors for metastasis, currently not evaluable.

CONCLUSIONS

The classifications are unsuitable for a realistic estimate of the risk of metastasis which is possible using a combination of tumor size and thickness. The N staging system should consider histopathologic findings.

Quantitative expression study of four cytokeratins and p63 in squamous cell carcinoma of the tongue: suitability for sentinel node navigation surgery using one-step nucleic acid amplification

Aims

Sentinel node navigation surgery (SNNS) is currently considered to provide better staging of regional metastasis. For rapid and accurate sentinel lymph node analysis, one-step nucleic acid amplification using cytokeratin 19 (CK19) has been applied, particularly in breast cancer. On the other hand, additional quantitative reverse transcription PCR targets containing cytokeratins have been reported recently in head and neck cancer. In this report, CK19 and p63 were immunohistochemically examined in primary tumours for use as molecular markers and were compared with cytokeratin 903 (CK903), cytokeratin 8/18 (CK8/18) and cytokeratin (AE1/AE3), which are used in diagnostic immunohistochemistry for head and neck squamous cell carcinoma.

Methods

The study reviewed 17 patients with T1/T2, N0 (UICC) oral squamous cell carcinoma of the tongue who were treated surgically at Kyorin University Hospital between 2002 and 2009. The intensity and proportion of tumour cells stained for CK19, CK903, p63, CK8/18 and AE1/AE3 were evaluated.

Results

CK19 and CK8/18 staining in cytoplasm was patchy among carcinoma cells, indicating weak expression. Staining proportion for p63, CK903 and AE1/AE3 was greater than for CK19 and CK8/18, although staining intensity for CK903 was weaker than for p63 and AE1/AE3. The difference in total score between CK19 and CK8/18 staining and p63, CK903 and AE1/AE3 staining was statistically significant (p<0.001). p63 and AE1/AE3 may be better markers than CK903, CK19 and CK8/18.

Conclusions

This suggests that p63 is of clinical utility in SNNS and that CK19 is unsuitable for early tongue carcinoma. Further studies are needed before clinical application of these markers.

Sentinel node navigation surgery versus observation as a management strategy for early tongue carcinoma

BACKGROUND

The status of lymph nodes in the neck is the most important prognostic factor for the outcomes of patients with oral tongue cancer. However, surgical prophylaxis of the neck is controversial.

METHODS

We reviewed 22 patients with clinically T1/T2, N0 Union Internationale Contre le Cancer oral squamous cell carcinoma of the tongue. Patients were assigned to groups according to the management strategy selected for the neck. One group underwent a "watchful waiting" policy and the other underwent sentinel node navigation surgery (SNNS).

RESULTS

Three of 11 patients (27%) in the watchful waiting group developed regional recurrence and underwent neck dissection. Only 1 of 11 patients (9.1%) in the SNNS group developed regional recurrence. Although the groups did not significantly differ, the SNNS group tended to have less regional recurrence.

CONCLUSION

SNNS should be the third strategy formanaging early oral tongue carcinoma.

Evaluation of Immunohistochemical Fine Sectioning for Sentinel Lymph Node Biopsy in Oral Squamous Cell Carcinoma

Objective. To determine the level of sentinel lymph node sectioning necessary to accurately detect nodal micrometastasis.

Study Design. Cross-sectional.

Setting. Tertiary care university medical center.

Subjects and Methods. Fine sections of oral squamous cell carcinoma sentinel lymph nodes previously sectioned at 2-mm intervals in a prospective clinical trial were reexamined. The results yielded from prior hematoxylin and eosin and immunohistochemical staining were compared with results following exhaustive serial sectioning at 150-µm intervals using identical staining methods. These experimental findings were compared with pathologic results of immediate completion selective neck dissection, previously recorded prospectively.

Results. Reexamination of 35 sentinel nodes at 150-µm intervals has not revealed any missed micrometastatic disease at 2-mm intervals used initially. Both comparisons of 150-µm sectioning analysis to the original 2-mm section samples and to the neck dissection pathology reports demonstrate a 100% negative predictive value.

Conclusion. These data suggest that sentinel lymph node sectioning at 2-mm intervals for oral carcinoma using hematoxylin and eosin staining and then immunohistochemical analysis maximizes efficiency, accuracy, and expenditure for the detection of micrometastasis.

Gene Expression Signatures of Lymph Node Metastasis in Oral Cancer: Molecular Characteristics and Clinical Significances

Even though lymph node metastasis accounts for the vast majority of cancer death in patients with oral cancer (OC), the molecular mechanisms of lymph node metastasis remain elusive. Genome-wide microarray analyses and functional studies in vitro and in vivo, along with detailed clinical observations, have identified a number of molecules that may contribute to lymph node metastasis. These include lymphangionenic cytokines, cell adhesion molecules, basement membrane-interacting molecules, matrix enzymes and relevant downstream signaling pathways. However, defined gene signatures from different studies are highly variable, which hinders their translation to clinically relevant applications. To date, none of the identified signatures or molecular biomarkers has been successfully implemented as a diagnostic or prognostic tool applicable to routine clinical practice. In this review, we will first introduce the significance of lymph node metastasis in OC, and clinical/experimental evidences that support the underlying molecular mechanisms. We will then provide a comprehensive review and integrative analysis of the existing gene expression studies that aim to identify the metastasis-related signatures in OC. Finally, the remaining challenges will be discussed and our insights on future directions will be provided.

Head and neck oncology--2010, Part I

This article reviewed the current state of the art in head and neck oncology. These include very important and stimulating new areas of interest including the marked acceptance of chemoradiation in favor of surgery in patients with cancer of the head and neck. The concept of HPV as a cause of cancer of the oropharynx is relatively new and very important in the epidemiology of these tumors. New modalities such as PET CT scanning and robotic surgery are discussed and appear to be very important in management of cancer of the head and neck. Endoscopic endonasal skull base surgery is another new high technology contribution to the field of head and neck surgery as is the use of endoscopic assisted thyroid surgery. These and other new concepts are discussed in this manuscript.

Oral cavity squamous cell carcinoma and the clinically n0 neck: the past, present, and future of sentinel lymph node biopsy

Oral cavity squamous cell carcinoma (OCSCC) has a yearly incidence of 274,000 patients. Twenty percent to 30% of patients will harbor occult regional metastases, an important feature that correlates with worse outcomes. Supraomohyoid neck dissection (SND) is the gold standard treatment, but because of recent successes of sentinel lymph node (SLN) biopsy in the management of breast cancer and melanoma, many have begun evaluating its use in head and neck mucosal cancers. SLN biopsy offers patients decreased morbidity compared with SND, and has shown reproducibly low false-negative rates, high-negative predictive values, and high sensitivities. Limitations with floor-of-mouth primaries and delayed secondary SNDs have been described, but a new agent designed to address these shortcomings, Lymphoseek (Neoprobe Corp.; Dublin, OH), is currently under investigation. This article reviews the current literature on SLN biopsy and introduces a phase 3 study evaluating the efficacy of Lymphoseek in SLN biopsy of OCSCCs.

Recent advances in surgery for head and neck cancer

PURPOSE OF REVIEW

This paper reviews the advances in surgery in head and neck cancer patients.

RECENT FINDINGS

Sentinel node biopsy is a promising diagnostic technique to detect occult lymph node metastases, especially in oral carcinomas. Fludeoxyglucose-PET seems to be useful in detecting recurrent (laryngeal) carcinoma after radiotherapy. The role of fludeoxyglucose-PET to detect residual disease in the neck after radiotherapy with or without chemotherapy is not yet clear. The armamentarium of reconstructive surgery is still expanding. Endonasal endoscopic, robotic surgery and image-guided surgery are used as minimal invasive surgery in selected patients. Other advances include photodynamic therapy, ultrasonic surgery and mechanical sutures.

SUMMARY

New diagnostic techniques are used to avoid futile extensive surgery. Technical improvements have been made to treat head and neck cancer patients with minimal invasive surgery. Large prospective trials are needed to determine the indications for each technique.

Sentinel node detection in head and neck malignancies: innovations in radioguided surgery

Sentinel node mapping is becoming a routine procedure for staging of various malignancies, because it can determine lymph node status more precisely. Due to anatomical problems, localizing sentinel nodes in the head and neck region on the basis of conventional images can be difficult. New diagnostic tools can provide better visualization of sentinel nodes. In an attempt to keep up with possible scientific progress, this article reviews new and innovative tools for sentinel node localization in this specific area. The overview comprises a short introduction of the sentinel node procedure as well as indications in the head and neck region. Then the results of SPECT/CT for sentinel node detection are described. Finally, a portable gamma camera to enable intraoperative real-time imaging with improved sentinel node detection is described.

Sentinel node biopsy for skin melanoma

BACKGROUND/AIM

Skin melanoma is one of the most malignant diseases with increasing incidence rate. Sentinel node biopsy (SNB) is very important for early detection of metastatic spread. The aim of the study was to analyze the first 40 patients with skin melanoma of 1 to 4 mm Breslow thickness when SNB was indicated.

METHODS

The patient characteristics, localization of the primary melanoma as well as histology grade were analyzed. SNB with intraoperative radiocolloid and methylene blue dye detection was performed.

RESULTS

Complication rate after SNB was analyzed and seroma was found in 5% of the patients. The therapeutic node dissection was performed in 10 patients with positive sentinel biopsy. The follow-up lasted two years. In five patients the false negative SNB was defined after the mean time of 11 months and the therapeutic dissection was performed.

CONCLUSION

SNB in melanoma patients is a useful diagnostic procedure. It is advised for melanoma of 1 to 4 mm Breslow thickness.

Head and neck sentinel lymph node biopsy: current state of the art

Sentinel node biopsy is an alternative to elective neck dissection for the management of T1/T2 oral and oro-pharyngeal squamous cell carcinomas and is also finding application to head and neck cancer at other sites. The main clinical aim of sentinel node biopsy is to achieve better staging and there is now evidence that the procedure reduces morbidity. Reported detection rates for sentinel neck nodes are greater than 95% and there is also a negative predictive value of 95% for negative sentinel nodes. Current histopathological protocols have been developed for use in the research setting and are designed to identify all micrometastatic disease. However the use of step serial sectioning at 150 micron intervals with pan-cytokeratin immunohistochemistry is currently advised and appears to upstage nodes by approximately 20% over the initial single routine stained section. Adoption of the UICC/TNM definitions is recommended for future sentinel node studies, but further refinements and descriptions are required. The SENT trial has recruited over 300 cases from 10 European centres and a quality control study of the pathological material is in progress. At the first consensus meeting of the SENT pathology group there were excellent levels of agreement on the diagnosis of positive and negative nodes, and a number of potential pitfalls such as non-malignant inclusions and staining artefacts were identified.

Functional imaging of head and neck cancers

PURPOSE OF REVIEW

Functional imaging including single photon emission computed tomography, PET and MRI techniques in head and neck squamous cell cancer allows disease characterization beyond structure and morphology.

RECENT FINDINGS

In patients without clinical signs of lymph node involvement, sensitivity of fluoro-2-deoxy-D-glucose PET is only 50%. This has led to the use of sentinel lymph node scintigraphy that seems to be a valid alternative to elective stage dissection. Additionally, the use of single-photon emission computed tomography-computed tomography imaging enables a more accurate localization of the sentinel lymph node scintigraphy. The fluoro-2-deoxy-D-glucose uptake intensity of the head and neck squamous cell carcinoma sites is related to locoregional control and overall survival. In case of suspicion for residual or recurrent head and neck squamous cell carcinoma after surgery or (chemo)radiotherapy, fluoro-2-deoxy-D-glucose-PET has a high sensitivity and seems to be cost-effective in selecting patients for direct laryngoscopy. Diffusion-weighted MRI in combination with size and morphological criteria is a strong predictor of presence of malignant lymph nodes. Initial reports indicate the use of diffusion-weighted imaging for response assessment as early as 1 week after beginning of radiochemotherapy. Perfusion MRI is studied for the measurement of drug effects on tumour (micro)vascularity and capillary permeability.

SUMMARY

Functional imaging improves the initial staging and the detection of residual or recurrent disease following therapy.