Pattern of drainage in sentinel lymph nodes after intra-arterial chemotherapy for oral and oropharyngeal cancer

Surgical treatment and prognosis of posteriorly invading oral cancer: Potential clinical significance of pterygomandibular raphe

Background/purpose

The prognosis of oral squamous cell carcinoma (OSCC) with posterior invasion is poor. We examined whether the pterygomandibular raphe (PMR) is useful for the diagnosis of invasion and determination of surgical methods.

Materials and methods

Of 390 patients with OSCC treated surgically at our hospital between June 2009 and June 2020, 80 patients with posterior invasion were included in the study. Preoperative magnetic resonance imaging was used to classify the lesions into three types: non-contact with PMR (non-contact type), contact with PMR (contact type), and invasion beyond PMR (invasion type). We compared the local control, recurrence, and survival rates of each of the three types.

Results

The invasion type showed a significantly higher recurrence rate than the non-contact type (P < 0.001) and contact type (P = 0.018). Overall survival rate comparisons showed that the invasion type had significantly worse prognosis than the non-contact (P = 0.004) and contact types (P = 0.041).

Conclusion

OSCCs with posterior invasion beyond the PMR showed a poor treatment outcome and, therefore, should be treated with caution. The initial surgery is especially important and must ensure local control. This study indicates that the PMR is an important criterion for surgical method determination and that invasion beyond the PMR is a predictor of local recurrence and poor prognosis.

Platinum concentration in sentinel lymph nodes after preoperative intra-arterial cisplatin chemotherapy targeting primary tongue cancer

CONCLUSION

We conclude that intra-arterially injected cisplatin passed via lymph flow into sentinel nodes (SNs) as the platinum concentration in the SNs was higher than that in the non-sentinel nodes (NSNs). It is possible that preoperative intra-arterial chemotherapy targeting primary cancer also has a therapeutic effect on subclinical metastatic SNs.

OBJECTIVES

Intra-arterial chemoradiotherapy has been reported to be effective against not only primary tumors but also nodal metastases. We considered the hypothesis that intra-arterially injected cisplatin passed via lymph flow into regional nodes. This study aimed to investigate intra-arterially injected cisplatin distribution to regional nodes by comparing platinum concentrations in SNs and NSNs.

METHODS

Five patients with T1-2 N0 tongue cancer were treated with preoperative intra-arterial chemotherapy (cisplatin, 100 mg/m(2)) targeting primary cancer. Partial glossectomy together with SN biopsy and elective neck dissection were performed 2 weeks after intra-arterial chemotherapy. Platinum concentrations in the lymph nodes were measured using a Zeeman atomic absorption spectrometer.

RESULTS

Thirteen SNs were harvested together with eight NSNs from the areas adjacent to the SNs. Platinum concentrations were then measured, revealing a significant difference in platinum concentration between the SNs and the NSNs (mean ± SD, 0.682 ± 0.246 µg/g vs 0.506 ± 0.274 µg/g; p = 0.049).

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

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

The diagnostic role of radioactivity in sentinel nodes in oral and oropharyngeal cancer

Sentinel lymph node biopsy (SNB), using radioactive tracers, is a novel, interesting tool in the staging of patients with oral and oropharyngeal squamous-cell carcinoma (OOSCC), which could lead to a reduced rate of elective neck dissections. The aim of the study was to evaluate the ranking of measured radioactivity in the sentinel lymph nodes (SLNs) and to correlate these findings with histopathological results to assess the number of SLN being sufficient for exact staging of the neck. In 77 consecutive patients with T1-4 OOSCC clinically and positron emission tomography-staged N0, between 15 and 55 MBq of Tc- 99m-labeled albumin-microcolloids were injected peritumorally and 213 SLNs were excised by small skin incisions using a gamma probe 2-3 hours later. The counts per second (cps) were measured ex vivo and excised SLNs were ranked according to their cps defining the LN with the highest activity as primary SLN, followed by a 2nd, 3rd, and so forth, SLN. Elective neck dissections were not performed. Median activity was 213 cps. All levels harbored SLNs with a maximum (43%) in level II and a minimum in level V (1%). SLNs in level II had significantly higher tracer accumulation (median, 289 cps) than those in levels I (144 cps) and IV (149 cps), but distant levels did not have significantly lower counts, compared to proximal. Eight (8) pathologically positive SLNs in 7 patients (7/77 = 9%; median activity, 157 cps) were detected. The median counts of the positive SLNs were not significantly different from those of the 205 negative SLNs (235 cps). The positive SLN was the one with the highest tracer accumulation in 4 cases, with the second highest in 1 case, and with the third highest tracer accumulation in 2 cases. Three (3) positive SLN were in level IB, 4 in level IIA, and 1 in level III. One (1) patient had 2 positive SLNs: a SLN with the third highest activity in level IIB and a SLN with the fifth highest activity in level III. In OOSCC, excision of only 1 SLN is not feasible. The positive SLNs were not necessarily the hottest nodes. Utilizing radiotracer lymphatic mapping, the 3 SLNs with the highest activity should be excised for exact staging of the neck in patients with T1-3 tumors. Excision of all radioactive nodes is recommended until further studies will prove this result. Large T4a tumors should not be staged using SNB.

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

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

[Organ-preserving treatment in inoperable patients with primary oral and oropharyngeal carcinoma: chances and limitations]

INTRODUCTION

The aim of this study was to demonstrate the chances of nonoperative therapy in those patients from an unselected population suffering from primary previously untreated squamous cell carcinomas of the oral cavity and the oropharynx who did not seem to be operable.

PATIENTS AND METHODS

Following interdisciplinary counseling and extensive individual discussion, 72 (21%) of 340 consecutive patients (1997-2004) did not or did not reasonably seem to be operable; three other patients with stage II disease refused surgery. Of the inoperable patients, 95%suffered from far-advanced stage IV disease, 8% had distant metastases, 14% had synchronous malignancies, 9% were aged over 85 years combined with advanced malignant disease, and nearly 50% were limited in their activity or were even bedridden. Depending on fitness and tumor extent, three therapy regimens were used: intra-arterial (i.a.) high-dose chemotherapy with systemic antagonization for palliation, induction with this i.a. high-dose chemotherapy followed by additional radiotherapy, and induction with the i.a. high-dose chemotherapy followed by additional radiochemotherapy.

RESULTS

Thirty-two patients were treated with i.a. chemotherapy alone for palliation with few acute side effects. The response rate was 34%, and a further growth of the tumour could be inhibited in 49%. The 1- and 2-year survival rates were 21 and 14%, respectively. The three patients who refused surgery experienced complete clinical remission and survived 8, 6, and 2 years, respectively, to date. Twenty-three patients were fit enough to receive additional radiotherapy, and 17 an additional radiochemotherapy. Of the patients, 22% had to cut short additional radiotherapy and 47% had to discontinue concomitant chemotherapy. The 1- and 2-year survival rates were 41 and 25%, respectively; 14 of these irradiated patients experienced long-lasting complete clinical remission >2 years.

CONCLUSION

About 20% of the patients classified as inoperable could achieve long-lasting remission. Viewed with caution, sex (male), performance state (ECOG) <3, and positive response to i.a. chemotherapy could be regarded as predictors for therapeutic success. The combination of i.a. chemotherapy and radiochemotherapy seemed to be most successful. Conversely, the therapies offered could not achieve a substantial improvement of survival in 80% of patients classified as inoperable; the most successful therapy combination could be offered to merely 23% of patients as classified inoperable due to reduced general condition. The i.a. high-dose chemotherapy has to be regarded as a well tolerated and effective palliation. This descriptive analysis must be followed by specific studies to establish clinical treatment recommendations.