Reappraisal of metastatic lymph node topography in head and neck squamous cell carcinomas

Nodal yield and topography of nodal metastases from oral cavity squamous cell carcinoma - An audit of 1004 cases undergoing primary surgical resection

OBJECTIVES

Nodal metastasis is an important prognostic factor in oral squamous cell carcinoma (OSCC). Detailed topographic study of metastasis can guide surgical and adjuvant radiation treatment protocols.

METHODS

Retrospective analysis of distribution of nodal spread was done by auditing pathology records of 1004 patients who underwent primary surgical management at our center.

RESULTS

The median nodal yield was 41 (range of 9-166) nodes, per patient. Metastasis was present in 42.9% patients, of which 52.3% demonstrated extranodal extension. Reclassification by AJCC8 criteria resulted in up-staging in 35.6% patients (pN1, pN2a, pN2b, pN2c, pN3a and pN3b in 13.1%, 3.7%, 6.9%, 0.9%, 0%, 18.1% respectively). Ipsilateral levels Ib and IIa were involved in a quarter of patients each, while IIb, IV and V were involved in < 4%, 3% and 1% of patients, respectively. Contralateral nodal metastasis was present in 5.4%. Skip metastases to level IV were 2.2% and 1.2% for tongue and gingivobuccal primaries. Tongue primaries had a lower likelihood of involving level Ib, but higher of level IIa and III, compared to gingivobuccal primaries, and a lower likelihood of extranodal extension. Primary site did not influence nodal metastasis to levels IIb, IV or V, but other factors like lymphovascular invasion, pT stage and margin status had an influence.

CONCLUSION

This large series with high nodal yield, shows low level of metastasis to level IIb, IV and V, which can help modify future guidelines for extent of surgery and avoid targeted adjuvant radiation to specific levels.

[Oral cavity and pharyngo-laryngeal squamous cell carcinoma. What lymph node volumes to select for external beam radiation therapy?]

The selection of target volumes for head and neck cancer radiation therapy, particularly prophylactic volumes that reflect infra-clinic spreads, is a complex process. It is based on the knowledge of the natural history of these tumors and must take into consideration the special challenges due to the diversity and complexity of head and neck anatomy. The dosimetric and ballistic precision provided by modern radiation techniques has required strong strategic deliberation to ensure the relevance and reproducibility of target volumes. Specifically, regarding cervical lymph node volumes, two issues emerged. What lymph node area to select depending on the location and the staging of the primary tumor? How to convey that choice in the process of treatment planning and delivery? This debate has been progressively enriched over time resulting in the publication of several international guidelines to standardize the terminology of head and neck lymph node areas and to lay solid science-based foundations to drive practices. This abundance of information makes these guidelines complex, but their accurate understanding is required for adequate usage. We provide an overview of the main published recommendations for the selection of lymph node target volumes when treating oral cavity and pharyngo-laryngeal squamous cell carcinoma with radiation therapy.

Cervical lymph node metastases in salivary gland adenoid cystic carcinoma: a systematic review and meta-analysis

Background

The purpose of this research was to determine whether neck dissection is necessary for the adenoid cystic carcinoma (ACC) of head and neck.

Materials and methods

This article screened the abstract and full-text papers that investigated salivary gland primary ACC of head and neck. Two independent reviewers searched for articles published before October 2017 in three databases (Web of Science, PubMed, and Ovid), having no limits in date and language. Statistical data were analyzed statistically by Review Manager 5.3.

Results

In total, 18 studies involving 2993 patients were included in the analysis. Of the 2993 patients, 473 patients had cervical lymph node metastasis, with a merge frequency of 16% (95% CI: 13-19). Among included articles, only 4 involved cervical lymph node occult metastases, with a merge frequency of 14% (95% CI: 9-20). There were 5 articles containing minor salivary glands (MiSGs) involving 370 patients of which 92 patients had cervical lymph node metastases and the merge frequency was 25% (95% CI: 11-38). Moreover, there were 4 studies on major salivary glands involving 904 patients of which 158 patients had cervical lymph node metastases and the merge frequency was 17% (95% CI: 15-20).

Conclusion

Elective neck dissection is unnecessary for all patients with salivary gland ACC of head and neck. Moreover, compared with major salivary glands, MiSGs have a higher cervical lymph node metastases rate in ACC. The overall cervical lymph node metastases rate of MiSGs is 25%, which is enough to attract our attention. Therefore, we suggest that neck dissection might be applied to ACC of MiSGs.

Cervical level IIb metastases in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis

Purpose

The aim of this study was to clarify whether level IIb dissection should be performed or avoided in the treatment of oral squamous cell carcinoma by meta-analysis.

Materials and methods

Articles that were published before June 2017 were searched electronically in four databases (Web of Science, PubMed, Ovid and China National Knowledge Infrastructure) without any date or language restrictions by two independent reviewers. Abstracts and full-text papers which investigated the cervical metastases to level IIb from primary head and neck cancers and were deemed potentially relevant were screened. Data were analyzed using RevMan 5.3.

Results

Four hundred and fifty-five abstracts and 129 full-text papers were screened, and 22 studies were included in the analysis. Among the 2001 patients included, 112 patients had level IIb metastases, the pooled frequency of which was 6% (95% confidence interval [CI]: 4.0–7.0). Among the 400 patients with tongue squamous cell carcinoma from 12 studies, 37 patients had level IIb metastases, the pooled incidence of which was 7% (95% CI: 5.0–10.0). Metastases to level IIb always went together with level IIa, and only three patients were found to have isolated level IIb metastases without involving the other levels.

Conclusion

Due to the low frequency of level IIb nodal metastases in oral squamous cell carcinoma patients and rare occurrence of isolated level IIb, level IIb dissection could be avoided when the primary lesions were in early stages (T1 and T2), with the exception of tongue cancer. It is recommended to dissect level IIb tongue cancers without considering the stages of primary lesions and the lymph nodes status. It is also suggested that level IIb dissection should be performed in patients preoperatively or intraoperatively found with multilevel neck metastasis, especially level IIa metastasis.

Is it worthy? Removal of level IIB nodes during selective neck dissection (I-III) for oral carcinomas

Aims:

The aim was to correlate the incidence of metastasis to Level IIB of neck lymph nodes (LNs) for oral cavity carcinomas with the site, size, and histological grade of tumor.

Settings and Design:

Total 30 patients of either sex, with biopsy-proven oral squamous cell carcinoma of any site, size or histologic grade, but N0/N1 were taken for selective neck dissection (SND).

Materials and Methods:

Thirty patients who underwent SND for oral carcinoma were analyzed for the relation of the site, size, and histological grade of malignancy with metastatic involvement to Level IIB nodes. Level IIB nodes were dissected separately and sent for histopathological examination.

Statistical Analysis Used:

The data were entered in custom written software in Excel (MS office 2007, Windows XP) and the data were analyzed using statistical software STATA version 10.0. The statistical test used for the analysis of the result was Chi-square test. The critical level of statistical significance chosen was P < 0.05.

Results:

Only 2 of 30 patients (6.6%) had the involvement of Level IIB neck nodes. There was no relation between the site, size, and histologic grade of primary tumor with the metastasis to Level IIB. The Level IIA nodes were positive in both the positive cases of Level IIB.

Conclusions:

For tumors in oral cavity (N0/N1), while performing elective or therapeutic SND the dissection of Level IIB nodes could be omitted as it will provide significant decrease in operative time and also less of spinal accessory nerve trauma-related complications.

Elective neck dissection versus "wait and watch" policy in tongue carcinoma

Aim:

To evaluate the efficacy of elective neck dissection versus the “wait and watch” policy in the treatment of early squamous cell carcinoma of tongue.

Materials and Methods:

This is a retrospective study of 21 patients with surgical treatment between April 2009 and July 2011. The patients were divided into two groups, with Group 1 consisting of patients who underwent wide excision glossectomy with elective neck dissection and Group 2 consisting of patients who underwent glossectomy without the neck being surgically addressed. The selection of patients was done by the random double-blinded method and the review was done by a single reviewer. All patients were examined for an average period of 1 year postoperatively.

Results:

Twenty-one cases were treated, among which there were 17 T1 and 4 T2 carcinomas. All the patients had primary carcinoma involving only the tongue with no clinical neck palpable neck nodes. Eleven patients underwent wide excision of primary tumor with elective neck dissection (Group 1) and 10 patients underwent only resection of primary tumor without the neck being surgically addressed (Group 2). In Group 1, there were no recurrences, and in Group 2, there were two patients who developed subsequent cervical node metastasis with one patient undergoing further surgery to address the positive neck and the other patient was lost to follow-up.

Conclusions:

Regional recurrence was the most common cause of failure after surgical treatment of oral tongue carcinoma. Elective neck dissection significantly reduced mortality due to regional recurrence and also increased the overall survival. Our study suggests that elective neck dissection is a treatment strategy of choice for stages I and II carcinoma of the oral tongue. A prospective, randomized study is worthwhile to further evaluate the benefit of elective neck dissection in the treatment of early carcinoma of the tongue with a larger pool of patients and a lengthier follow-up period.

Metastases to level IIb in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis

BACKGROUND

In this study, a meta-analysis of level IIb metastases in squamous cell carcinoma (SCC) of the oral cavity was conducted.

METHODS

Two independent reviewers screened abstracts and full text papers deemed potentially relevant. Data were pooled using a random intercept model.

RESULTS

In this analysis, 729 abstracts and 177 full text papers were screened (Kappa statistic 0.8 and 1.0, respectively). A total of 332 patients in 9 papers were included in the analysis. Twenty patients had level IIb metastases (mean, 6%; range, 0% to 10.4%). The pooled percentage of level IIb metastases was 6.0% (95% CI: 3.5-8.6). Only 3 patients with level IIb metastases had isolated nodal disease. Eighty-five percent of those with level IIb metastases had additional nodal disease (95% CI: 64.0-94.8), with IIa being a common denominator among all.

CONCLUSION

Level IIb nodal metastases are relatively uncommon in previously untreated SCC of the oral cavity (6%). Furthermore, isolated level IIb nodal disease is uncommon. However, given the quality of evidence to date, it is recommended that dissection of level IIb remain the standard of care in oral cavity squamous cell cancer.

When to address level I lymph nodes in neck dissections?

Objective: To investigate the involvement of level I neck lymph node groups in head and neck carcinoma and compare the effect of primary tumor sites, such as oral cavity (OC), oropharynx (OP), hypopharynx (HP), and larynx (Lx), on level I lymph node metastasis.

Study Design: Case series with chart review.

Setting: Comprehensive Cancer Center.

Subjects and Methods: A total of 243 patients with OC and laryngopharyngeal carcinoma who underwent neck dissections in the last three years were included in the study. The primary tumor site was OC, followed by OP, Lx, HP, and carcinoma of unknown primary (CUP).

Results: Level I was involved in 29 of 243 (11.9%) patients. The other levels were also positive in all but five (17.2%) level I–involved patients. The primary tumor site with level I lymph node metastasis was OC (19.1%), followed by CUP (11.1%), OP (9.8%), Lx (4.4%), and HP (0%). The Lx primary site involved level I only if there were multiple other adverse prognostic features, such as N3 neck, extracapsular spread, pathologic involvement of all resected lymph nodes, involvement of all levels I-V, and invasion of the submandibular gland.

Conclusion: Although the submandibular content is resected as part of radical and modified radical neck dissections, level I–sparing selective neck dissections could be a safe and effective surgical neck management strategy in appropriately selected patients with OP, Lx, and HP carcinoma.

Cytology of head and neck squamous cell carcinoma variants

The most common diagnosis rendered with head and neck fine needle aspiration (FNA) biopsy is metastatic squamous cell carcinoma (SCC). While most cases of metastatic SCC pose little diagnostic difficulty, the diagnosis of metastatic histologic variants of SCC, often coupled with less common etiologies, can be more problematic. This manuscript reviews the clinicopathologic features of the histologic variants of upper aerodigestive tract SCC (verrucous, papillary, spindle cell, undifferentiated, acantholytic, and basaloid) and uncommon etiologies of head and neck SCC (human papillomavirus, Epstein-Barr Virus, and NUT midline carcinomas). Particular attention is paid to the cytologic features of these lesions. Differential diagnoses and the use of ancillary testing are discussed.