When to address level I lymph nodes in neck dissections?

Tagging the pre-metastatic node in oral cancer: A cross-sectional study

INTRODUCTION

Lymph node involvement is the first indication of spread of oral squamous cell carcinoma (OSCC) and it is also a most significant prognostic factor. Lymph nodes show various tumor-induced histological changes preceding actual metastasis, viz. increased vascularity, follicular hyperplasia and desmoplasia which leads to pre-metastatic niche formation. This pre-metastatic niche primarily provides a favorable microenvironment to for the survival and subsequent growth of cancer cells within the lymph node.

AIM

A retrospective study to evaluate carcinoma-induced changes in lymph nodes harvested from radical neck dissection in OSCC patients.

OBJECTIVES

1) To evaluate cancer-induced histological changes in positive and negative lymph nodes in OSCC patients. 2) To look for common histopathological changes in both pre-metastatic and metastatic lymph nodes.

MATERIALS AND METHODS

Forty lymph nodes harvested from seven OSCC patients were sectioned and stained (Hematoxylin-Eosin) for documentation of histologically evident morphological and functional alterations. The Chi-square test was applied between the non-metastatic and metastatic lymph nodes findings and a statistically significant difference was seen.

RESULTS

Sections from 28 negative nodes showed changes associated with pre-metastatic niche conditioning whereas, 12 sections exhibit frank metastases.

CONCLUSION

The modified immunological responses and remodeling of the vasculature are the most common histologic tumor-induced pre-metastatic changes. This study reviewed and categorized these histological changes that point to pre-metastatic niche conditioning of lymph nodes.

Metastatic Squamous Cell Carcinoma to the Cervical Lymph Nodes From an Unknown Primary Cancer: Management in the HPV Era

Background

Patients with metastases in the lymph nodes of the neck and no obvious primary tumor, neck cancer with unknown primary (NCUP), represent a management challenge. A majority of patients have metastatic squamous cell carcinoma (SCC), although other histologies do occur.

Methods

We comprehensively reviewed the literature, compared available guidelines, and conferred with an international team of experts.

Results

Positron emission tomography-computed tomography (PET-CT) and fine needle aspiration (FNA) under ultrasound guidance increase accuracy of diagnosis. Immunohistochemistry (IHC), determination of human papilloma virus (HPV) status, by p16 staining or by in situ hybridization (ISH), and next-generation gene sequencing can guide us regarding probable primary sites and tumor biology. Narrow Band Imaging (NBI) has been introduced for the early detection of subtle mucosal lesions. Direct laryngoscopy (DL) and tonsillectomy have long been procedures used in the search for a primary site. More recently, TransOral Robotic Surgery (TORS) or Transoral LASER Microsurgery (TLM) have been introduced for lingual tonsillectomy.

Conclusions

New technologies have been developed which can better detect, diagnose, and treat occult primary tumors. Decisions regarding therapy are based on the primary tumor site (if discovered) and N stage. Options include neck dissection with or without postoperative adjuvant therapy, primary irradiation, or combined chemotherapy with irradiation. The preferred treatment of patients whose primary remains unidentified is controversial.

Immuno-reactivity of excised lymph nodes in neck dissections of squamous cell carcinomas of oral cavity

Background:

Regional lymph nodes play an important role in acting as anatomic barriers to systemic dissemination of tumor cells. This reflects in the host immunologic response. Oral squamous cell carcinoma, is known to be associated with early deficiencies of cell-mediated immunity, the pathology of which is reflected in the histology of the regional lymph nodes.

Aim:

The goal of this study was to study the different immunity reactions in the lymph nodes and to correlate it with the histopathology of tumor proper.

Materials and Methods:

Out of 40 head and neck dissections, 30 were male and 10 females within the age range of 21–72 years. According to Tumor Node Metastasis classification, there were 12 cases of stage II and stage III, respectively while 16 were of stage IV. A total of 372 nodes were histologically evaluated. The harvested lymph nodes were categorized into metastatic and non-metastatic nodes exhibiting four patterns as: Lymphocyte predominance pattern, germinal center predominance pattern, lymphocyte depleted pattern and unstimulated pattern.

Results:

The predominant pattern of lymph node reactivity was of lymphocyte predominance (199 nodes) followed by germinal center predominance (117 nodes); lymphocyte depleted (17 nodes) and unstimulated node pattern (39 nodes). Twenty-seven nodes were positive for metastasis. A statistically significant relationship (P = 0.0019 and P = 0.0290, chi square, respectively) was observed between the number of nodes harvested and stage and level of lymph nodes. A brief follow-up period of 3 years was carried out.

Conclusion:

Further studies relating the immuno-morphologic assessment of the lymph nodes in conjunction with other factors may be helpful in assessing the metastases risk of the individual.

Current trends in initial management of hypopharyngeal cancer: the declining use of open surgery

Squamous cell carcinoma of the hypopharynx represents a distinct clinical entity. Most patients present with significant comorbidities and advanced-stage disease. The overall survival is relatively poor because of high rates of regional and distant metastasis at presentation or early in the course of the disease. A multidisciplinary approach is crucial in the overall management of these patients to achieve the best results and maintain or improve functional results. Traditionally, operable hypopharyngeal cancer has been treated by total (occasionally partial) laryngectomy and partial or circumferential pharyngectomy, followed by reconstruction and postoperative radiotherapy in most cases. Efforts to preserve speech and swallowing function in the surgical treatment of hypopharyngeal (and laryngeal) cancer have resulted in a declining use of total laryngopharyngectomy and improved reconstructive efforts, including microvascular free tissue transfer. There are many surgical, as well as nonsurgical, options available for organ and function preservation, which report equally effective tumor control and survival. The selection of appropriate treatment is of crucial importance in the achievement of optimal results for these patients. In this article, several aspects of surgical and nonsurgical approaches in the treatment of hypopharyngeal cancer are discussed. Future studies must be carefully designed within clearly defined populations and use uniform terminology and standardized functional assessment and declare appropriate patient or disease endpoints. These studies should focus on improvement of results, without increasing patient morbidity. In this respect, technical improvements in radiotherapy such as intensity-modulated radiotherapy, advances in supportive care, and incorporation of newer systemic agents such as targeted therapy, are relevant developments.