Supraomohyoid neck dissection

Role of Selective Neck Dissection in Clinically Single Node Positive Disease in Oral Cavity Cancers

Management of the neck in oral cavity squamous carcinoma is debatable. There is controversy regarding role of SND in single node positive neck in oral SCC. The aim of this study was to determine the efficacy of selective neck dissection (SND) for cN1 neck in patients with oral cancer. A retrospective chart review of 266 oral cancer patients who were clinically single node positive from August 2013 to December 2019 was done. Patients having clinical or radiological cN1 disease undergoing SND were included. Two hundred sixty-six patients were analysed with 86% male predominance. Median age was 48 years. The commonest primary site was Bucco-alveolar complex (64%). Total of 319 SNDs were done in 266 patients. At median follow-up of 29 months, 29 patients (9%) had neck recurrence among which 4 patients had recurrence at level V, along with recurrence at other nodal levels. Three-year regional control was 86%, while DFS and OS were 66% and 68% respectively. For oral cancer with single clinically node positive neck (cN1), SND is an effective and oncological safe treatment. Outcomes are similar with modified neck dissection reported in the literature.

Role of 18F-FDG PET/CT in Guiding Surgical Management of Clinically Node Negative Neck (cN0) in Carcinoma Oral Cavity

Conventional staging paradigm with clinical examination or imaging invariably leads to underestimation of occult metastatic neck disease in oral cavity carcinoma. The advantage of 18F-FDG PET/CT is in its ability to identify lymph nodes without morphological changes yet harboring occult metastases. We present findings of our study to evaluate diagnostic accuracy of 18F-FDG PET/CT, in detecting occult cervical lymph node metastasis in carcinoma oral cavity. In a single institution prospective study, 51 consecutive patients with histologically proven (cT1/T2) oral cavity carcinoma and clinically node negative neck (cNo), underwent 18F-FDG PET/CT before elective neck dissection of 58 neck sides. 18F-FDG PET/CT findings were compared with histopathology of dissected nodes, to calculate diagnostic accuracy. 18F-FDG PET/CT correctly characterized the occult lymph node metastasis status (true positive + true negative) in 51 of 58 neck sides, yielding diagnostic accuracy of 87.93%. Sensitivity of 18F-FDG PET/CT was 90% and specificity was 87.5%. While a positive 18F-FDG PET/CT accurately predicted the disease in only 60% (positive predictive value), a negative 18F-FDG PET/CT reasonably ruled out occult metastases in 97.67% (negative predictive value). If a decision regarding the need for neck dissection had been based solely on 18F-FDG PET/CT, the number of neck dissections would have been reduced by 74.13%. Based on diagnostic accuracy and high negative predictive value, incorporating 18F-FDG PET/CT in preoperative staging paradigm of cT1/T2 carcinoma oral cavity will guide in selection of patients in which cN0 neck can be safely observed.

Assessing Prognostic Value of Quantitative Neck Dissection Quality Measures in Patients With Clinically Node-Negative Oral Cavity Squamous Cell Carcinoma

Importance

In clinically localized (T1-2) oral cavity squamous cell carcinoma (OCSCC), regional lymph node metastasis is associated with a poor prognosis. Given the high propensity of subclinical nodal disease in these patients, upfront elective neck dissections (END) for patients with clinically node-negative disease are common and associated with better outcomes. Unfortunately, even with this risk-adverse treatment paradigm, disease recurrence still occurs, and our understanding of the factors that modulate this risk and alter survival have yet to be fully elucidated.

Objective

To investigate the prognostic value of lymph node yield (LNY), lymph node ratio (LNR), and weighted LNR (wLNR) in patients with clinically node-negative T1-2 OCSCC.

Design, Setting, and Participants

In this cohort study, data were collected retrospectively from 7 tertiary care academic medical centers. Overall, 523 patients with cT1-2N0 OCSCC who underwent elective neck dissections after primary surgical extirpation were identified.

Exposures

Lymph node yield was defined as the number of lymph nodes recovered from elective neck dissection. Lymph node ratio was defined as the ratio of positive nodes against total LNY. Weighted LNR incorporated information from both LNY and LNR into a single continuous metric.

Main Outcomes and Measures

Locoregional control (LRC) and disease-free survival (DFS) were both evaluated using nonparametric Kaplan-Meier estimators and semiparametric Cox regression.

Results

On multivariable analysis, LNY less than or equal to 18 lymph nodes was found to be significantly associated with decreased LRC (aHR, 1.53; 95% CI, 1.04-2.24) and DFS (aHR, 1.46; 95% CI, 1.12-1.92) in patients with pN0 disease, but not those with pN-positive disease. Importantly, patients with pN0 disease with LNY less than or equal to 18 and those with pN1 diseasehad nearly identical 5-year LRC (69.7% vs 71.4%) and DFS (58.2% vs 55.7%). For patients with pN-positive disease, LNR greater than 0.06 was significantly associated with decreased LRC (aHR, 2.66; 95% CI, 1.28-5.55) and DFS (aHR, 1.65; 95% CI, 1.07-2.53). Overall, wLNR was a robust prognostic variable across all patients with cN0 disease, regardless of pathologic nodal status. Risk stratification via wLNR thresholds demonstrated greater optimism-corrected concordance compared with American Joint Committee on Cancer (AJCC) 8th edition nodal staging for both LRC (0.61 vs 0.57) and DFS (0.61 vs 0.58).

Conclusions and Relevance

Movement toward more robust metrics that incorporate quantitative measures of neck dissection quality and regional disease burden, such as wLNR, could greatly augment prognostication in cT1-2N0 OCSCC by providing more reliable and accurate risk estimations.

Primary intraosseous carcinoma in the pediatric and adolescent mandible

BACKGROUND

Primary intraosseous carcinoma (PIOC) is a rare malignant odontogenic tumor that predominantly occurs in males older than 50 years. PIOC can be misdiagnosed as odontogenic cyst because it occasionally shows a well-defined border on radiography. In this study, related literatures of pediatric and adolescent PIOC cases were analyzed under strict PRISMA guidelines along with an adolescent case who was provisionally misdiagnosed as an odontogenic cyst.

METHODS

All case reports for PIOC published in English from 1966 to 2021 were collected. Cases under the age of 20 were classified as pediatric and adolescent populations in this study. A total of 12 pediatric and adolescent cases including 11 PIOCs from the literature and one new case of a 14-year-old female were analyzed. Clinical and radiographic features, diagnosis and treatment approaches, and prognosis were investigated.

RESULTS

Ages ranged from 4 to 18 years. The female to male ratio was 1.4:1. Seven cases occurred in the mandible. Swelling was observed in 11 patients. The radiologic borders were well-defined in six cases and corticated in four cases. Tooth displacement and root resorption were observed in four and six cases, respectively. The provisional diagnosis for seven patients was odontogenic cyst and enucleation was performed in six cases including the new case. During the follow-up period, local recurrence occurred in three patients. The pediatric and adolescent PIOC cases with local recurrence showed poor prognosis. The locally recurred lesion in the new case did not decrease in size despite concurrent chemo-radiation therapy.

CONCLUSIONS

Three-dimensional imaging modalities and incisional biopsy with multiple specimens are necessary to rule out PIOC in the lesions with atypical radiographic findings. PIOC should be diagnosed differentially from odontogenic cyst even in pediatric and adolescent populations to properly manage the disease with poor prognosis.

Clinicopathological Risk Factors for Contralateral Lymph Node Metastases in Intraoral Squamous Cell Carcinoma: A Study of 331 Cases

The current study aimed to examine the effects of clinicopathological factors, including the region, midline involvement, T classification, histological grade, and differentiation of the tumor on the rate of contralateral lymph node metastasis for oral squamous cell carcinoma and to assess their effects on survival rates. A total of 331 patients with intraoral squamous cell carcinomas were included. The influence of tumor location, T status, midline involvement, tumor grading, and the infiltration depth of the tumor on the pattern of metastasis was evaluated. Additionally, the effect of contralateral metastases on the prognosis was examined. Metastases of the contralateral side occurred most frequently in squamous cell carcinomas of the palate and floor of the mouth. Furthermore, tumors with a high T status resulted in significantly higher rates of contralateral metastases. Similarly, the midline involvement, tumor grading, existing ipsilateral metastases, and the infiltration depth of the tumor had a highly significant influence on the development of lymph node metastases on the opposite side. Oral squamous cell carcinomas require a patient-specific decision. There is an ongoing need for further prospective studies to confirm the validity of the prognostic factors described herein.

Prognostic significance of extranodal extension in oral cavity squamous cell carcinoma with occult neck metastases

A grade of extranodal extension (ENE) may advance risk stratification related to survival in patients with metastatic oral cavity squamous cell carcinoma (OCSCC). Pathological examination of 174 OCSCC patients who were primarily surgically treated with tumour resection and elective neck dissection was performed. Data of ENE presence, its extent (in millimetres), patients and tumour characteristics were statistically analysed with respect to disease-free survival (DFS) and overall survival (OS). Ninety patients (51.7%) were identified with occult nodal disease, with 41 patients (23.6%) presenting with ENE. Receiver operating characteristics (ROC) curve analysis set the threshold at 1.9 mm as an optimal ENE cut-off regarding both DFS and OS. Patients were divided by extent into minor ENE (≤1.9 mm) and major ENE (>1.9 mm) subgroups. The subgroup with minor ENE had significantly higher DFS and OS rates compared with major ENE. ENE cut-off threshold at 1.9 mm discriminates low and high-risk subgroups of patients with occult OCSCC in terms of DFS and OS.

Selective neck dissection in the treatment of head and neck squamous cell carcinoma patients with a clinically positive neck

OBJECTIVE

To determine the effectiveness and outcomes of SND in the treatment of patients with squamous cell carcinoma of the head and neck (SCCHN) with clinically positive neck (cN+) at diagnosis.

MATERIAL AND METHODS

We retrospectively reviewed 159 patients with SCCHN with cN+ at diagnosis, who underwent a SND with curative intent at a tertiary care academic teaching hospital in Spain. We registered patient and tumor characteristics, date and site of recurrences, together with the outcomes. Survival rates were calculated by the Kaplan-Meier method. The minimum follow-up was 18 months or till death.

RESULTS

A total of 28 neck recurrences were found in the whole series but only 10 neck recurrences occurred in absence of local recurrence. The regional control in the neck in absence of local recurrence was observed in 94% of patients. The neck recurrence rates did not correlated with the pN classification (P = 0.49), the administration of postoperative radiotherapy (P = 0.49) or extranodal extension (P = 0.43). The 5-year regional recurrence-free survival rate was 80% and 92% if only isolated neck recurrences are considered.

CONCLUSIONS

SND offers an effective and oncologically safe surgical procedure in selected patients with clinically positive metastatic nodes in the neck. Our findings suggest that in cN1 and cN2 tumors, SND could replace the modified radical neck dissection without compromising oncologic efficacy.

Histological Assessment of the Carotid Sheath in Patients With Oral Squamous Cell Carcinoma

PURPOSE

During surgical management of the neck using various types of neck dissection, the carotid sheath is removed, in particular, the part adjacent to the jugular lymph node chain, with the intention of preventing recurrence from the lymphatics present within it. The role of the carotid sheath as a potential origin for nodal recurrence has not been proved thus far. Working in a tissue plane between the carotid sheath and the neurovascular structures of the neck can lead to a greater chance of damage to these structures. Also, the carotid sheath is a strong fibroelastic tissue barrier that shields the internal jugular vein and carotid artery from saliva and local infection during the postoperative period. Thus, this study investigated the histopathology of the carotid sheath in patients with oral squamous cell carcinoma (OSCC) and assessed the pathologic infiltration of the carotid sheath when grossly uninvolved.

PATIENTS AND METHODS

Pathologic infiltration and histopathologic characteristics of the entire length of the carotid sheath were assessed in 30 biopsy-proved cases of OSCC; these patients underwent surgical excision of the lesion in addition to neck dissection from 2013 to 2015 in the craniofacial unit of the authors' institution.

RESULTS

The carotid sheath consisted of fibrofatty tissue and interspersed nerve bundles. Neutrophilic infiltration and dilated lymphatic channels were seen in all 30 cases. Miniature lymph nodes adherent to the carotid sheath were seen in 5 cases and some lymphoid aggregates were seen in 15 cases. The carotid sheath in all 30 cases (metastatic and nonmetastatic) was free from tumor deposit and lymphatic tumor emboli, which are indicators of tumor cell infiltration.

CONCLUSION

Indicators of tumor cell infiltration were not found in any of the 30 cases. The result did not vary with the age or gender of the patient, tumor size, location, staging or grading of the tumor, or even when there were metastatic lymph nodes in the gross specimen. Hence, the role of the carotid sheath as a potential origin for nodal recurrence is questionable and its removal needs reconsideration.

Neck dissection for oral squamous cell carcinoma: our experience and a review of the literature

Objectives

This article describes our experience with neck dissection in 10 patients with oral squamous cell carcinoma.

Materials and Methods

Between January 2007 and October 2009, 10 patients underwent primary surgery for the treatment of squamous cell carcinoma of the oral cavity. For patients with N₀ disease on clinical exam, selective neck dissection (SND [I-III]) was performed. In patients with palpable cervical metastases (N+), modified radical neck dissections were performed, except in one patient in whom SND (I-III) was performed. The histopathologic reports were reviewed to assess the surgical margins, the presence of extra-capsular spread, perineural invasion, and lymphatic invasion.

Results

On histopathologic examination, positive soft tissue margins were found in three patients, and regional lymph node metastases were present in five of the ten patients. Perineural invasion was noted in five patients, and extra nodal spread was found in four patients. Regional recurrence was seen in two patients and loco-regional recurrence plus distant metastasis to the tibia was observed in one patient. During the study period, three patients died. Seven patients remain free of disease to date.

Conclusion

Histopathological evaluation provides important and reliable information for disease staging, treatment planning, and prognosis. The philosophy of neck dissection is evolving rapidly with regard to the selectivity with which at-risk lymph node groups are removed. The sample size in the present study is small, thus, caution should be employed when interpreting these results.

Influence of extracapsular nodal spread extent on prognosis of oral squamous cell carcinoma

BACKGROUND

An objective definition of clinically relevant extracapsular nodal spread (ECS) in head and neck squamous cell carcinoma (SCC) is unavailable.

METHODS

Pathologic review of 245 pathologically positive oral cavity SCC neck dissection specimens was performed. The presence/absence of ECS, its extent (in millimeters), and multiple nodal and primary tumor risk factors were related to disease-specific survival (DSS) at a follow-up of 73 months.

RESULTS

ECS was detected in 109 patients (44%). DSS was significantly better for patients without ECS than patients with ECS. Time-dependent receiver operator curve (ROC) analysis identified a prognostic cutoff for ECS extent at 1.7 mm. In multivariate analyses, DSS was significantly lower for patients with major ECS compared with patients with minor ECS, but not significantly different between patients with minor ECS and patients without ECS.

CONCLUSION

ECS is clinically relevant in oral cavity SCC when it has extended more than 1.7 mm beyond the nodal capsule. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1192-E1199, 2016.

A meta-analysis on selective versus comprehensive neck dissection in oral squamous cell carcinoma patients with clinically node-positive neck

OBJECTIVE

Properly management of cervical lymph node metastases is a critical treatment for patients with oral squamous cell carcinoma (OSCC). However there is no consensus on the optimal treatment for oral cancer patients with clinically node-positive (cN+) neck. This study aims to access the feasibility of selective neck dissection in oral cancer patients with cN+neck.

METHOD

We searched PubMed and EMBASE up to April 2015 to identify the studies which compared selective neck dissection (SND) with comprehensive neck dissection (CND) in OSCC patients with cN+neck. Data were extracted by two authors. The meta-analysis was conducted with regional recurrence and disease specific death as primary endpoints.

RESULT

Five studies with a total of 443 patients met our inclusion criteria. No significant difference was found regarding regional recurrence, disease specific death or overall death between the SND and CND group.

CONCLUSION

These findings suggest that cN+OSCC patients treated with SND in conjunction with adjuvant therapy got comparable clinical outcome to CND.

The role of neck dissection in squamous cell carcinoma of the head and neck

ORIGINAL STATEMENT

Lymph node metastases in the neck are a major prognostic factor in patients with head and neck squamous cell carcinoma (HNSCC). Assessment and treatment of lymph nodes in the neck are of utmost importance. Inappropriate management of lymph node metastases can result in regional failure. Radical neck dissection has been and is still considered the "gold standard" for the surgical management of lymph node metastases of HNSCC. However, the philosophy of treatment of the neck has evolved during the last decades. Surgeons progressively realized that extensive neck dissections were associated with a higher morbidity but not always with a better oncologic outcome than more limited procedures. Today, a comprehensive therapeutic approach of the neck is multidisciplinary, taking into account the patient's quality of life without jeopardizing cure and survival. A better understanding of the patterns of lymph node metastasis promoted the use of selective neck dissection in selected patients. Sentinel lymph node biopsy is a reliable diagnostic procedure for staging the neck in node-negative early oral cavity squamous cell carcinoma. With increasing use of chemoradiation in locally advanced HNSCC, paradigms are evolving. Currently, there are strong arguments supporting the position that neck dissection is no longer justified in patients without clinically residual disease in the neck.

Supraomohyoid neck dissection and modified radical neck dissection for clinically node-negative oral squamous cell carcinoma: a prospective study of prognosis, complications and quality of life

BACKGROUND

To assess the prognosis and morbidity between supraomohyoid neck dissection (SOND) and modified radical neck dissection (MRND) for oral squamous cell carcinoma (OSCC) in patients with a clinically node-negative neck (cN0).

PATIENTS AND METHODS

This prospective randomized study began in June 1999, and patient accrual concluded in May 2010. The cN0 neck was confirmed on clinical palpation by senior doctors. Ultimately, there were 322 patients recruited into the study.

RESULTS

Patient demographics were well balanced between the two groups. There were 10 patients in the SOND group and 21 patients in the MRND group who developed nodal recurrence without associated local recurrence or distant metastasis. The 3-year neck control rate (NCR) rate was 92.6% for the SOND group and 87.5% for the MRND group (in favor of SOND, P = 0.108). There was no significant difference between the SOND group and the MRND group in the 3-year disease-specific survival (DSS) rate (79.0% vs. 76.9%, P = 0.659). Importantly, there were significantly fewer complications in the SOND group compared with the MRND group (13.0% vs. 21.9%, P = 0.040). The disease-free survivors in the SOND group also reported better pain relief (P = 0.013) and shoulder function (P < 0.001) than those in the MRND group one year after treatment.

CONCLUSIONS

We recommend SOND as a priority treatment for cN0 OSCC patients.

Supraomohyoid neck dissection in the management of oral squamous cell carcinoma: special consideration for skip metastases at level IV or V

PURPOSE

The aim of this study was to evaluate the therapeutic safety and prognosis of supraomohyoid neck dissections for oral squamous cell carcinoma, with a special focus on the risk of skip metastases in level IV or V.

MATERIALS AND METHODS

A retrospective study was conducted of 637 patients with oral squamous cell carcinoma who were admitted to the department of oral and maxillofacial surgery from September 1995 through July 2010. After completing a diagnostic evaluation, all patients underwent surgery (wide primary excision with supraomohyoid neck dissection, extended supraomohyoid neck dissection, or modified radical or radical neck dissection) and were followed periodically.

RESULTS

Levels I, II, and III were the most common sites of occult metastasis. Skip metastases alone at level IV or V and any neck recurrence at level IV or V were not found. Three-year neck recurrence-free survival and disease-specific survival were not significantly different among the patients who underwent supraomohyoid neck dissection, extended supraomohyoid neck dissection, or modified radical or radical neck dissection owing to cN0 to cN(+) disease.

CONCLUSIONS

The rate of skip metastasis at level IV or V is very rare and is very difficult to diagnose accurately. The results of this retrospective study show that supraomohyoid neck dissection for oral squamous cell carcinoma is an appropriate treatment.

Conservative neck dissection in oral cancer patients: a 5 year retrospective study in Malaysia

OBJECTIVE

The impact of ablative oral cancer surgery was studied, with particular reference to recurrence and nodal metastasis, to assess survival probability and prognostic indicators and to elucidate if ethnicity influences the survival of patients.

METHODS

Patients who underwent major ablative surgery of the head and neck region with neck dissection were identified and clinical records were assessed. Inclusion criteria were stage I-IV oral and oropharyngeal malignancies necessitating resection with or without radiotherapy from 2004 to 2009. All individuals had a pre-operative assessment prior to the surgery. The post operative assessment period ranged from 1 year to 5 years. Survival distributions were analyzed using Kaplan-Meier curves.

RESULTS

87 patients (males:38%; females:62%) were included in this study, with an age range of 21-85 years. Some 78% underwent neck dissections while 63% had surgery and radiotherapy. Nodal recurrence was detected in 5.7% while 20.5% had primary site recurrence within the study period. Kaplan-Meier survival analysis revealed that the median survival time was 57 months. One year overall survival (OS) rate was 72.7% and three year overall survival rate dropped to 61.5%. On OS analysis, the log-rank test showed a significant difference of survival between Malay and Chinese patients (Bonferroni correction p=0.033). Recurrence-free survival (RFS) analysis revealed that 25% of the patients have reached the event of recurrence at 46 months. One year RFS rate was 85.2% and the three year survival rate was 76.1%. In the RFS analysis, the log-rank test showed a significant difference in the event of recurrence and nodal metastasis (p<0.001).

CONCLUSION

Conservative neck is effective, in conjunction with postoperative radiotherapy, for control of neck metastases. Ethnicity appears to influence the survival of the patients, but a prospective trial is required to validate this.

The diagnosis and treatment of oral cavity cancer

BACKGROUND

About 10,000 persons are diagnosed as having carcinoma of the oral cavity or the throat in Germany every year. Squamous-cell carcinoma accounts for 95% of cases.

METHODS

We systematically reviewed the pertinent literature on predefined key questions about these tumors (which were agreed upon by a consensus of the investigators), concerning imaging, the removal of cervical lymph nodes, and resection of the primary tumor.

RESULTS

246 clinical trials were selected for review on the basis of 3014 abstracts. There was only one randomized, controlled trial (evidence level 1-); the remaining trials reached evidence levels 2++ to 3. Patients with mucosal changes of an unclear nature persisting for more than two weeks should be examined by a specialist without delay. The diagnosis is made by computed tomography or magnetic resonance imaging along with biopsy and a standardized histopathological examination. Occult metastases are present in 20% to 40% of cases. Advanced disease (stages T3 and T4) should be treated by surgery followed by radiotherapy, with or without chemotherapy. 20% of the patients overall go on to have a recurrence, usually within 2 to 3 years of the initial treatment. The 5-year survival rate is somewhat above 50%. Depending on the radicality of surgery and radiotherapy, there may be functional deficits, osteoradionecrosis, and xerostomia. The rate of loss of implants in irradiated bone is about 10% in 3 years.

CONCLUSION

The interdisciplinary planning and implementation of treatment, based on the patient's individual constellation of findings and personal wishes, are prerequisites for therapeutic success. Reconstructive measures, particularly microsurgical ones, have proven their usefulness and are an established component of surgical treatment.

Neck metastases in oropharyngeal cancer: Necessity and extent of bilateral treatment

BACKGROUND

Bilateral neck treatment in oropharyngeal squamous cell carcinoma (OPSCC) is controversial. This study determined the rate of bilateral neck metastases in OPSCC and formulated a neck treatment algorithrm for OPSCC.

METHODS

In all, 212 consecutive patients with OPSCC underwent ipsilateral level I-V and contralateral I-III or I-V neck dissections. Pathology results were used to identify factors predicting bilateral neck metastases.

RESULTS

A total of 171 patients (81%) had ipsilateral and 41 patients (24%) bilateral neck metastases. Multivariate logistic regression found cT4 and ≥cN2a significantly associated with contralateral neck metastases (p < .05). However, tumor site was not predictive (p > .05). High-risk pathology features predicted contralateral neck disease (p < .05). cN0 and cN1 necks were unlikely to harbor disease in level V (<5%). Both 2- and 5-year contralateral neck recurrence rates were 1% and 2%.

CONCLUSIONS

Bilateral neck disease in OPSCC is more common than once thought. Patients with OPSCC with cT4 or cN2a+ would benefit from bilateral neck treatment. Posttreatment high-risk features should guide treatment escalation.

Comparison of PET/CT with conventional imaging modalities (USG, CECT) in evaluation of N0 neck in head and neck squamous cell carcinoma

BACKGROUND

Evaluation of a clinically N0 neck is mandatory in cases of squamous cell carcinoma of head and neck region in order to determine the need to address the neck. The study was designed to compare the accuracy of PET/CT scan with that of USG and CECT Neck in assessing clinically N0 neck in cases of squamous cell carcinoma of upper aerodigestive tract.

METHODS

Single center, prospective, study over a 2 year period. All Cases of squamous cell carcinoma of upper aerodigestive tract with no palpable neck lymphadenopathy and who were scheduled for surgery were evaluated with USG, CECT and 18F-FDG PET/CT, of the neck. Post operative histopathology was correlated with pre-operative nodal status. Statistical analysis was done using the chi square test.

RESULTS

In the 49 patients enrolled, 51 neck sides underwent dissections. Sensitivity of USG, CECT and PET-CT was 4.76%, 23.80% and 71.43% respectively while the specificity was 93.33%, 93.33% and 96.67% respectively. The positive predictive value (PPV) calculated for USG, CECT and PET-CT was 33.33%, 71%, 93.5% respectively while the negative predictive value (NPV) 58.33%, 63.63% and 82.85% respectively.

CONCLUSIONS

In N0 neck in head and neck squamous cell carcinoma, though FDG-PET-CT is more accurate than either USG or CECT in staging of the neck, it is not accurate enough to alter the current treatment paradigm.

Late nodal metastasis of T2 oral cancer can be reduced by a combination of preoperative ultrasonographic examination and frozen section biopsy during supraomohyoid neck dissection

CONCLUSION

The occult metastasis rate for T2 oral cancer can be reduced by ultrasonography (US). Also, the late metastasis rate is considered to be reduced by combining US with frozen section biopsy (FSB) during supraomohyoid neck dissection (SOHND).

OBJECTIVES

Early oral cancer has been reported to show occult metastases in 15-53% of patients, but the criteria or methods for the diagnosis of cervical lymph node metastasis are unclear in many studies, and there is no clear definition of occult metastasis. In patients with T2 oral cancer, the diagnosis of lymph node metastasis by US and its pathological diagnosis (pN) after neck dissection were compared to evaluate the usefulness and limitations of US, occult metastasis rate, significance of SOHND as preventive neck dissection, and use of FSB.

METHODS

A total of 73 patients with T2 oral cancer were investigated retrospectively. Modified radical neck dissection (MRND) was performed in N+ patients, and SOHND was carried out in N0 patients. FSB was performed in all patients undergoing SOHND. US and pN diagnoses were compared.

RESULTS

The occult metastasis rate was 18% when occult metastases were limited to those detected by SOHND and 22% when late nodal recurrences were also included.

Nodal yield and survival in oral squamous cancer: Defining the standard of care

BACKGROUND

Elective neck dissection (END) is commonly used as a staging and therapeutic procedure for oral squamous cell carcinoma (SCC) at high risk of nodal metastases. The authors aimed to determine whether the extent of lymphadenectomy, as defined by nodal yield, is a prognostic factor in this setting.

METHODS

A retrospective database review identified 225 patients undergoing END with curative intent for oral SCC between 1987 and 2009. Nodal yield was studied as a categorical variable for association with overall, disease-specific, and disease-free survival in univariate and multivariate analyses.

RESULTS

Nodal yield <18 was associated with 5-year overall survival of 51% compared with 74% in those with nodal yield ≥ 18 (P = .009). Five-year disease-specific survival rates were 69% in those with <18 nodes and 87% in patients with ≥ 18 nodes (P = .022). Similar results were obtained for disease-free survival, with 5-year rates of 44% with <18 nodes versus 71% with ≥ 18 nodes (P = .043). After adjusting for the effect of age, nodal status, T stage, and adjuvant radiotherapy on multivariate analysis, nodal yield <18 was associated with reduced overall (hazard ratio [HR], 2.0; 95% confidence interval [CI], 1.1-3.6; P = .020), disease-specific (HR, 2.2; 95% CI, 1.1-4.5; P = .043), and disease-free survival (HR, 1.7; 95% CI, 1.1-2.8; P = .040). In the pathologically lymph node-negative subgroup (n = 148), similar results were obtained.

CONCLUSIONS

Nodal yield is an independent prognostic factor in patients undergoing END for oral SCC. These results suggest that an adequate lymphadenectomy in this setting should include at least 18 nodes.

Indications for radiotherapy after neck dissection

Up-front surgery and postoperative radiotherapy constitute a well-recognized treatment concept for locally or regionally advanced squamous cell carcinoma of the head and neck. This "treatment package" is further intensified with the concomitant application of chemotherapy during irradiation when high-risk features (ie, microscopically involved resection margins, extracapsular extension of the tumor from neck nodes, the presence of soft tissue deposits) are found on histopathologic examination of a resected specimen. With regard to neck disease, however, the demarcation line between low- and higher-risk clinical situations, which would differ with respect to the need for postoperative radiotherapy, is not clear. In an attempt to define the low-risk characteristics of disease in the neck that do not require adjuvant irradiation, we reviewed the available literature reports for any direct or indirect evidence on the value of postoperative radiotherapy in various clinical scenarios. The number of positive lymph nodes found in a dissected tissue specimen that should be used as a "cut-off" point for introduction of postoperative radiotherapy was evaluated in the context of both primary tumor characteristics and type of neck dissection.

Utilizing computed tomography as a road map for designing selective and superselective neck dissection after chemoradiotherapy

OBJECTIVE

To determine whether computed tomography can distinguish low risk neck levels that can be omitted when neck dissection is undertaken after chemoradiotherapy.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

Head and neck squamous cell carcinoma patients undergoing neck dissection after chemoradiotherapy between January 1998 and June 2008. We compared computed tomography findings after chemoradiotherapy with neck dissection pathology results; used primary location and computed tomography findings to design selective or superselective neck dissection; and determined whether these surgeries would have contained all metastatic disease.

RESULTS

A total of 104 patients were identified, providing 110 heminecks, 531 neck levels, and 3009 lymph nodes for analysis. Neck dissections were positive in 20 (19%) of 104 patients, corresponding to 20 hemineck dissections, 31 neck levels, and 53 lymph nodes. The negative predictive value for computed tomography was 95 percent. The negative predictive value for computed tomography per neck level was as follows: I, 100 percent; II, 96 percent; III, 96 percent; IV, 97 percent; and V, 96 percent. A selective neck dissection or a superselective neck dissection, guided by level specific computed tomography findings and limited to necks with post treatment partial response in one level, would have captured all disease in 52 (95%) of 55 and 51 (93%) of 55 heminecks.

CONCLUSION

Negative computed tomography accurately predicts pathologic complete response at neck dissection. Neck dissection can be avoided in these patients. Additionally, computed tomography reliably identifies low risk neck levels that do not require dissection, permitting selective neck dissection or superselective neck dissection in partial response patients with limited residual disease.

Therapeutic selective neck dissection outcomes

Objective: To evaluate the effectiveness of selective neck dissection in patients with nodal metastases from head and neck squamous cell carcinoma.

Study Design: Historical cohort study.

Setting: Academic medical center.

Subjects and Methods: A chart review was performed on 156 subjects with clinically positive regional nodal metastases managed initially with surgery, including neck dissection. Sixty-nine subjects underwent selective neck dissection (less than 5 levels), and the majority received postoperative radiotherapy (80%). Primary outcomes included Kaplan-Meier three-year ipsilateral regional control and five-year overall survival. Cox proportional univariate and multivariate analyses were performed to determine those factors associated with outcome.

Results: There were two ipsilateral regional recurrences among those undergoing selective neck dissection, yielding a regional control rate of 95.9 percent. Among those undergoing comprehensive neck dissection, nine ipsilateral regional recurrences occurred, yielding a control rate of 86.0 percent ( P = 0.053). No selective neck dissection recurrences occurred in a preserved level. Selective neck dissection, as compared to comprehensive neck dissection, was not adversely associated with regional recurrence, survival, or distant metastasis, even after adjusting for possible confounders (hazard ratio 0.21, P = 0.055).

Conclusion: These results demonstrate high rates of regional disease control (96%) following selective neck dissection and radiotherapy in patients with positive neck node metastases. In this population, performing selective neck dissection with adjuvant radiotherapy for the majority of patients is supported as an effective treatment approach.

Selective neck dissection for N0 and N1 oral cavity and oropharyngeal cancer: are skip metastases a real danger?

OBJECTIVES

To contribute to insight in therapeutic safety of selective neck dissections for oral cavity and oropharyngeal cancer with a special focus on the risk of skip metastases.

DESIGN

Retrospective data analysis.

SETTING

Tertiary referral centre.

PARTICIPANTS

A total of 291 patients operated for oral cavity or oropharyngeal squamous cell cancer between 1999 and 2004.

MAIN OUTCOME MEASURES

Incidence of skip metastases in both pathologically N0 and N+ necks for oral cavity and oropharyngeal cancer.

RESULTS

Of all neck dissections (n = 226) performed for oral cavity cancer, skip metastases to level III or level IV occurred in 14 cases (6%). Ten skip metastases occurred in level III only (10/226 = 4%). Thus, four necks had metastases in level IV, which would not have been removed in case of a Selective neck dissection level I-III (supraomohyoid neck dissection). In case of oropharyngeal cancer, skip metastases to level III or level IV occurred in six of 92 cases (7%). Five skip metastases occurred in level III only (5/92 = 5%). This means that of the necks containing skip metastases, only one neck (1%): had metastases in level IV, which would not have been removed in case of a Selective neck dissection level I-III (Supraomohyoid neck dissection).

CONCLUSIONS

The question whether level IV should be included in the treatment of N0 and even N1 necks of patients with cancer of the oral cavity and oropharynx cannot be answered by all data available to us now. The fear of skip metastases including level IV does not seem to be justified.

Metastatic neck disease beyond the limits of a neck dissection: attention to the 'para-hyoid' area in T1/2 oral tongue cancer

OBJECTIVE

We evaluated patients with small oral tongue cancer suffering from recurrence, which develops in the intervening area between the primary site and the neck. Lesions in the area around the cornu of the hyoid bone ('para-hyoid' area) often involve the hypoglossal nerve and the root of the lingual artery, resulting in treatment failure and death.

METHODS

A 10-year retrospective chart review was conducted of 248 oral tongue cancer patients with small primary tumors (T1/2). No patients who underwent postoperative radiotherapy (PORT) were included.

RESULTS

After excluding those who had local failure or developed new primary lesions, 6.3% of the patients were noted to have a para-hyoid lesion. A similar incidence was observed between the patients with and without previous neck dissection, 6.9% and 5.7%, respectively. All but one patient died due to uncontrolled neck disease.

CONCLUSIONS

Recurrent para-hyoid lesions could occur, irrespective of a previous neck dissection. In other words, the para-hyoid area is beyond the limits of a neck dissection. Once a para-hyoid lesion becomes clinically evident, it seems difficult to salvage. Therefore, a careful inspection of the area should be included intraoperatively in any type of neck dissection (i.e. elective or therapeutic) for patients with oral tongue cancer. This may be the key to improving the regional control rate of patients with small oral tongue cancer. We believe that some patients will benefit from more aggressive treatment of the neck, although PORT seems unnecessary for the majority of the patients with limited neck disease.

Pattern of lymph node metastases in squamous cell carcinoma of the tonsil: implication for selective neck dissection

The aim of this study was to prospectively analyze the distribution of neck metastases and the outcome in patients surgically treated for tonsillar carcinoma in order to deduce implications for selective neck dissection. The criteria for inclusion in the study were (1) previously untreated, histologically proven, resectable squamous cell carcinoma of the tonsil, (2) curative surgical intent on the primary tumor and neck, (3) no history of prior head and neck cancer, (4) absence of synchronous second primary in the upper aerodigestive tract, lung and esophagus, (5) absence of distant metastases. Fifty-eight previously untreated consecutive patients with tonsillar squamous cell carcinoma were included in this prospective study. Among 22 patients with clinically negative cervical lymph nodes, 4 patients (18.2%) had metastatic lymph nodes on pathologic examination. Occult node metastases were mainly located in ipsilateral II level. No occult metastases occurred at levels I and V. Among 36 patients with clinically positive cervical lymph nodes, 3 patients (8.3%) had an occult pathologic metastatic involvement of cervical lymph nodes of ipsilateral level V. Level I was free of lymph node metastases. Clinical N category >N2a (p=0.003), nodal metastases to levels III (p=0.026) and IV (p=0.009) were significantly related to level V nodal metastases. The 2 and 5 years actuarial disease-free survival was 82.7% (95% CI 71.2-93.5%) and 58.3% (95% CI 36.7-79.9%), respectively. The actuarial recurrence-free survival was 87.9% (95% CI 78.9-96.8%) and 72.2% (95% CI 53.9-90.5%) at 2 and 5 years, respectively. Our findings support the role of a selective lateral neck dissection in the management of clinically N0 necks and in selected N+ necks (N1 and N2a disease located at level II) in patients with tonsillar carcinoma without oral involvement.

Management of gingivobuccal complex cancer

INTRODUCTION

Squamous cell carcinoma of the oral cavity ranks as the 12th most common cancer in the world and the 8th most frequent in males. It accounts for up to one-third of all tobacco-related cancers in India. Cancer of the gingivobuccal complex is especially common in Indians due to their tobacco habits. This review focuses on the management of lower gingivobuccal complex cancers.

PATIENTS AND METHODS

References for this review were identified by search of Medline and other bibliographic information available in the PubMed database. The search terms carcinoma oral cavity, and cancer oral cavity, buccal mucosa, gingiva, gingivobuccal complex, and alveolus cancer/carcinoma were used. References from relevant articles and abstracts from international conferences were also included. Only articles published in the English language were used.

RESULTS

Treatment of gingivobuccal complex cancer is primarily surgical. Radical neck dissection, or its modification, is the standard treatment for the node-positive neck. Supraomohyoid neck dissection is the accepted treatment for the node-negative neck. Radiotherapy is usually not the preferred modality of treatment for early gingivobuccal complex cancer. It is used either as postoperative adjuvant treatment or as definitive treatment for advanced cancer with or without chemotherapy. Chemotherapy has been used as neo-adjuvant, adjuvant or palliative treatment. Advanced cancers are common and continue to pose a challenge to the multidisciplinary team.

CONCLUSIONS

Gingivobuccal complex cancer remains a major public health problem despite being highly preventable and easily detectable. Advanced cancers constitute a major proportion of patients presenting for treatment. These patients are difficult to treat and have a poor outcome.

Predictive value of sentinel node biopsy in head and neck cancer

CONCLUSIONS

The negative predictive value (NPV) of sentinel lymph node biopsy (SNB) in this study was 95%. The accuracy of SNB compared to histopathologic evaluation of surgical specimen of subsequent neck dissection (ND) was 96%.

OBJECTIVE

To evaluate NPV of SNB in head and neck cancer.

PATIENTS AND METHODS

This was a prospective clinical study comprising 35 patients (50 necks) with squamous cell carcinoma (SCC) of head and neck with clinically (cN0) and radiologically negative necks, without previous treatment, who underwent SNB with gamma probe and subsequent ND. The NPV, accuracy, sensitivity, and specificity of SNB were compared to histopathologic assessment of surgical specimens from NDs. Negative sentinel lymph nodes (SLNs) on histopathology were evaluated with step serial section (SSS) and immunohistochemistry (IHC). When a neck had a positive SLN, all lymph nodes of subsequent NDs were studied with SSS and IHC.

RESULTS

There were primaries of the oral cavity (n=24), lip (n=3), oropharynx (n=3), and larynx (n=5). All patients had detected SLNs. In all, 41 necks were SLN-negative on histopathologic evaluation but 2 (5%) had metastases in non-SLNs after ND. Of these 41 necks, SLNs were level Ib (26%), IIa (45%), III (21%), and IV (8%). Nine necks presented positive SLN on histopathologic evaluation, level Ib (n=3), IIa (n=5), and III (n=2), and subsequent NDs were negative on conventional histopathologic analysis, but after SSS and IHC, two presented micrometastases.

[Extended supraomohyoid neck nodes dissection in early nodal stages of oral cavity and oropharynx squamous cell cancer]

BACKGROUND

Extended supraomohyoid neck nodes dissection (ESOHND) involves surgical resection of nodal levels from I to IV. The incidence of occult metastases in level V is rare and mainly depends of the location and size of the primary tumour in oral cavity and oropharynx squamous cell cancer.

AIM

The aim of this study was to present the results of treatment with extended supraomohyoid neck dissection.

METHODS

The records of 72 patients with cancer of the oral cavity undergoing extended supraomohyoid neck dissection (ESOHND) during the period 15.12.2003 - 13.06.2005 were reviewed.

RESULTS

Tumor and nodal stage were: T2-9(13%), T3-39(54%), T4-24(33%), N0-14(19%), N1-31(43%), N2-25(35%), N3-2(3%). 64 patients were treated with surgery and postoperative adjuvant radiotherapy. The follow-up period ranged from 11 to 27 months. The surgical failure rate was 8% (occurred in 6 of 72 patients).

CONCLUSIONS

Preliminary analysis suggests extended supraomohyoid neck nodes dissection to be considered as a therapeutic and diagnostic procedure in patients with squamous cell cancer of oral cavity and oropharynx.

Results of selective neck dissection in the primary management of head and neck squamous cell carcinoma

Selective neck dissection (SND) is known to be a valid procedure to stage the clinically N0 neck but its reliability to control metastatic neck disease remains controversial. This study analysed if selective neck dissection is a reliable procedure to prevent regional metastatic disease in head and neck squamous cell carcinoma (HNSCC). We retrospectively analysed the medical records of 163 previously untreated patients with squamous cell carcinoma of the oral cavity, oropharynx, larynx and hypopharynx treated initially in our department from January 1990 to December 2002. All patients had unilateral or bilateral SND, in combination with surgical resection of the primary tumour. SND was performed in 281 necks. Finally, 146 patients who underwent 249 SND (39 I-III, I-IV, 210 II-IV, II-V) had adequate follow-up and were assessed for the regional control. The median follow-up was 37 months (1-180 months). The end points of the study were neck control following SND and overall survival. Twenty-five percent (30/119) of patients staged cN0 had lymph node (LN) metastasis. Overall, regional recurrence was observed in 2.8% of the necks (7/249): 1.6% (4/249) in dissected field and 1.2% (3/249) in undissected field. Seventy-eight percent (194/249) of the necks were staged pN0 with a subsequent failure rate of 1.5% (3/194); 16% (39/249) were staged pN1 and postoperative radiotherapy (PORT) was proposed in 21 of these patients. The failure rate with PORT was 9.5% and 5.5% without PORT. Six percent (16/249) of the necks were staged pN2b and all had PORT with one subsequent recurrence. Extracapsular spread (ECS) was reported in 16.5% of positive SND specimens (9/55); all by one were treated by PORT with a subsequent failure rate of 22% (2/9). At 3 years, overall survival for the whole population was 70% and statistically highly correlated with pN stage (p<0.001). These results support the reliability of SND to stage the clinically N0 neck. SND is a definitive operation not only in pN0 but also in most pN1 and pN2b necks. PORT is not justified in pN1 neck without ECS. In pN2b necks, the low rate of recurrence supports adjuvant PORT. The presence of ECS, despite adjuvant PORT, remains associated with a higher risk of recurrence.

The effect of occult nodal metastases on survival and regional control in patients with head and neck squamous cell carcinoma

OBJECTIVES

To determine factors associated with disease-free survival (DFS) and regional control in clinically node-negative head and neck squamous cell cancer (HNSCC) patients with occult metastasis.

STUDY DESIGN

Non-randomized retrospective analysis.

MATERIALS AND METHODS

Patients who underwent elective neck dissection (END) from 1985 to 2002 were analyzed.

RESULTS

A total of 337 patients underwent END. The majority of patients (67%) had advanced stage disease (T3/T4). Occult metastases were present (pN+) in 168 patients (50%), with extracapsular spread (ECS) present in 72 patients (43%). Five-year DFS for patients with histologically node negative necks was 62% versus 36% for pN+ patients (P < .0001). Postoperative radiation (XRT) did not significantly influence DFS for pN+ patients with less than three nodes involved, but had a significant association with DFS with three or more nodes involved (P < .0001). XRT showed a trend toward improved regional control rates in patients with less than three positive nodes (86% vs. 78%; P = .7579) and patients with three or more positive nodes (62% vs. 50%; P = .0014). When ECS was present, XRT did not affect DFS in patients with less than three nodes (36%), but had a significant effect on DFS in patients with three or more nodes (20% vs. 0%; P = .0075). Regional control rates were not improved with XRT in ECS-positive patients with less than three nodes (62% vs. 75%) or with three or more nodes involved (43% vs. 50%; P = .0678).

CONCLUSIONS

There is a high incidence of occult metastases in clinically node-negative patients which adversely affects survival, regardless of the use of adjuvant XRT. Postoperative XRT did not significantly affect regional control or survival rates in patients with <3 positive nodes. When ECS was present, survival was poor regardless of the number of nodes. These data emphasize the prognostic and therapeutic role of END and highlight the need for the development of novel therapeutic regimens to improve disease control and survival in HNSCC patients with nodal metastases.

Extent of prophylactic lymph node dissection in the central neck area of the patients with papillary thyroid carcinoma: comparison of limited versus comprehensive lymph node dissection in a 2-year safety study

BACKGROUND

To compare the "comprehensive" (including bilateral paratracheal, pretracheal, prelaryngeal lymph nodes) (CCND) with "limited" (saving contralateral paratracheal lymph nodes) central node dissection (LCND) for postoperative complications and disease recurrence rate in sonographically node-negative papillary thyroid carcinomas.

MATERIALS AND METHODS

From 2003 to 2005, 114 consecutive patients, diagnosed as sonographically node-negative thyroid papillary carcinomas, were included retrospectively. Among them, the LCND was performed in 56 patients and CCND in 58 patients, in combination with total thyroidectomy, based on the operator-dependent decision. We compared the complication rates and the recurrence rates between these two groups with a mean follow-up duration of 2 years.

RESULTS

Transient hypocalcemia was more frequent in the CCND group than in the LCND group (48.3% vs 26.8%, P = .02, odds ratio [OR] = 2.55). However, the other complication rates were similar in the two groups. In addition, the immediate postoperative reduction of parathyroid hormone (PTH) was more evident in the CCND group. The postoperative PTH levels increased up to a similar level (12.4 vs 11.8 pg/mL) over 6 months. The incidence of permanent hypocalcemia did not differ significantly between the two groups. Four (7.1%) and five recurrences (8.6%) were found in two groups, respectively, implying similar oncological safety during the 2-year follow-up.

CONCLUSION

The LCND with total thyroidectomy could be an alternative treatment option for node-negative papillary thyroid carcinomas, because LCND had fewer short-term hypocalcemia and similar oncological outcomes during the 2-year follow-up. Further study enrolling a large number of patients with long-term follow-up is needed.

Selective neck dissection for treating node-positive necks in cases of squamous cell carcinoma of the upper aerodigestive tract

CONTEXT AND OBJECTIVE

Modified radical neck dissection (MRND) is the classical treatment for neck metastases of squamous cell carcinoma (SCC) of the upper aerodigestive tract. However, it may still be accompanied by significant sequelae. One alternative for this treatment would be selective neck dissection (SND), which has a lower incidence of sequelae. The aim of this study was to define which neck metastasis cases would really be suitable candidates for SND.

DESIGN AND SETTING

Retrospective clinical-surgical trial at the Division of Head and Neck Surgery, Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP).

METHODS

We retrospectively studied 67 patients with SCC of the upper aerodigestive tract, divided into two groups: 1) 47 patients treated by means of SND (node-negative or node-positive), 2) 20 patients treated by means of MRND (all node-positive).

RESULTS

Our results demonstrated that there was no difference between the patients treated with SND or MRND in relation to disease evolution, and that the main prognostic factor was lymph node involvement. We observed that patients with pharyngeal SCC and older patients presented worse evolution and would probably not be suitable candidates for SND.

CONCLUSIONS

SND may be a good option for treating node-positive necks in selected cases.

Initial CT findings in early tongue and oral floor cancer as predictors of late neck metastasis

Detecting the risk factors for late neck metastasis (LNM) in early tongue and oral floor cancer is important for establishing an accurate prognosis, as well as for increasing survival rates. Patients with either stage I or II tongue and oral floor cancer underwent either a resection of the primary tumor or interstitial radiotherapy without neck dissection. We measured the short- and long-axis diameters of lymph nodes on initial CT images. Of the 38 patients, 20 had LNM and 18 did not. CT images showed a total of 161 lymph nodes. Twenty-five "occult lymph nodes" developed into LNM, whereas the remaining 136 "reactive lymph nodes" did not. Comparison between "occult" and "reactive" lymph nodes revealed significant differences in the short-axis diameters (p=0.01). The measure of short-axis diameters of neck lymph nodes on initial CT images is a useful predictor of LNM in patients with early tongue and oral floor cancer.

Metastasis of squamous cell carcinoma of the oral tongue

Squamous cell carcinoma of the oral tongue (SCCOT) is one of the most prevalent tumors of the head and neck region. Despite advances in treatment, the survival of patients with SCCOT has not significantly improved over the past several decades. Most frequently, treatment failure takes the form of local and regional recurrences, but as disease control in these areas improves, SCCOT treatment failures are occurring more often as distant metastasis. The presence of cervical lymph node metastasis is the most reliable adverse prognostic factor in patients with SCCOT, and extracapsular spread (ECS) of cervical lymph nodes metastasis is a particularly reliable predictor of regional and distant recurrence and death from disease. Decisions regarding the elective and therapeutic management of cervical lymph node metastases are made mainly on clinical grounds as we cannot always predict cervical lymph node metastasis from the size and extent of invasion of the primary tumors. Therefore, the treatment of these metastases in the management of SCCOT remains controversial. The promise of basing treatment decisions on biomarkers has yet to be fully realized because of our poor understanding of the mechanisms of regional and distant metastases of SCCOT. Here we summarize the current status of investigations of SCCOT metastases and the potential of these studies to have a positive impact on the clinical management of SCCOT in the future.

Sentinel lymph node biopsy in squamous cell carcinomas of the lips and the oral cavity—A single center experience

BACKGROUND AND OBJECTIVES

Despite the availability of initial data on sentinel lymph node biopsy (SLNB) in OSCC, its value in clinical practice remains unclear. The aim of this study is to evaluate the feasibility and potential of SLNB as a reliable staging procedure in early stage SCC of the lips and the oral mucosa.

METHODS

From 2001 to 2004, 40 patients with early stage SCC of the lips and oral cavity were enrolled. The main inclusion criteria were: cN0 category by MRI and ultrasound, tumor category T1-T2, for certain sites also T3. Patients with positive SLN underwent MRND and/or radiation. Patients with negative SLN were monitored monthly.

RESULTS

In eight patients, the SLN were positive. Two patients with negative SLN subsequently developed nodal disease (5% false negatives). Twenty-one patients have a follow-up longer than 24 months. Five patients died (one from nodal disease, one from local recurrence, and three from unrelated causes). One patient developed a second primary tumor, the remaining patients are free of disease.

CONCLUSIONS

SLNB may contribute to more targeted lymph node dissection strategies. Further studies will have to ensure the safety of this procedure in comparison to selective neck dissection.

Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.

Selective neck dissection (I–III) for node negative and node positive necks

Selective neck dissection (I-III) for oral cancers offers similar regional control rates with less morbidity as compared with modified radical neck dissection. Charts of 414 patients with oral cancer, who underwent selective neck dissection (I-III) during 1994-2001, were analysed retrospectively. Seventy nine percent of the patients had a primary tumour in the gingivo-buccal complex. Cancer of tongue showed a trend towards higher regional failure (12.3%) as compared to gingivo-buccal cancers (6.5%). Primary tumour was staged as T1-8%, T2-47%, T3-19% and T4-26%. Sixty five percent of the patients were clinically node negative. Isolated neck failure was observed in 4.8% of patients at 2 years and in 5.8% at 5 years. De-differentiation of primary tumour and perineural spread were associated with regional failures. Eighty three percent of the neck recurrences were in the ipsilateral neck and only 16% of these were at levels IV or V. In all, 30% of all regional failures were outside the field of dissection.

Elective neck dissection for carcinomas of the oral cavity: occult metastases, neck recurrences, and adjuvant treatment of pathologically positive necks

BACKGROUND

Supraomohyoid neck dissection (SOHND) is currently performed in patients with carcinoma of the oral cavity with clinically negative neck. Most investigators consider SOHND as a staging procedure.

METHODS

Records of 100 patients with cancer of the oral cavity and clinically negative neck undergoing SOHND were reviewed. The rate and significance of occult metastases are evaluated, the neck recurrences are analyzed and the indication of adjuvant radiation of pN+ necks is discussed.

RESULTS

In 34 of 1814 of analyzed lymph nodes, metastatic disease was detected as follows: 30 macrometastases and 4 micrometastases. In 13 of 34 metastases (38%), extracapsular spread was observed. Twenty of 100 patients (20%) had to be upstaged. In 9 of 87 (10%) patients without local recurrence and with a minimal follow-up of 24 months, 5 ipsilateral (4 within the dissection field) and 5 contralateral neck recurrences were observed. Regional recurrence developed in 4% and 35% of patients with pN0 and pN+ necks, respectively.

CONCLUSIONS

In 20% of patients with oral cavity tumors and pN0 neck, occult metastases were disclosed. Neck recurrences developed significantly more often in patients with pN+ than in those with pN0 necks. To evaluate the exact indication for an adjuvant treatment of patients with cN0/pN+ necks, prospective studies should be performed.