Diagnostic evaluation of the neck

Patterns of Discordance Between Clinical and Pathologic Stage in Head and Neck Cancer

OBJECTIVE

To enhance understanding in patterns of discordance between clinical and pathological T and N staging in multiple sites of head and neck squamous cell cancer.

METHODS

A retrospective cohort of 580 newly diagnosed and surgically treated head and neck squamous cell carcinoma patients from a single institution over a 10-year period are presented. Clinical and pathologic staging are compared.

RESULTS

Notably, 33% of cases had staging discordance. Overall Cohen's kappa agreement was κ = 0.55 (moderate agreement). Highly discordant site stages with κ < 0.45 included: T2 oral cavity, T2 oropharynx, T3 larynx, and N1 lymph node. T2-4 oral cavity cancers were often overstaged, and more than one-third of T3 larynx cancers were understaged. Highly concordant site stages with κ>0.65 included: T1 larynx, T4 oropharynx, N0 lymph node, and N3 lymph node.

CONCLUSION

There exists a quantifiable and, in certain sites, clinically relevant pattern of discordance between clinical and pathologic staging. Tumor board multidisciplinary evaluation can highlight these discrepancies and aide in limiting effects on treatment decisions. However, discordant staging can affect the interpretation and application of prognostication, treatment, and data accuracy. Further investigation is warranted to improve clinical staging accuracy in areas of highest discordance.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:4284-4291, 2024.

The use of a battery of examination methods for detection of cervical metastases in squamous cell carcinoma of the oral cavity

INTRODUCTION

In patients with squamous cell carcinoma of the orofacial area, the presence of cervical metastases represents a single most significant prognostic factor. This fact underlines the importance of thorough examination of the cervical lymph nodes for potential tumor involvement. To verify this, the most common investigative methods are physical examination (PE), sonography (US) and computed tomography (CT), which have also been used to assess the stage of the disease in the patients in our research.

OBJECTIVE

To evaluate the performance of individual methods (physical examination, sonography, computed tomography) and combinations.

METHOD

Patients with squamous cell carcinoma of the oral cavity, who had undergone physical, US and CT examinations at our department followed by radical neck dissection were included in this retrospective study. A total of 57 patients were included.

RESULTS

The sensitivity of PE, US and CT were 38%, 69% and 61%, respectively, however CT+US combination yielded 83% sensitivity and combination of all these methods 86% sensitivity. The number of false positives was however relatively high with specificity of the 3-way combination at 65%.

CONCLUSION

A combination of our three widely available inexpensive methods detected 86% of metastases in cervical nodes. The large number of false positives however indicates that the method should rather be used for screening in selecting patients who need additional and more expensive imaging than for diagnosing cervical metastases. Also, as 14% of cervical metastases pass undetected using our method, we would recommend an additional examination at least by US+PE several weeks to a few months after the initial examination.

Diagnostic accuracy of F-18 FDG PET or PET/CT for detection of lymph node metastasis in clinically node negative head and neck cancer patients; A systematic review and meta-analysis

OBJECTIVE

The purpose of the current study was to investigate the diagnostic performance of F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) or positron emission tomography/computed tomography (PET/CT) for the detection of cervical lymph node (LN) metastasis in clinically node negative head and neck squamous cell cancer (cN0 HNSCC) patients through a systematic review and meta-analysis.

METHODS

The PubMed and EMBASE database, from the earliest available date of indexing through April 30, 2018, were searched for studies evaluating the diagnostic performance of F-18 FDG PET or PET/CT for the detection of LN metastasis in cN0 HNSCC patients. We determined the sensitivities and specificities across studies, calculated positive and negative likelihood ratios (LR+ and LR-), and constructed summary receiver operating characteristic (SROC) curves.

RESULTS

Across 18 studies (1044 patients), the pooled sensitivity for F-18 FDG PET or PET/CT for the detection of LN metastasis was 0.58 and a pooled specificity of 0.87 for patient based analysis. Neck side based analysis showed the pooled sensitivity of 0.67 and a pooled specificity of 0.85. Level based study demonstrated the pooled sensitivity of 0.53 and a pooled specificity of 0.97 (95% CI; 0.95-0.98). In meta-regression analysis, no definite variable was the source of the study heterogeneity.

CONCLUSION

The current meta-analysis showed the low sensitivity and moderate specificity of F-18 FDG PET/CT for the detection of cervical LN metastasis in cN0 HNSCC patients. Level based analysis of F-18 FDG PET or PET/CT has a high specificity and NPV for the detection of cervical metastatic LN detection.

The prognostic significance of E-cadherin expression in laryngeal squamous-cell carcinoma: a systematic review

The aim of this study was to systematically review publications that investigated the prognostic role of E-cadherin immunostaining in patients affected by laryngeal squamous cell carcinoma. An appropriate string was run on PubMed to retrieve articles dealing with this topic. A double cross-check was performed on citations and full-text articles by two authors independently to analyse all manuscripts and perform a comprehensive quality assessment. Among 89 abstracts identified, 13 articles were included. These studies reported on 1,121 patients with histologically confirmed diagnosis of laryngeal squamous cell carcinoma. Overall, there were 10 studies that showed a significant correlation between E-cadherin immunohistochemical expression and at least one of the clinical and histopathological parameters considered by the authors. In particular E-cadherin expression was significantly associated with N stage (five studies), grading (four studies) and disease-free survival/disease-specific survival (six studies). In conclusion, the findings of our review appear similar to the results published by other authors on the putative role of E-cadherin in progression of malignancy. In fact, for laryngeal squamous cell carcinoma it seems that lower levels of E-cadherin correlate with increased tumoural aggressiveness and worse prognosis. Nevertheless, further high-quality prospective studies should be carried out to clarify if E-cadherin expression may be considered as an independent prognostic factor for patients affected by laryngeal cancer.

Diagnostic Efficacy of Computed Tomography in Detecting Cervical Metastases in Clinically N0 Head and Neck Squamous Cell Carcinoma

The search for a single non-invasive highly accurate diagnostic modality for identification of cervical metastasis in head and neck squamous cell carcinoma (HNSCC) is yet to bear fruit. Thirty proven cases of HNSCC with no palpable neck nodes were selected, requiring surgery for the primary tumour. Detailed clinical evaluation and contrast enhanced computed tomography (CECT) scans were done. Patients underwent elective neck dissection along with surgery for the primary tumour. Specimens were sent for histopathological examination (HPE), considered gold standard. Results of CECT were compared with HPE. Clinical examination had a NPV of 80 % and CECT had a sensitivity, specificity, PPV, NPV, and accuracy of 83, 75, 45.5, 94.7, and 76.7 % respectively. A CECT may be added to the initial assessment of a patient of HNSCC, allowing for earlier diagnosis of nodal metastasis that may allow for a better chance at survival.

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.

Focal adhesion kinase overexpression: correlation with lymph node metastasis and shorter survival in oral squamous cell carcinoma

BACKGROUND

Focal adhesion kinase (FAK) has been identified as a key mediator in tumor progression. The objective of this study was to determine the role of FAK as a predictor of neck node metastasis and poor prognosis in oral squamous cell carcinomas (OSCCs).

METHODS

FAK expression in normal oral mucosa and in 69 OSCCs was examined by immunohistochemistry, and the percentage of stained cells was recorded. The correlation of these findings with clinicopathologic variables and survival was studied.

RESULTS

FAK expression in OSCCs was heterogeneous: 33.3% of cases showed weak expression; 23.2%, moderate expression, and 33.3% cases showed high expression. FAK expression significantly correlated with tumor size (p = .010), neck node metastasis (p = .01), and local tumor recurrence (p = .01). FAK expression was an independent prognostic factor in the survival analysis (p = .017).

CONCLUSIONS

Increased expression of FAK may play a role in invasiveness and metastasis of OSCCs, which contribute to poor prognosis and low survival.

Management of the clinically negative neck in early-stage head and neck cancers after transoral resection

The decision regarding treatment of the clinically negative neck has been debated extensively. This is particularly true with early-stage tumors for which surgery is the treatment of choice, and the tumor has been resected transorally without a cervical incision. Elective neck dissection in this situation is an additional procedure with potential associated morbidity. The alternative strategy for the clinically negative neck is to "wait and watch." Both an elective neck dissection policy and a "watchful waiting" policy have their proponents. The purpose of this article was for us to review the literature about this subject to try to answer the following question: if the tumor has been resected transorally, should an elective treatment of the neck be performed or is a "watchful waiting" policy safe and adequate? We conclude that, currently, the best available evidence suggests that elective neck dissection does not seem to be superior to the policy of observation without neck surgery, with regard to survival and control of neck disease. This review highlights the need for further well-designed prospective studies that will provide more reliable answers to the debatable issue of the management of the clinically negative neck in such cases.

Cervical lymph node metastasis in oral squamous carcinoma preoperative assessment and histopathology after neck dissection

BACKGROUND

The presence or absence of nodal metastasis has a great impact on the prognosis and survival of patients with head and neck cancer. The risk of occult metastasis is related to the method by which the lymph nodes are evaluated. It is possible to reduce the risk of undiagnosed metastasis with accurate imaging techniques and thus probably reduce the number of elective neck treatments.

AIMS AND OBJECTIVES

To assess the accuracy of clinical palpation, CT Scan, Ultrasound and Ultrasound guided FNAC in prediction of lymph node metastasis in oral squamous cell carcinoma so that a suitable surgical neck dissection can be carried out.

METHODS

Ten patients with oral squamous cell carcinoma who underwent 10 neck dissections (4 RND, 6 SOND) were included. All the patients underwent examination of neck pre operatively by palpation, Computed Tomography with contrast, Ultrasound and Ultrasound guided FNAC for no detection. The findings were correlated with the results of histopathologic examination of the neck specimen. The results were obtained after statistical analysis.

RESULTS

Six neck dissection specimens showed metastatic lymph node involvement in postoperative histopathology. Lymph node involvement was identified preoperatively by palpation in 7 necks, CT in 3 necks, US in 9 necks and USFNAC was positive in 4 cases. The palpation showed 83% sensitivity, 50% specificity. CT showed sensitivity of 50%, specificity of 100%, US showed sensitivity of 100%, specificity of 25% and US-FNAC showed sensitivity of 67%, specificity of 100%.

CONCLUSION

The palpation, CT Scan and US are equally accurate but the USFNAC is the most accurate technique in assessing metastasis in lymph nodes in patients with oral squamous cell carcinoma.

Is There a Need for Positron Emission Tomography Imaging to Stage the N0 Neck in T1-T2 Squamous Cell Carcinoma of the Oral Cavity or Oropharynx?

Objectives:

We assess whether negative findings on computed tomography (CT), magnetic resonance imaging (MRI), and/or 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) may contribute to the decision-making process of elective neck dissection (eND) in patients with squamous cell carcinoma of the oral cavity or the oropharynx (oSCC) staged cT1-T2 cN0 cM0.

Methods:

We interpreted CT, MRI, and 18FDG-PET images separately, after combining the data of CT with those of 18FDG-PET and the data of MRI with those of 18FDG-PET. Each set of results was then compared with the histopathologic results of ipsilateral or bilateral eND in a prospective, blinded study.

Results:

The histopathologic examination of 594 lymph nodes revealed 4 metastases less than 4 mm in diameter and 3 micrometastases (less than 2 mm) in 6 of 17 patients. On CT, MRI, and 18FDG-PET, respectively, 5, 5, and 0 cases were true-malignant (true positives) and 4, 10, and 1 cases were false-malignant (false positives). The accuracy was not enhanced by fusing CT with 18FDG-PET or MRI with 18FDG-PET.

Conclusions:

The detectability threshold of occult metastases appears to be below the spatial and contrast resolution of CT, MRI, and 18FDG-PET. The decision for eND in patients with cT1-T2 cN0 cM0 oSCC cannot be based upon cross-sectional imaging at the resolutions currently available.

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.

Cranial location of level II lymph nodes in laryngeal cancer: Implications for elective nodal target volume delineation

PURPOSE

To analyze the cranial distribution of level II lymph nodes in patients with laryngeal cancer to optimize the elective radiation nodal target volume delineation.

METHODS AND MATERIALS

The most cranially located metastatic lymph node was delineated in 67 diagnostic CT data sets. The minimum distance from the base of the skull (BOS) to the lymph node was determined.

RESULTS

A total of 98 lymph nodes were delineated including 62 ipsilateral and 36 contralateral lymph nodes. The mean ipsilateral and contralateral distance from the top of the most cranial metastatic lymph node to the BOS was 36 mm (range, -9-120; standard deviation [SD], 17.9) and 35 mm (range, 14-78; SD 15.0), respectively. Only 5% and 12% of the ipsilateral and 3% and 9% of the contralateral metastatic lymph nodes were located within 15 mm and 20 mm below the BOS, respectively. No significant differences were found between patients with only ipsilateral metastatic lymph nodes and patients with bilateral metastatic lymph nodes. Between tumors that do cross the midline and those that do not, no significant difference was found in the distance of the most cranial lymph node to the BOS and the occurrence ipsilateral or contralateral.

CONCLUSIONS

Setting the cranial border of the nodal target volume 1.5 cm below the base of the skull covers 95% of the lymph nodes and should be considered in elective nodal irradiation for laryngeal cancer. Bilateral neck irradiation is mandatory, including patients with unilateral laryngeal cancer, when elective irradiation is advised.

Role of diffusion weighted MR in the discrimination diagnosis of the cystic and/or necrotic head and neck lesions

PURPOSE

The purpose was to determine whether the diffusion weighted imaging (DWI) was able to differentiate necrotic tumor or metastatic lesions from infected necrotic lesions such as abscesses and necrotic lymphadenitis in the neck.

MATERIALS AND METHODS

DWI was performed on 37 consecutive patients with 85 head and neck necrotic and cystic lesions. The lesions were classified into four categories: metastatic lymph node involvement including lymphoma, necrotic tumor, abscesses and necrotic lymphadenitis. Each lesion was histopathologically studied and proved.

RESULTS

In 12 patients, there were 35 necrotic lymphadenitis (necrotic tuberculosis lymphadenitis, n=18; necrotic nonspecific suppurative lymphadenitis, n=17). Of the 15 necrotic metastatic nodes, 11 lesions were lymphomatous involvement and 4 lesions were other tumor involvement. Other 11 patients have abscesses. Thirteen primary tumoral necrotic lesions arose in the neck of nine patients. All of the abscesses and necrotic lymphadenitis showed hyperintensity on DWI, in contrast to necrotic tumor and necrotic nodal metastasis that showed hypointensity on DWI. DWI successfully differentiated metastatic nodes and necrotic tumors from necrotic lymphadenitis and abscesses.

CONCLUSION

DWI may be supportive for differentiating necrotic tumor lesions such as necrotic tumor and metastatic necrotic nodes from the infective necrotic lesions such as necrotic lymphadenitis and abscesses in the head and neck.

USPIO-enhanced magnetic resonance imaging for nodal staging in patients with head and neck cancer

PURPOSE

To determine the accuracy of ultrasmall superparamagnetic iron oxide (USPIO)-enhanced magnetic resonance imaging (MRI) for nodal staging in patients with head and neck cancer.

MATERIALS AND METHODS

Twenty patients with carcinomas of the upper aerodigestive tract were prospectively enrolled. MRI was performed before and 24-36 hours after intravenous infusion of an USPIO agent, ferumoxtran-10 (Sinerem; Guerbet, France; and Combidex; Advanced Magnetics) at a dose of 2.6 mg Fe/kg using T2-weighted spin-echo and gradient-echo sequences. Surgery was performed the same day or the day after the ferumoxtran-10-enhanced MR examination. Based on MRI, selected nodes were surgically removed and directly correlated with pathology using hematoxylin-eosin (H&E) and Perls stainings.

RESULTS

A total of 63 nodes were studied; 36 were nonmetastatic, 25 metastatic, and two inflammatory. Ferumoxtran-10-enhanced MRI allowed diagnosis of 24 metastatic and 30 nonmetastatic nodes, yielding a sensitivity of 96%, a specificity of 78.9%, a positive predictive value of 75%, and a negative predictive value of 96.8%, compared to 64%, 78.9%, 66.6%, and 76.9%, respectively, for nonenhanced MRI. Accuracy of ferumoxtran-10-enhanced MRI was 85.7%. The gradient-echo T2-weighted sequence was the most accurate to detect signal loss in nonmetastatic nodes.

CONCLUSION

USPIO-enhanced MRI is useful for nodal staging of patients with head and neck cancers.

The role of 99mTc-tetrofosmin scintigraphy for staging patients with laryngeal cancer

Diagnosis and staging of laryngeal cancer is currently based on physical examination, endoscopy, and imaging techniques such as computed tomography (CT) and/or magnetic resonance (MR) and histology. While imaging techniques have a pivotal role for defining the size of the primary tumor, they are less accurate for defining metastatic involvement of regional lymph nodes, especially if lymph nodes are smaller than 10-15 mm. The aim of this study was to comparatively assess the relevance of (99m)Tc-tetrofosmin scintigraphy for the staging of laryngeal tumors versus the CT scan. We evaluated the sensitivity of imaging with (99m)Tc-tetrofosmin in 28 consecutively enrolled patients with squamous cell laryngeal carcinoma. Total-body scintigraphy with 99mTc-tetrofosmin was performed preoperatively, and the results were compared to CT images of the neck and mediastinum. CT and (99m)Tc-tetrofosmin scintigraphy were equally sensitive (96%) in identifying the primary tumor. While CT was more sensitive for detecting metastatic lymph nodes (100% versus 50%), (99m)Tc-tetrofosmin scintigraphy was more specific (100% versus 56%; p < 0.04). The overall diagnostic capabilities of the two techniques for detecting lymph node metastases were comparable (Youden Index: J = 0.56 for CT and J = 0.50 for (99m)Tc-tetrofosmin scintigraphy). (99m)Tc-tetrofosmin scintigraphy is a useful complement to CT for staging laryngeal tumors, especially for detecting metastatic lymph nodes and distant metastases.

c-met overexpression in supraglottic laryngeal squamous cell carcinoma and its relation to lymph node metastases

BACKGROUND

The c-met oncogene encodes the receptor for the hepatocyte growth factor/scatter factor (HGF/SF), which is known to have the effects of stimulation of cell motility, dissociation of epithelial sheets, invasion of cellular matrix, and induction of angiogenesis. Many studies in solid tumors have indicated a role for c-met and HGF/SF in the progression of the disease.

METHODS

The expression of c-met in tissue specimens was studied by immunohistochemical examination in 60 patients with supraglottic laryngeal squamous cell carcinoma. Patients were chosen such that there were 30 with lymph node metastases in the neck and 30 without metastases. TNM staging, differentiation, lymphovascular and perineural invasion, and growth pattern for tumors were also recorded, and their relation to lymph node metastases was analyzed.

RESULTS

Overexpression of c-met was observed in 90% of the cases at the primary site and in 83% of the cases with lymph node metastases in the neck. Lymphovascular invasion (P = 0.005) and the N stage (P = 0.001) were found to be related to lymph node metastases, but other variables-c-met overexpression, the T stage, perineural invasion, and growth pattern-were found to have no relation to lymph node metastases in multivariate analysis of the data with linear regression.

CONCLUSIONS

c-met overexpression is observed in both the primary site and the neck in supraglottic laryngeal squamous cell carcinoma. We believe that it may have a role in the progression of malignancy, but we were unable to find a definite relation between c-met expression and lymph node metastases.

Palpación y tc para evaluar las adenopatías cervicales en los tumores de cabeza y cuello

Lymphatic metastasis is an important prognostic factor in patients with head and neck squamous cell carcinomas. Diagnostic evaluation and treatment of this adenopathies is very important. We can use physical examination, computered tomography (CT), magnetic resonance, ultrasound... but none of these give us a 100% security. This study evaluates the accuracy of physical examination and CT in detecting cervical lymph nodes. 120 neck dissections were performed after palpation and CT of 72 patients with head and neck carcinoma. Sensitivity of palpation was 51.7 and specificity 96.7. CTs sensitivity was 65 and specificity 86.7. Both, physical examination and palpation have a high number of mistakes evaluating cervical nodes. N0 necks are still a problem for Head and Neck Surgeons.

Disparity in pathologic and clinical lymph node staging in oral tongue carcinoma. Implication for therapeutic decision making

BACKGROUND

Regional lymph node metastasis is the most reliable predictor of treatment outcomes for patients with squamous cell carcinoma of the oral tongue (SCCOT). A recent American Joint Committee on Cancer staging update of malignant melanoma has incorporated pathologic lymph node staging. The authors hypothesized that pathologic lymph node staging (pN) would be a more reliable predictor of treatment outcomes than clinical lymph node staging (cN).

METHODS

The authors retrospectively reviewed 266 patients who received primary surgical treatment for SCCOT, including a neck dissection, from January 1980 to December 1995. Overall and disease-specific survival and disease-free interval were compared with respect to clinical and pathologic lymph node stages.

RESULTS

Statistically significant survival differences were identified for both clinical (cN0-cN2) and pathologic lymph node stages (pN0-pN2). However, survival and disease-free interval differences for pathologic lymph node staging reached higher statistical significance (P < 0.0001) than for clinical lymph node staging (P < 0.002). This disparity can be explained by stage migration (i.e., patients with cN0-1 disease have a more advanced lymph node stage at the time of pathologic review compared with patients without cN0-1 disease). The authors found a 34% rate of occult lymph node disease in the cN0 group (19% of occult lymph nodes had extracapsular spread [ECS]). Similarly, 43% of cN1 patients had a higher stage than pN2b disease and 50% had ECS.

CONCLUSIONS

Pathologic lymph node staging, based on a staging or therapeutic neck dissection, should be considered for patients treated for SCCOT to identify high-risk patients who may benefit from additional adjuvant therapy. Prospective studies are essential to validate these findings before pathologic lymph node staging is included in standard staging criteria.

A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography

OBJECTIVES

Pre-operative staging of the clinically N(0) neck in patients with oral squamous cell carcinoma is hindered by the relatively high false negative/positive rates of conventional imaging techniques. The aim of this study is to evaluate the utility of (18)F-fluoro-deoxy-glucose (FDG) positron emission tomography (PET) and sentinel lymph node (SLN) imaging and biopsy to determine the true disease status of the loco-regional lymphatics.

METHODS

Nineteen patients with biopsy proven disease without palpable or radiological evidence of neck metastases underwent pre-operative (18)F-FDG PET and SLN imaging. All patients underwent whole-body FDG PET and a single view of the head and neck. SLN technique was performed using four peri-tumoural injections of (99m)Tc labeled albumin colloid each of 10 MBq. Dynamic and static imaging followed in the antero-posterior and lateral projections. At operation 1 ml of 2.5% Patent Blue Dye and a hand held gamma probe (Neoprobe 1500) were used in combination to identify and remove the SLN. Surgery then continued along conventional lines including a neck dissection. Histology of the resultant specimen was correlated with that of the SLN and pre-operative imaging.

RESULTS

In all patients SLN harvesting was feasible. In 15/19 patients the SLN(s) and the residual neck dissection were -ve for tumour. In 3/19 patients the SLN(s) were +ve for tumour as were other neck nodes. In 1/19 patients the SLN was -ve but another single tumour +ve node was identified in the neck. This patient occurred early in our series with a SLN close to the primary tumour. (18)F-FDG PET failed to identify nodal disease in all four patients with histologically proven lymph node metastases. The size of these nodes ranged from 12 mm x 10 mm x 3 mm to 25 mm x 15 mm x 10 mm.

CONCLUSION

SLN imaging and biopsy with probe and Patent Blue Dye guided harvest is feasible in patients with oral squamous cell carcinoma and can predict cervical nodal status. (18)F-FDG PET may be less useful.

Elective treatment of the neck in squamous cell carcinoma of the larynx: clinical experience

BACKGROUND

In head and neck cancer, the best prophylactic treatment for the N0 neck is a subject of debate. Some authors propose lateral selective lymph node dissection (levels II-IV) on the basis of the probability of finding occult metastases in those lymph nodes. A more extensive procedure including Vth level is considered unnecessary because of the low incidence of metastases in the posterior triangle.

METHODS

We retrospectively evaluated 346 N0 patients affected by laryngeal carcinoma and consecutively treated at the Department of Otorhinolaryngology of the Ospedale di Circolo, Varese, Italy. The patients underwent elective selective neck dissection (levels II-V) for a total of 602 dissected heminecks.

RESULT

Seventy heminecks (11.6%) were pN+, and in 10 of 70 cases (14.3%) level V was involved; in 5 of 10 metastases were isolated.

CONCLUSION

Our retrospective study confirms the probabilistic criteria of the incidence of occult metastasis by level in laryngeal cancer. On the basis of our data Vth level nodes, although very rarely, 10 of 604 (1.6%), are involved with laryngeal cancer. Our approach to routinely dissect Vth level nodes is discussed.

A needle free system for cervical lymphatic mapping and sentinel node biopsy in oral squamous cell carcinoma

The techniques of lymphatic mapping and sentinel node biopsy are finding increasing utility in the management of the loco-regional lymphatics in many areas of oncology. Our unit is currently investigating their feasibility in relation to the management of the clinically node negative neck in oral squamous cell carcinoma. In order to reduce patient discomfort, and to remove the possibility of sharps injury, particularly in the high-risk patient, we report the use of a needle free device for the intra-oral delivery of the radiopharmaceutical. We believe that this is the first report using such a device in the oral cavity for the purpose of lymphoscintigraphy, and that it has significant advantages over the conventional hypodermic needle in certain patient groups.

The distribution of lymph node metastases in supraglottic squamous cell carcinoma: therapeutic implications

BACKGROUND

The treatment of the neck in cancer of the upper aerodigestive tract is still a matter of controversy, even though nowadays there is a trend in the literature toward elective surgery in the N0 neck when the probability of occult lymph node metastasis is greater than 20%. In the elective setup, every effort is made for preservation of uninvolved nonlymphatic structures in positive neck. The aim of this study is to analyze in a large cohort of patients treated for supraglottic carcinoma the prevalence of lymph node metastases and their distribution through various neck levels to redefine our policy of neck treatment.

METHODS

A retrospective review of 402 consecutive patients, who underwent surgery in the Department of Otolaryngology of the University of Brescia (Italy) for supraglottic squamous cell carcinoma in a 14-year period, has been performed. The prevalence of neck metastases was assessed by pT category and site (marginal vs vestibular) of the primary tumor. The side(s) of neck disease was related to the side of the primary tumor, whether lateral or central. The distribution of involved lymph nodes through the neck levels was determined.

RESULTS

Overall lymph node metastases accounted for 40%; their prevalence rate increased with pT category from 10% to 57% (p =.0001). Occult metastases were found in 26% of N0 patients from 0% in pT1 to 40% in pT4 (p =.02). There was no difference in metastases rate between marginal vs vestibular, and central vs lateral neoplasms, whereas bilateral metastases were more frequent in central tumors (20% vs 5%; p <.0001). Level IV was involved only in association with level II and/or level III. Levels I and V were rarely involved when overt metastases were present and never by occult metastases.

CONCLUSIONS

Elective lateral neck dissection (levels II-IV) is recommended in T2-T4 N0 supraglottic cancers; clearance of both sides of the neck is indicated whenever the lesion is not strictly lateral. We still perform a selective neck dissection including levels II-V whenever there is clinical, radiologic, or intraoperative evidence of metastases at any level.

Does histologic grade have a role in the management of head and neck cancers?

PURPOSE

High histologic grade is usually associated with a greater propensity to distant metastases (DM). Its role to predict DM in head and neck cancer is not yet defined. The aim of this study is to evaluate the role of histologic grade as an independent predictor of DM and to determine a subgroup of patients who may benefit from systemic chemotherapy.

PATIENTS AND METHODS

This is a retrospective study of 1,266 consecutive patients treated by definitive or postoperative radiotherapy between 1989 and 1997. All patients received at least 50 Gy. All stages and subsites of head/neck were included. DM rates were evaluated by the Kaplan-Meier method with a subsequent Cox analysis.

RESULTS

There is a strong correlation of grade with N stage (P <.000001). The metastases-free survival (MFS) was 98%, 90%, and 72% for grades 1, 2, and 3, respectively (P <.000001). In patients with N0 stage, MFS is always greater than 90%, whatever the grade. In the 222 N1 patients, MFS was more than 90% in grade 1 and 2 but dropped to 75% for grade 3 (P =.001). In patients with N2 and N3, MFS was 91%, 79%, and 59% for grades 1, 2, and 3, respectively (P =.008). The same conclusion is applicable when only patients with neck control are analyzed. In a Cox model, grade was an independent predictor of DM (P =.000001) as well as T stage (P =.003), N stage (P =.000001), and neck failure (P =.0003). Higher grade was also an independent predictor of survival (P =.02).

CONCLUSION

Patients with histologic grade 1 and grade 2 (except N3) are at low risk of DM. Patients with grade 2 and N3 or patients with grade 3 and N1 to N3 have a higher risk of distant metastases and should be considered for systemic treatment.

Elective neck dissection versus observation in stage I squamous cell carcinomas of the tongue and floor of the mouth

A retrospective study was undertaken of patients with T1N0M0 squamous cell carcinoma of the oral tongue and floor of the mouth who underwent surgical treatment between 1985 and 1995. Evaluation of two groups of patients (neck dissection versus observation) was made according to the management of the neck. Results were obtained regarding the presence of occult metastases, recurrence in the neck, treatment failure, results of salvage treatment, and disease-free survival. Forty-nine patients underwent surgical treatment: 25 resection of primary and 24 resection plus neck dissection. Overall incidence of regional metastases was 24.5%. Eight patients (16%) developed recurrence of the disease. Seven (14%) had regional recurrences (including 1 with distant metastases) and 1(2%) had local recurrence. Twenty-four percent of patients from the resection of primary group developed neck recurrences in comparison with 4% of the resection plus neck dissection group (P = 0.05). Overall salvage rate was 37.5%. Second primary tumors developed in 16% of patients. Patients who underwent elective neck dissection had a 23% higher disease-free survival rate compared with those who underwent resection of the tumor alone (P = 0.03). The findings of this study stress the importance of control of the neck in early oral cancer. Elective neck dissection significantly improved regional control of the disease.

Selective neck dissection and sentinel node biopsy in head and neck squamous cell carcinomas

The Sentinel Node concept is now well established for HNSCC and gives us a strong basis to treat patients with N0 neck where the rate of occult node metastasis is high. At the present time, the most accurate method for staging N0 neck is pathologic examination of the neck content. In this way, sentinel node dissection (SND) and sentinel node biopsy (SNB) are complementary surgical procedures. SNB has limited indications in HNSCC because of the inaccessibility of most of the primary sites to local injection of Tc99m colloid. However it seems to be an encouraging approach for small tumors of the oral cavity. In other primary sites, except for small glottic tumors, patients must undergo an SND. Supraomohyoid neck dissection which removes levels I, II and III, is performed in oral cavity tumors. Lateral neck dissection which removes levels II, III and IV, is used by many authors for laryngeal, oropharyngeal and hypopharyngeal tumors. In our experience, SND could be limited to levels II and III for laryngeal and oropharyngeal tumors without more neck failures. SND is a reliable procedure, we report only 1.5% of skip nodal metastases in 464 patients who had this staging procedure.

Pathologic detection of occult metastases in regional lymph nodes in patients with head and neck cancer

Squamous carcinomas of the head and neck region are exceedingly common problems in the routine practice of head and neck tumour surgery. Well-defined treatment protocols have evolved to manage patients afflicted with such tumours. This article explores the role of the hospital pathologist in the detection of occult metastases. The conventional approach to evaluation of cervical nodes from a neck dissection is reviewed, and then the potential utility of more recently developed diagnostic approaches (such as immunohistochemistry and polymerase chain reaction) is explored.

Management of the neck in cancer of the larynx

In the Department of Otolaryngology at the University of Pittsburgh School of Medicine, cancer of the larynx is usually treated by primary surgery. Radiotherapy is used as adjuvant treatment in certain patients who have cancer that has adverse histologic features such as perineural, vascular, and/or cartilage invasion. With this approach, patients rarely develop local recurrence. Patient survival is therefore unlikely to be improved by changes to the management of the primary tumor. Survival may, however, be improved by reducing the incidence of recurrence in the neck, as well as distant. Hence, we have adopted an aggressive surgical approach to the cN+ as well as the N0 neck. The theoretical basis for this aggressive surgical approach to the neck will be considered under the following headings: staging, regional control, distant metastasis, survival, choice of neck dissection, and the pathologically positive elective neck dissection.