Comment on "Nationwide randomised trial evaluating elective neck dissection for early-stage oral cancer (SEND study) with meta-analysis and concurrent real-world cohort."

N0 neck trial: Does intensification of follow-up (Ultrasound + Physical Examination) influence outcomes in early-stage oral cancer?

AIM OF THE STUDY

We previously reported a survival benefit of elective neck dissection (END) over therapeutic neck dissection (TND) in patients with clinically node-negative early-stage oral cancer. We now report the results of the second question in the same study addressing the impact of adding neck ultrasound to physical examination during follow-up on outcomes.

METHODS

Patients with lateralized T1/T2 oral squamous cell carcinoma (SCC) were randomized to END or TND and to follow-up with physical-examination plus neck ultrasound (PE+US) versus physical-examination (PE). The primary endpoint was overall survival (OS).

RESULTS

Between January 2004 and June 2014, 596 patients were enrolled. This is an intention to treat analysis of 592 analysable patients, of whom 295 were allocated to PE+US and 297 to PE with a median follow-up of 77.47 months (interquartile range (IQR) 54.51-126.48). There was no significant difference (unadjusted hazard ratio [HR], 0.92, 95% CI, 0.71-1.20, p = 0.54) in 5-year OS between PE+US (70.8%, 95% CI, 65.51-76.09) and PE (67.3%, 95% CI, 61.81-72.79). Among 131 patients with neck node relapse as the first event, the median time to relapse detection was 4.85 (IQR 2.33-9.60) and 7.62 (IQR 3.22-9.86) months in PE+US and PE arms, respectively. The N stage in the PE+US arm was N1 33.8%, N2a 7.4%, N2b/c 44.1% and N3 14.7% while in PE was N1 28.6%, N2a 9.5%, N2b/c 39.7%, N3 20.6% and unknown 1.6%.

CONCLUSION

Adding neck ultrasound to physical examination during follow-up detects nodal relapses earlier but does not improve overall survival.

Sentinel node biopsy in node negative early oral cancers: Solution to the conundrum!

Ideal management of the node-negative neck in early oral cancers is a debated issue. Elective neck dissection (END) is recommended in these patients as it offers a survival benefit. However, about 50-70% of patients who do not harbor occult metastasis are overtreated with this approach. Surgery is associated with morbidity, predominantly shoulder dysfunction. Numerous attempts have been made to identify true node-negative patients through imaging and prediction models but none have high diagnostic accuracy to safely spare the neck dissection. The recent publications of 2 large randomized controlled trials comparing the outcomes of sentinel node biopsy (SNB) and END have spurred interest in SNB. Both the trials reported SNB to be an oncologically safe procedure and spared unnecessary neck dissections. The functional outcomes of the trials showed that SNB limits the morbidity compared to END, which albeit evens out at the end of one-year post-surgery. Despite its benefits, SNB has failed to gain widespread acceptability due to various limitations including the need for infrastructure, equipment costs, staff, and multidisciplinary collaboration of nuclear medicine, surgical, and pathology fraternity. The labor-intensive pathology protocol with serial step sectioning and immunohistochemistry poses a challenge to the feasibility at a high-volume center. This perspective discusses these limitations and propose plausible solutions to the conundrum. To make it widely applicable and feasible across the globe efforts should be directed to understand biology better, find novel solutions, and implement the lessons learned over decades from other sites.