Level IIB Neck Dissection in Oral Squamous Cell Carcinoma: Science or Myth?

Prevalence of Positive Level IIb Lymph Nodes in Tongue Carcinoma: Experience From a Tertiary Care Center in North India

Introduction

Complications during and after dissection of level IIb lymph nodes include spinal accessory nerve (SAN) dysfunction, which results in the limitation of shoulder movements and, thus, hurts the quality of life. The current study aims to know the occurrence of level IIb lymph node positivity in tongue carcinoma.

Methods

This cross-sectional study was conducted from January 2019 to December 2019 in a tertiary care center in North India. Adult cases with primary ulcer-proliferative growth over the lateral border of the tongue were included in the study. The level IIb lymph node positivity from the postoperative histopathology report was the primary outcome measure of this study. To investigate the potential association of tumor size on level IIb lymph node positivity, we compared the maximum tumor dimensions among the level IIb lymph node-positive and -negative groups. In addition, to analyze the impact of the tumor's invasive nature on level IIb lymph node positivity, we compared the depth of invasion and proportion of cases with muscle involvement among the level IIb lymph node-positive and -negative groups. Lastly, to investigate their concurrent occurrences, we compared the number of level IIb lymph node-positive cases among the level IIa lymph node-positive and -negative groups.

Results

A total of 39 patients fulfilling the inclusion criteria were included in the study. Only six had positive level-IIb lymph nodes. No significant associations of tumor size, invasion depth, muscle invasion, or involvement of level IIa lymph nodes with the positivity of level IIb lymph nodes were found. However, only three were level IIb lymph node-positive in 28 level IIa lymph node-negative cases.

Conclusion

Considering the low risk of isolated level IIb lymph node positivity in level IIa lymph node-negative cases, the dissection of level IIb nodes could be omitted during the surgical excision of the tumor. However, radiological investigations detecting metabolic activity should be used in the preoperative period and postoperative follow-up to detect early lymph node involvement and disease recurrence.

Prevalence of occult level 2b nodal metastases in cN0 squamous cell carcinoma of the oral cavity: A systematic review and meta-analysis

Elective neck dissection of levels I, II and III is being increasingly used for detecting occult node metastases in patients with oral squamous cell carcinoma (OSCC) and clinically negative neck (cN0). The most frequent potential long-term complication of this procedure is shoulder dysfunction, because of micro- or macroscopic damage to the spinal accessory nerve (SAN). In particular, many studies have reported an association between SAN damage and dissection of level 2b. Furthermore, level 2b dissection is a technically demanding and time-consuming procedure. Our study aims to clarify whether level 2b sparing in cN0 patients with OSCC can be oncologically justifiable. The PubMed, Cochrane and Scopus databases were searched by three different authors for articles on this topic. The primary endpoint of the meta-analysis was the overall prevalence of occult metastases in cervical level 2b nodes in patients with OSCC and clinically negative neck. The meta-analysis was performed using R version 4.0.1. A total of 13 studies and 937 patients were included. The cumulative rate of occult nodal metastases in level 2b was 0.8% (n = 937, 95% CI: 0.1% - 2.2%, τ² = 0.004). No isolated level 2b metastases was found among the patients with positive level 2b, and in the six studies that reported this association, all patients with nodal disease in level 2b had a positive level 2a. This meta-analysis highlights how level 2b can be safely spared in supraomohyoid neck dissection (SOHND) of patients with OSCC and clinically negative neck, reducing the risk of postoperative shoulder dysfunction.

How is neck dissection performed in Oral and Maxillofacial Surgery? Results of a representative nationwide survey among university and non-university hospitals in Germany

Introduction

Neck dissection (ND) is a surgical procedure addressing cervical lymph nodes and metastases in patients with oral squamous cell carcinoma (OSCC). The aim of this study was to analyze clinical decisions regarding indications and variations of ND in Oral and Maxillofacial Surgery (OMFS) in Germany.

Material and methods

A nationwide survey of the German Association of Oral and Maxillofacial Surgery was performed using dynamic online questionnaires including 38 questions. Data about oncological centers, case numbers, and staging procedures were collected. Relevant aspects, such as inclusion of level IIb and levels IV and V to ND, uni- vs. bilateral ND, and the influence of extra-nodal extension (ENE) of metastases on extension of ND were evaluated.

Results

Eighty-four OMFS of university and non-university hospitals participated in the study (responding rate 21.4%). Sixty-six (78.57%) stated to work at certified cancer centers and 53.57% of the hospitals treated between 50 and 100 OSCC cases per year. CT and/or MRI of the head and neck was performed in most of the staging procedures. Level IIb was included by 71 (93.42%) of the participants in selective ND. Levels IV and V were included by 53 (69.74%) in node-positive neck. In solitary ipsilateral metastases (ENE−), 49 participants (62.82%) stated to perform exclusively an ipsilateral ND and 40 (51.95%) stated to perform only an ipsilateral ND in ENE+.

Conclusion

This study demonstrated a high rate of certified cancer centers in Germany showing differences regarding staging procedures, indications, and extension of ND, especially in increasingly complex cases.

Clinical relevance

Clinical decisions regarding ND are dependent on case-individual aspects and must be decided individually.

The necessity of IIb dissection in T1-T2N0M0 oral squamous cell carcinoma: protocol for a randomized controlled trial

Background

There is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, “shoulder syndrome” appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1–2N0M0 oral squamous cell carcinoma (OSCC).

Methods

We designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression–free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant–Murley scale to measure shoulder function.

Discussion

Currently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1–T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1800019128. Registered on 26 October 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3683-y) contains supplementary material, which is available to authorized users.

Results of a randomized controlled trial of level IIb preserving neck dissection in clinically node-negative squamous carcinoma of the oral cavity

BACKGROUND

The lymphatic spread from the cancers of the oral cavity follows an orderly progression and involvement of lower nodes without involvement of upper nodes and skip metastasis is rare. Selective neck dissections are increasingly being performed for node-positive patients; however, in node-negative patients the options of wait and watch, prophylactic radiotherapy, and prophylactic elective node dissections are debated. Quality of life and shoulder functions are important to choose the appropriate therapeutic modality.

PATIENTS AND METHODS

Patients with oral squamous carcinoma with clinically and radiologically negative neck were randomized to IIb preserving superselective neck dissection or conventional supraomohyoid neck dissection. The primary end point of the study was recurrence of disease (clinical or radiological) and shoulder function as demonstrated by the clinical examination and electromyography. The secondary end point was quality of life as measured by the FACT-HN version 4 questionnaire at the end of 1 year follow-up.

RESULTS

The mean number of lymph node harvested per patient was 25.6 (range 8-85). Of the 32 patients, 3 had histologically positive node in level Ib, one of these patients had single positive node while the remaining two had three positive nodes in level Ib. At median follow-up of 36 months disease-free survival in IIb, sparing group was 83% compared to 91% in control arm, the difference in survival between two groups was statistically not significant (p = 0.694). EMG of the shoulder showed denervation pattern in 45% patients undergoing IIb preserving surgery at 1 month follow-up compared to 95% in conventional surgery group, this recovered in all patients but one at 3 months and 100% recovery was seen at 6 months.

CONCLUSIONS

The results of the present study indicate that superselective IIb preserving neck dissections are technically feasible and appear to be oncologically safe procedures when performed as elective prophylactic procedures in highly select group of patients. A significant number of occult metastasis seen in the present study suggests prophylactic dissection to be better than wait and watch policy. Results also show initial higher shoulder morbidity at 1 month in patients undergoing IIb preserving dissections; however, at the end of 1 year recovery is complete and both procedures are comparable.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov with registration no NCT00847717 ; registered on February 19, 2009.

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

Purpose

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

Materials and methods

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

Results

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

Conclusion

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

An update on the latest evidence for managing the clinically negative neck (cN0) in oral squamous cell carcinoma

The single most important prognostic indicator for survival in oral squamous cell carcinoma (OSCC) is the presence of lymph node metastases in the neck. While the treatment of the clinically node positive (cN+) neck is well established, the management of the clinically negative neck (cN0) is controversial. Various strategies have been advocated including close observation including regular ultrasound imaging, elective neck dissection and sentinel lymph node biopsy. Neck dissection surgery is not without potential morbidity with shoulder dysfunction being the main complication. A number of factors are associated with increased risk of neck node metastasis including primary tumour thickness and peri-neural invasion. A recent prospective randomised trial has found survival benefit following neck dissection even in patients with a cN0 neck at presentation. We discuss the latest evidence for managing the cN0 in OSCC and include our own experience on the role of neck dissection in certain cases.