Equivalence Randomized Trial to Compare Treatment on the Basis of Sentinel Node Biopsy Versus Neck Node Dissection in Operable T1-T2N0 Oral and Oropharyngeal Cancer

The efficacy and potential mechanisms of pyrotinib in targeting EGFR and HER2 in advanced oral squamous cell carcinoma

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) plays an important role in the progression of multiple solid tumors and induces resistance to epidermal growth factor receptor (EGFR) target treatment. However, the expression status and the clinical significance of HER2 in oral squamous cell carcinoma (OSCC) is still controversial. Pyrotinib (PYR) is a promising novel EGFR/HER2 dual inhibitor, whose efficacy in OSCC has not been determined.

METHODS

57 locally advanced de novo OSCC patients were included in this study to investigate the relationship between the HER2 expression levels and the prognosis by the tissue microarray analysis (TMA). In vitro and in vivo experiments were performed to retrieve the efficacy of PYR in OSCC. The main downstream of HER2 was evaluated by western blotting in OSCC cell lines and xenograft tumors to explore the potential mechanism of PYR.

RESULTS

This study revealed the primary tumor of OSCC had higher HER2 expression levels. Patients with HER2 overexpression had poor overall survival (P < 0.014) and poor disease free survival (P < 0.042). In vitro, PYR suppressed the proliferation, colony formation and migration of OSCC cells. It also promoted apoptosis of OSCC cells and induced cell cycle arrest. Furthermore, PYR was able to inhibit the occurrence and development of OSCC effectively in vivo. Western blotting revealed that PYR suppressed OSCC by inhibiting the phosphorylation of HER2, AKT and ERK.

CONCLUSIONS

This study exhibited the anti-OSCC effects of PYR in vitro and in vivo, and demonstrated PYR inhibited OSCC cells by inducing apoptosis via the HER2/ AKT and ERK pathway. The result of this study also indicated locally advanced OSCC patients might benefit from HER2 assay and EGFR/HER2 dual inhibit treatment.

Prediction of nodal disease in oral squamous cell carcinoma of the tongue: histopathological risk assessment with the focus on depth of invasion

OBJECTIVE

Cervical lymph node metastasis (CLNM) is one of the most relevant influencing factors for the oncological outcome of patients with oral squamous cell carcinoma (OSCC). Several studies showed that the tumors depth of invasion (DOI) influences the risk for CLNM, however varying across the oral subsites. The aim of this study is to investigate the role of DOI and other risk factors in OSCC of the tongue in relation to the occurrence of occult CLNM.

MATERIALS AND METHODS

In this retrospective study, n = 139 patients with primary OSCC of the tongue, treated by complete surgical resection (R0) with curative intention between 2013 and 2021, were included. For data analysis, epidemiologic data as well as preoperative tumor staging, surgical therapy including neck management, histopathological tumor data and follow-up were considered. Uni- and multivariate logistic regression were used to determine association between histopathological risk factors and the occurrence of occult CLNM.

RESULTS

The rate of occult cervical metastasis was 19.4%. T-staging, cervical nodal disease (pN+) and lymphatic invasion were significantly associated with reduced OS and RFS. While DOI had no relevant influence on the OS and RFS (p = 0.88 and p = 0.91 respectively), there was significant correlation between DOI and the occurrence of occult CLNM (OR: 1.17, 95%CI: 1.05-1.30; p < 0.01). The optimal cutoff in predicting occult CLNM was 6 mm (Sensitivity: 84.2%, Specificity: 73.5%, AUC: 0.75).

CONCLUSIONS

The DOI is a helpful risk parameter to predict the occurrence of occult nodal disease in OSCC of the tongue. Given the critical decision cutoff between 2 and 4 mm DOI for performing elective neck dissection in the current guidelines, our data suggests that in these cases, surgical de-escalation could be feasible with close follow-up.

CLINICAL RELEVANCE

This study highlights the relevance of DOI as a risk parameter in the prediction of CLNM with the aim to specify the individual patient risk and to deescalate surgical therapy in order to decrease comorbidities while improving the oncological prognosis.

Factors Affecting Drain Output in Oral Carcinoma

Introduction

Advanced oral carcinoma surgery results in large denuded areas leading to seroma and hematoma. Closed suction drains obliterate dead space and create negative pressure on wound bed. Non-placement or early removal of drain can lead to various complications, while placement for long duration can cause surgical site infection. The study aims to evaluate factors affecting postoperative neck drain volume, guiding surgeons for decision making for time of drain removal.

Methods

The study comprised of 222 patients with oral squamous cell carcinoma who underwent primary tumor resection and neck dissection. Demographical, clinical, and surgical details were retrospectively analyzed.

Results

The mean age of patients was 49.1 years. Majority of patients had advanced disease requiring extensive surgery. Patients with radical neck dissection and those reconstructed with pedicled flap had statistically significant drain volume as compared to those with selective neck dissection and free flaps, respectively. Patients with longer duration of surgery, higher blood loss, low postoperative albumin value, and complications showed increased drain volume. Mean duration of drain removal was 7 days, and all drains were removed by day 10.

Discussion

Advanced stage primary disease, radical and modified neck dissections, PMMC flap reconstruction, longer duration of surgery, and higher blood loss had higher drain output. Thus, patient parameters, tumor factors, and surgery factors influence drain output and hospitalization.

Conclusion

Diligent preoperative and perioperative assessment of various factors can aid trainee surgeons to make decisions for appropriate time for drain removal.

Risk Factors Associated with Occult Nodal Metastasis and Outcomes for cT1-2N0 Maxillary and Mandibular gingival Carcinoma: A Retrospective Study

Objective

This study aims to identify the rate of occult nodal metastasis (ONM), risk factors associated with ONM, and compare regional recurrence (RR), 2-year disease-free survival (DFS) in patients treated with elective neck dissection (END) versus expectant management (OBS) for primary T1-T2 gingival squamous cell carcinoma (GSCC) of the maxilla and mandible.

Methods

A retrospective analysis was conducted and included patients from 2014 to 2021 who were treated at a tertiary referral center.

Results

Twenty patients underwent END and 36 were managed expectantly, with a mean follow-up period of 28 months. ONM was observed in 26% of the study cohort with 16.7% occurring in the maxilla and 36.4% in the mandible. No specific histopathologic features were predictive for ONM. No regional recurrence occurred. Local recurrence occurred in 5% and 2.8% of END and OBS groups, respectively. Two-year DFS were comparable between the END (93.8%) versus OBS (83.9%) as well as maxilla (90.9%) versus mandible (83.4%), P > 0.05.

Conclusion

ONM remains variable in cT1-T2N0 GSCC with a greater incidence occurring in the mandible when compared to the maxilla, respectively. An END should be strongly considered for mandibular GSCC. Overall, END for the N0 neck has been shown to provide significant overall and disease-free survival benefits. However, further prospective randomized studies are needed to verify risk factors for ONM and validate the disease-related survival benefit of an elective neck dissection in this patient population.

Ultra-fast confocal fluorescence microscopy for neck lymph node imaging in head and neck cancer

OBJECTIVES

We evaluated ultra-fast confocal fluorescence microscopy (UFCM) as a new modality for pathology practice in head and neck cancer (HNC). This was assessed through an ex vivo study to estimate the accuracy, specificity, and sensitivity of interpretation of UFCM images by pathologists for the detection of metastatic lymph nodes in HNC patients undergoing sentinel lymph node biopsy or selective or complete neck dissection.

MATERIALS AND METHODS

44 patients with 32 cN0 and 12 cN+ HNC were included. The macroscopically non-invaded fresh bisected lymph nodes were stained with acridine orange and imaged with Histolog® Scanner (UFCM). Two pathologists interpreted independently the UFCM images postoperatively and gave a consensus diagnosis in case of disagreement. The gold standard was the diagnosis based on hematoxylin-eosin-saffron (HES) sections.

RESULTS

201 lymph nodes were imaged by UFCM. Thirty nodes (15 %) were invaded on final histology: 3 with micrometastases and 27 with macrometastases. The concordance rate between the pathologists on the UFCM images was 192/201 = 95.5 % and the Cohen kappa coefficient was 0.80. The accuracy of UFCM was 95.5 % (95 %CI: 91.7 %-97.9 %) with a high specificity at 98.8 % (95 %CI: 95.8 %-99.9 %) but an insufficient sensitivity at 76.7 % (95 %CI: 57.7 %-90.1 %). The three micrometastases and four of the 27 macrometastases were missed on UFCM images.

CONCLUSION

The UFCM is providing promising detection values with a very good specificity and moderate sensitivity carrying room for improvement.

Advances and residual knowledge gaps in the neck management of head and neck squamous cell carcinoma patients with advanced nodal disease undergoing definitive (chemo)radiotherapy for their primary

PURPOSE

Substantial changes have been made in the neck management of patients with head and neck squamous cell carcinomas (HNSCC) in the past century. These have been fostered by changes in cancer epidemiology and technological progress in imaging, surgery, or radiotherapy, as well as disruptive concepts in oncology. We aimed to review changes in nodal management, with a focus on HNSCC patients with nodal involvement (cN+) undergoing (chemo)radiotherapy.

METHODS

A narrative review was conducted to review current advances and address knowledge gaps in the multidisciplinary management of the cN+ neck in the context of (chemo)radiotherapy.

RESULTS

Metastatic neck nodes are associated with poorer prognosis and poorer response to radiotherapy, and have therefore been systematically treated by surgery. Radical neck dissection (ND) has gradually evolved toward more personalized and less morbid approaches, i.e., from functional to selective ND. Omission of ND has been made feasible by use of positron-emission tomography/computed tomography to monitor the radiation response in cN+ patients. Human papillomavirus-driven oropharyngeal cancers and their cystic nodes have shown dramatically better prognosis than tobacco-related cancers, justifying a specific prognostic classification (AJCC) creation. Finally, considering the role of lymph nodes in anti-tumor immunity, de-escalation of ND and prophylactic nodal irradiation in combination are intense areas of investigation. However, the management of bulky cN3 disease remains an issue, as aggressive multidisciplinary strategies or innovative combined treatments have not yet significantly improved their prognosis.

CONCLUSION

Personalized neck management is an increasingly important aspect of the overall therapeutic strategies in cN+ HNSCC.

Prognostic role of lymph node micrometastasis in oral and oropharyngeal cancer: A systematic review

BACKGROUND

An estimated 20% of patients with oral and oropharyngeal squamous cell carcinoma (OOSCC) have micrometastases (Mi) or isolated tumor cells (ITC) in the cervical lymph nodes that evade detection by standard histological evaluation of lymph node sections. Lymph node Mi and ITC could be one reason for regional recurrence after neck dissection. The aim of this study was to review the existing data regarding the impact of Mi on the survival of patients with OOSCC.

METHODS

PubMed and the Cochrane Library were searched for articles reporting the impact of Mi and ITC on patient survival. Two authors independently assessed the methodological quality of retrieved studies using the Downs and Black index. Data were also extracted on study type, number of included patients, mode of histological analysis, statistical analysis, and prognostic impact.

RESULTS

Sixteen articles with a total of 2064 patients were included in the review. Among the 16 included studies, eight revealed a statistically significant impact of Mi on at least one endpoint in the Kaplan-Meier and/or multivariate analysis. Three studies regarded Mi as Ma, while five studies found no impact of Mi on survival. Only one study demonstrated an impact of ITC on patient's prognosis in the univariate but not in the multivariate analysis.

CONCLUSION

The majority of cases included in the review were patients with oral cancer. The findings provide low-certainty evidence that Mi negatively impacts survival. Data on ITC were scarcer, so no conclusions can be drawn about their effect on survival. The lower threshold to discriminate between Mi and ITC should be defined for OOSCC since the existing thresholds are based on data from different tumors. The histological, immunohistological, and anatomical characteristics of Mi and ITC in OOSCC as well as the effect of radiotherapy on Mi should be further investigated separately for oral and oropharyngeal carcinomas.

Primary Management of Operable Locally Advanced Oral Cavity Squamous Cell Carcinoma: Current Concepts and Strategies

INTRODUCTION

Locally advanced oral cavity carcinoma (LAOCSCC) is primarily treated with surgery followed by radiotherapy with or without chemotherapy.

METHODS

A review of literature using PubMED was performed for studies reporting the management of LAOCSCC. Based on the reviewed literature and opinions of experts in the field, recommendations were made.

RESULTS

Studies have shown that outcomes following resection of T4a and infranotch (inferior to mandibular notch) T4b are comparable. We discuss the concept of compartmental resection of LAOCSCC and issues concerning the management of the neck. Further, patients who refuse or are unable to undergo surgery can be treated with chemoradiotherapy with uncertain outcomes. The role of neoadjuvant chemotherapy has shown promise for organ (mandibular) preservation in a select subset of patients.

CONCLUSION

The management strategy for LAOCSCC should be determined in a multidisciplinary setting with emphasis on tumor control, functional preservation, and quality of life of the patient.

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.

Role of 18F-FDG PET/CT in Head and Neck Squamous Cell Carcinoma: Current Evidence and Innovative Applications

This article provides an overview of the use of 18F-FDG PET/CT in various clinical scenarios of head-neck squamous cell carcinoma, ranging from initial staging to treatment-response assessment, and post-therapy follow-up, with a focus on the current evidence, debated issues, and innovative applications. Methodological aspects and the most frequent pitfalls in head-neck imaging interpretation are described. In the initial work-up, 18F-FDG PET/CT is recommended in patients with metastatic cervical lymphadenectomy and occult primary tumor; moreover, it is a well-established imaging tool for detecting cervical nodal involvement, distant metastases, and synchronous primary tumors. Various 18F-FDG pre-treatment parameters show prognostic value in terms of disease progression and overall survival. In this scenario, an emerging role is played by radiomics and machine learning. For radiation-treatment planning, 18F-FDG PET/CT provides an accurate delineation of target volumes and treatment adaptation. Due to its high negative predictive value, 18F-FDG PET/CT, performed at least 12 weeks after the completion of chemoradiotherapy, can prevent unnecessary neck dissections. In addition to radiomics and machine learning, emerging applications include PET/MRI, which combines the high soft-tissue contrast of MRI with the metabolic information of PET, and the use of PET radiopharmaceuticals other than 18F-FDG, which can answer specific clinical needs.

Latin American Consensus on the Treatment of Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is well known as a serious health problem worldwide, especially in low-income countries or those with limited resources, such as most countries in Latin America. International guidelines cannot always be applied to a population from a large region with specific conditions. This study established a Latin American guideline for care of patients with head and neck cancer and presented evidence of HNSCC management considering availability and oncologic benefit. A panel composed of 41 head and neck cancer experts systematically worked according to a modified Delphi process on (1) document compilation of evidence-based answers to different questions contextualized by resource availability and oncologic benefit regarding Latin America (region of limited resources and/or without access to all necessary health care system infrastructure), (2) revision of the answers and the classification of levels of evidence and degrees of recommendations of all recommendations, (3) validation of the consensus through two rounds of online surveys, and (4) manuscript composition. The consensus consists of 12 sections: Head and neck cancer staging, Histopathologic evaluation of head and neck cancer, Head and neck surgery-oral cavity, Clinical oncology-oral cavity, Head and neck surgery-oropharynx, Clinical oncology-oropharynx, Head and neck surgery-larynx, Head and neck surgery-larynx/hypopharynx, Clinical oncology-larynx/hypopharynx, Clinical oncology-recurrent and metastatic head and neck cancer, Head and neck surgery-reconstruction and rehabilitation, and Radiation therapy. The present consensus established 48 recommendations on HNSCC patient care considering the availability of resources and focusing on oncologic benefit. These recommendations could also be used to formulate strategies in other regions like Latin America countries.

Evaluation of micrometastasis and isolated tumor cells in node-negative early-stage oral tongue squamous cell carcinoma: a cross-sectional study in tertiary-level hospitals in eastern India

OBJECTIVE

The present study aimed to investigate the incidence of micrometastasis (MMs) and isolated tumor cells (ITCs) in node-negative early-stage oral tongue squamous cell carcinoma (T1-T2 N0). The secondary objective was to correlate the incidence with the clinicopathologic parameters of age, sex, depth of invasion, pattern of invasion, host lymphocytic response, and size and grade of primary tumor.

STUDY DESIGN

Micrometastasis and ITCs in cervical nodes of 30 patients with early-stage oral tongue squamous cell carcinoma were detected and compared using 3 methods: routine hematoxylin and eosin staining, serial-sectioning at intervals of 150 microns employing hematoxylin and eosin, and serial sectioning pan-cytokeratin immunostaining. Associations with clinicopathological variables were analyzed.

RESULTS

Metastatic tumor cells were detected in the cervical nodes of 2 patients using serial sectioning and immunohistochemistry, resulting in upstaging of 6.6% of all cases. Level I and II lymph nodes were primarily involved.

CONCLUSIONS

Early-stage oral tongue squamous cell carcinoma has a significant potential for MMs that frequently go undetected in routine histopathologic examination. However, laborious and technique-sensitive, serial sectioning in combination with pan-cytokeratin staining (AE1/AE3) may aid in detecting MMs and ITCs in patients with early-stage OTSCC.

Fluorescent Guided Sentinel Lymph Mapping of the Oral Cavity with Fluorescent-Labeled Tilmanocept

OBJECTIVE

With the shift toward utilization of sentinel lymph node biopsy (SLNB) in oral cavity cancer, improved techniques for intraoperative sentinel node identification are needed. This study investigates the feasibility of fluorescently labeled tilmanoscept in SLNB in an oral cancer rabbit model.

METHODS

An animal study was designed using 21 healthy male New Zealand rabbits. Gallium-68-labeled tilmanocept labeled with IRDye800CW was injected submucosally into the buccal mucosa (n = 6) or lateral tongue (n = 7) followed by PET imaging. One hour after injection, SLNB was performed using fluorescence imaging followed by a bilateral neck dissection and sampling of non-nodal surrounding tissue. All tissues were measured for radioactivity and fluorescence. In addition, eight rabbits were injected with delayed SLNB performed 48 h after injection.

RESULTS

Buccal injections all had ipsilateral SLN drainage and tongue injections exhibited 18.2% contralateral drainage. An average of 1.9 ± 1.0 SLN (range 1-5) were identified. In addition, an average of 16.9 ± 3.3 non-sentinel lymph nodes were removed per animal. SLNs had an average of 0.69 ± 0.60 percent-of-injected dose (%ID) compared with non-sentinel nodes with 0.012 ± 0.025 %ID and surrounding tissue with 0.0067 ± 0.015 %ID. There was 98.0% agreement between sentinel lymph nodes identified using fluorescence compared to radioactivity with Cohen's kappa coefficient of 0.879. In 48-h delayed SLNB, results were consistent with 97.8% agreement with radioactivity and Cohen's Kappa coefficient of 0.884. Fluorescence identified additional lymph nodes that were not identified by radioactivity, and with one false negative.

CONCLUSION

Fluorescent-labeled Tc-99 m-tilmanocept represents a highly accurate adjunct to enhance SLNB for oral cavity cancer.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:1299-1307, 2024.

Management of clinically node-negative early-stage oral cancer: network meta-analysis of randomized clinical trials

The best treatments for the clinically node-negative (cN0) neck in early-stage oral squamous cell carcinoma (OSCC) patients are a subject of ongoing debate and there is no consensus. A network meta-analysis (NMA) of randomized clinical trials (RCTs) was conducted to determine the most effective treatment and to rank treatments based on their effectiveness. A systematic search was performed in accordance with the PRISMA guidelines to retrieve RCTs that compared therapeutic neck dissection (TND), sentinel lymph node biopsy (SLNB), and elective neck dissection (END). The outcomes analysed were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and nodal recurrence. Hazard ratios and risk ratios were calculated by direct meta-analysis and NMA. Ten RCTs with a total of 1858 patients were eligible for inclusion. Direct meta-analysis showed END to be superior to TND and comparable to SLNB. The NMA revealed no statistically significant difference between END and SLNB (very low quality evidence) regarding OS, DSS, DFS, and nodal recurrence. However, END was found to significantly improve OS and DFS, and reduce nodal recurrence when compared to TND (moderate quality evidence). END ranked as probably the top treatment option for maximizing OS and DSS, and reducing nodal recurrence in early-stage OSCC, followed by SLNB and TND. There was very low quality evidence supporting SLNB as non-inferior to END for patients with early-stage OSCC. This NMA yielded favourable results for the use of END (with moderate quality evidence) in early-stage OSCC patients, although excellent results have also been obtained with SLNB. However, data in the literature for SLNB are scarce, as this technique has not yet been formalized in many countries. There is a need to further explore SLNB for early-stage OSCC patients, as well as its value in detecting occult lymph node metastases on the contralateral side. More studies comparing morbidity, quality of life, and costs between the different management strategies for the clinically negative neck in early-stage OSCC patients are needed.

Reliability and outcomes of lymph nodes biopsy in cT1-cT2 N0 supraglottic laryngeal squamous cell carcinoma

BACKGROUND

In oral and oropharyngeal squamous cell carcinoma (SCC), sentinel node biopsy (SNB) was described as a reliable and reproductive alternative to elective neck dissection for the staging of clinical N0 T1-T2 patients. The SNB technique in supraglottic laryngeal SCC was successfully described in small series. The aim of this study is to analyze retrospectively the results of SNB technique in supraglottic SCC in CHU Godinne, to determine if the technique is reliable and may be proposed in a future multicentral prospective trial.

METHODS

The study involved a retrospective analysis of 39 patients who underwent surgery between 2003 and 2019 at CHU Godinne. All patients presented with clinical N0 neck status. The SNB procedure included general anesthesia, 99-technetium colloid peritumoral injection, and lymphoscintigraphy. The hand-held gamma probe was utilized for SNB after tumoral resection during the same operating session. Out of 39 patients, 36 underwent SNB as the sole staging tool, while 3 patients received SNB in combination with elective neck dissection. Primary outcome was the 2-years neck recurrence-free survival (RFS). Secondary outcomes were the 2- and 5-years disease-specific survival (DSS). Additionally, sensitivity and negative predictive value (NPV) of the SNB technique were analyzed.

RESULTS

Sentinel nodes were successfully identified in all 39 patients. An average of 4 nodes excised per patient. Positives SN were detected in 23% (9 in 39) cases, leading to subsequent selective neck dissection. Two cases of neck recurrence were observed, both considered as false negatives, occurring after an average of 3.5 months. Th median follow-up period was 48 months with a 2-year RFS of 95%. Sensitivity and NPV of the SNB technique were found to be 82% and 94%, respectively. Two and five years DSS were 84% and 71.7%, respectively.

CONCLUSIONS

The results suggest that SNB in T1-T2 supraglottic SCC is a feasible and reliable technique for managing the neck in N0 early-stage patients. However, to establish its oncological equivalence with selective node dissection, further prospective and comparative studies are warranted. The findings of this study underscore the importance of ongoing research in refining and validating the role of SNB in the management of supraglottic SCC, potentially paving the way for more widespread adoption in clinical practice.

Summary of Japanese clinical practice guidelines for head and neck cancer - 2022 update edited by the Japan society for head and neck cancer

The aim of the "Japanese Clinical Practice Guidelines for Head and Neck Cancer - 2022 Update" is to review the latest evidence regarding head and neck cancer and to present the current standard approaches for diagnosis and treatment. These evidence-based recommendations were created with the consensus of the Guideline Committee, which is composed of otorhinolaryngologists and head and neck surgeons, together with radiologists, radiation oncologists, medical oncologists, plastic surgeons, dentists, palliative care physicians, and rehabilitation physicians. These guidelines were created by the Clinical Practice Guideline Committee of the Japan Society for Head and Neck Cancer based on the "Head and Neck Cancer Treatment Guidelines 2018 Edition," and the revised draft was compiled after evaluation by the Assessment Committee and public comments. The 'Clinical questions and recommendations' section consists of 13 categories, and 59 clinical questions are described in total. Here we describe 6 clinical questions specific to other sets of guidelines with recommendations and comments.

Sentinel lymph node biopsy versus elective neck dissection in management of the clinically negative (cN0) neck in patients with oral squamous cell carcinoma: A systematic review and meta-analysis

Oral squamous cell carcinoma (OSCC) is the most prevalent type of head and neck cancer, and lymph node metastasis is a crucial prognostic factor that has a direct correlation with the survival rate. The standard procedure for managing clinically negative (cN0) neck in OSCC patients is elective neck dissection (END), but it can lead to various complications that affect the patient's quality of life. Therefore, medical professionals are exploring the use of the sentinel lymph node biopsy (SLNB) to manage cN0 neck in OSCC patients. The aim of this systematic review and meta-analysis was to compare the overall survival (OS) and disease-free survival (DFS) of patients undergoing SLNB and END in the surgical management of early cN0 neck in OSCC patients. To conduct this study, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used to report the systematic reviews. The study included all comparative clinical studies, including randomized clinical trials (RCTs), clinical perspective studies, and retrospective studies that compared END to SLNB for early cN0 neck in OSCC patients. The hazard ratio (HR) and risk ratio (RR) with 95% confidence interval (CI) were calculated using comprehensive meta-analysis. The primary outcome variables were OS, DFS, and disease-specific survival (DSS). The secondary outcome variable was the nodal recurrence rate without local or distant metastasis. The GRADE system was used to assess the evidence's certainty. The meta-analysis included 12 clinical studies, comprising three RCTs and seven non-RCTs. The results showed no statistically significant difference between END and SLNB concerning OS (HR = 0.993, CI: 0.814 to 1.211, P = 0.947, low-quality evidence), DFS (HR = 0.705, CI: 0.408 to 1.29, P = 0.21, low-quality evidence), and nodal recurrence (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). Additionally, SLNB was non-inferior to END regarding DSS (RR = 1.028, CI: 0.969 to 1.090, P = 0.907, low-quality evidence). In conclusion, this research affirms the safety and precision of SLNB as a means to stage cN0 OSCC patients, with outcomes that are comparable to END in terms of survival and nodal recurrence. Nevertheless, it's crucial to acknowledge that the quality of evidence in this study was relatively low. Therefore, additional RCTs comparing END to SLNB are warranted to validate these results and offer more robust guidance for managing cN0 OSCC patients.

Prognostic study of sentinel lymph node biopsy in early-stage oral squamous cell carcinoma with computed tomography lymphography

PURPOSE

Occult metastasis is a prognostic factor for early-stage oral squamous cell carcinoma (OSCC). Sentinel lymph node (SLN) biopsy (SLNB) is a promising method to detect such metastases. The present study aimed to evaluate the diagnostic reliability of SLNB with computed tomography lymphography (CTL) for early-stage OSCC and to clarify patient outcomes after SLNB.

METHODS

The medical records of 42 patients with T1 or T2 cN0 OSCC who had undergone CTL the day before surgery were retrospectively collected and statistically analyzed.

RESULTS

SLNs were identified on CTL in 41 of 42 OSCC patients (97.6 %). Micrometastases were detected in 10 of 41 cases (24.4 %) and 11 of 65 SLNs (16.9 %) by intraoperative pathological diagnosis. Three cases showed occult metastasis within a year after the primary operation. Specificity and negative predictive value were 76.9 % and 90.3 %, respectively. The cumulative 5-year regional recurrence-free rate was 89.7 % in 31 SLNB-negative patients. Five-year overall and disease-free survival rates were 86.9 % and 70.1 %, respectively, in the 41 cases with identified SLNs.

CONCLUSION

CTL offers acceptable results and appears likely to be effective in treating early-stage OSCC patients with low-invasive surgery. Further investigation is necessary to compare radioisotope-based methods.

The potential of the Crystal Cam handheld gamma-camera for preoperative and intraoperative sentinel lymph node localization in early-stage oral cancer

PURPOSE

Evaluating the Crystal Cam handheld gamma-camera for preoperative and intraoperative sentinel lymph node (SLN) localization in early-stage oral cancer.

METHODS

The handheld gamma-camera was used complementary to conventional gamma-probe guidance for intraoperative SLN localization in 53 early-stage oral cancer patients undergoing SLN biopsy. In 36 of these patients, a blinded comparison was made between preoperative handheld gamma-camera and lymphoscintigraphy outcomes. Of those, the reliability for marking the SLN's location using both handheld gamma-camera and a 57Co-penpoint marker was evaluated in 15 patients.

RESULTS

In the entire cohort, the handheld gamma-camera preoperatively detected 116/122 (95%) of SLNs identified by lymphoscintigraphy. In those patients where the observer was blinded for lymphoscintigraphy (n = 36), 71/77 (92%) SLNs were correctly identified by handheld gamma-camera. Overlooked SLNs by handheld gamma-camera were mainly located near the injection site. The SLN's marked location by handheld gamma-camera and 57Co-penpoint marker was considered accurate in 42/43 (98%) SLNs. The intraoperative use of the handheld gamma-camera led to the extirpation of 16 additional 'hot' lymph nodes in 14 patients, 4 of which harbored metastases, and prevented 2 patients (4%) from being erroneously staged negative for nodal metastasis. In those with follow-up ≥ 24 months or false-negative outcomes < 24 months following SLNB, a sensitivity of 82% and negative predictive value of 93% was obtained.

CONCLUSION

The Crystal Cam handheld gamma-camera offers reliable preoperative and intraoperative SLN localization and might reduce the risk of missing a malignant SLN during surgery. Detecting SLNs near the injection site by handheld gamma-camera remains challenging.

Cost-Effectiveness of [99mTc]Tilmanocept Relative to [99mTc]Sulfur Colloid for Sentinel Lymph Node Biopsy in Early Stage Oral Cavity Cancer

BACKGROUND

Several studies have demonstrated varying rates of efficacy, reliability, and sensitivity of sentinel lymph node biopsy (SLNB) in identifying occult nodal disease for early stage oral cavity squamous cell carcinoma (OCSCC) depending on the radionuclide agent utilized. No head-to-head comparison of cost or clinical outcomes of SLNB when utilizing [99mTc]tilmanocept versus [99mTc]sulfur colloid has been performed. The goal of this study was to develop a decision model to compare the cost-effectiveness of [99mTc]tilmanocept versus [99mTc]sulfur colloid in early stage OCSCC.

PATIENTS AND METHODS

A decision model of disease and treatment as a function of SLNB was created. Patients with a negative SLNB entered a Markov model of the natural history of OCSCC parameterized with published data to simulate five states of health and iterated over a 30-year time horizon. Treatment costs and quality-adjusted life-years (QALYs) for each health state were included. The incremental cost-effectiveness ratio (ICER) was then estimated using $100,000 per additional QALY as the threshold for determining cost-effectiveness.

RESULTS

The base case cost-effectiveness analysis suggested [99mTc]tilmanocept was more effective than [99mTc]sulfur colloid by 0.12 QALYs (7.06 versus 6.94 QALYs). [99mTc]Tilmanocept was more costly, with a lifetime cost of $84,961 in comparison with $84,264 for sulfur colloid, however, the overall base case ICER was $5859 per additional QALY, well under the threshold for cost-effectiveness. Multiple one-way sensitivity analyses were performed, and demonstrated the model was robust to alternative parameter values.

CONCLUSION

Our analysis showed that while [99mTc]tilmanocept is more costly upfront, these costs are worth the additional QALYs gained by the use of [99mTc]tilmanocept.

Health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer: A systematic review

BACKGROUND

Elective neck dissection improves survival in early oral cancer. Sentinel lymph node biopsy may also do this with less morbidity. This systematic review compared health-related quality of life, functional outcomes, and complications after sentinel lymph node biopsy and elective neck dissection in early oral cancer.

METHODS

PRISMA guidelines were followed. Thirteen studies met inclusion criteria.

RESULTS

Results favoring sentinel lymph node biopsy were found in complications, scar length and appearance, length of hospital stay, time to drain removal, and objective shoulder measures at timepoints up to 12 months. Where differences in health-related quality of life were found, methodological issues make their clinical significance questionable.

CONCLUSIONS

Sentinel lymph node biopsy was associated with fewer complications and statistically better outcomes in a number of physical measures. There is as yet no strong evidence to suggest it is associated with better health-related quality of life outcomes. While a number of health-related quality of life outcome measures show promise, their interpretation is hampered by methodological concerns. Further rigorous research is required to address this.

Diagnostic Value of Preoperative uPAR-PET/CT in Regional Lymph Node Staging of Oral and Oropharyngeal Squamous Cell Carcinoma: A Prospective Phase II Trial

The detection of lymph node metastases is a major challenge in oral and oropharyngeal squamous cell carcinoma (OSCC and OPSCC). 68Ga-NOTA-AE105 is a novel positron emission tomography (PET) radioligand with high affinity to urokinase-type plasminogen activator receptor (uPAR), a receptor expressed on the surfaces of tumor cells. The aim of this study was to investigate the diagnostic value of uPAR-PET/CT (computerized tomography) in detecting regional metastatic disease in patients with OSCC and OPSCC compared to the current imaging work-up. In this phase II trial, patients with OSCC and OPSCC referred for surgical treatment were prospectively enrolled. Before surgery, 68Ga-NOTA-AE105 uPAR-PET/CT was conducted, and SUVmax values were obtained from the primary tumor and the suspected lymph nodes. Histology results from lymph nodes were used as the standard of truth of metastatic disease. The diagnostic values of 68Ga-uPAR-PET/CT were compared to conventional routine preoperative imaging results (CT and/or MRI). The uPAR expression in resected primary tumors and metastases was determined by immunohistochemistry and quantified digitally (H-score). A total of 61 patients underwent uPAR-PET/CT. Of the 25 patients with histologically verified lymph node metastases, uPAR-PET/CT correctly identified regional metastatic disease in 14 patients, with a median lymph node metastasis size of 14 mm (range 3-27 mm). A significant correlation was found between SUVmax and the product of the H-score and tumor depth (r = 0.67; p = 0.003). The sensitivity and specificity of uPAR-PET/CT in detecting regional metastatic disease were 56% and 100%, respectively. When added to CT/MRI, uPAR-PET was able to upstage 2/11 (18%) of patients with occult metastases and increase the sensitivity to 64%. The sensitivity and specificity of 68Ga-NOTA-AE105 uPAR-PET/CT were equivalent to those of CT/MRI. The significant correlation between SUVmax and uPAR expression verified the target specificity of 68Ga-NOTA-AE105. Despite the target specificity, the sensitivity of imaging is too low for nodal staging and it cannot replace neck dissection.

Indications for sentinel lymph node biopsy in node-negative oral cancers

BACKGROUND

We aimed to define the indications for sentinel lymph node biopsy (SLNB), the third option for cervical treatment in oral cancer with negative cervical lymph nodes.

METHODS

The greatest depth of invasion (DOI) and long diameter (LD) of the primary site were used as exposures. SLN metastasis was considered the outcome.

RESULTS

In three trials conducted between 2009 and 2016, 158 patients were eligible and reassigned to this study group. The scatterplot based on the respective values of DOI and LD would eventually be divided into three sections. In cases of sections T1, T2, and T3, the proportions of SLN metastasis positivity were 21.3%, 35.3%, and 51.2%, respectively. In certain cases of T1 with 2 mm < DOI ≤ 5 mm and 8 mm < LD ≤ 20 mm, the proportion of SLN metastasis positivity was 40.9%.

CONCLUSIONS

SLNB-navigated or assisted neck dissection can be added as an effective procedure for N0 neck control.

Sentinel lymph node biopsy in recurrent or secondary oral squamous cell carcinoma after previous neck dissection

OBJECTIVES

The aim of this retrospective study was to evaluate the potential of sentinel lymph node biopsy (SLNB) in patients with recurrent or a secondary oral squamous cell carcinoma (OSCC) without clinical signs of lymph node metastases (cN0), who were previously treated with a surgical approach.

PATIENTS AND METHODS

Retrospective analysis of all patients with cN0 recurrent or secondary OSCC, who were treated using SLNB after previous neck dissection. Endpoints were sentinel lymph node (SLN) detection rate, negative predictive value (NPV) and sensitivity.

RESULTS

A total of 17 patients with a mean age of 68.6 years were included. SLN were detected in 15 of 17 cases (detection rate: 88.2%). In seven patients (41.2%), a bilateral or contralateral lymph drainage of a unilateral carcinoma was found. Two patients (11.8%) demonstrated a positive SLN upon pathohistological analysis, which led to an upstaging. In one case, a non-SLN was positive, which is considered a false-negative result. The mean follow-up for all patients with histologically negative SLN including the patients without a detected SLN was 11.8 months (range: 0-31 months). Of these, one patient developed (isolated) neck recurrence after 12 months resulting in an overall NPV of 86.7% and a sensitivity of 50.0% for the SLNB as a neck staging procedure.

CONCLUSION

SLNB can improve the staging of patients with recurrent or secondary OSCC, who present with a history of a previous neck dissection. Further studies are required to demonstrate the oncological benefit of SLNB in this patient cohort.

Interventions for the treatment of oral cavity and oropharyngeal cancers: surgical treatment

BACKGROUND

Surgery is a common treatment option in oral cavity cancer (and less frequently in oropharyngeal cancer) to remove the primary tumour and sometimes neck lymph nodes. People with early-stage disease may undergo surgery alone or surgery plus radiotherapy, chemotherapy, immunotherapy/biotherapy, or a combination of these. Timing and extent of surgery varies. This is the third update of a review originally published in 2007.

OBJECTIVES

To evaluate the relative benefits and harms of different surgical treatment modalities for oral cavity and oropharyngeal cancers.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 9 February 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared two or more surgical treatment modalities, or surgery versus other treatment modalities, for primary tumours of the oral cavity or oropharynx.

DATA COLLECTION AND ANALYSIS

Our primary outcomes were overall survival, disease-free survival, locoregional recurrence, and recurrence; and our secondary outcomes were adverse effects of treatment, quality of life, direct and indirect costs to patients and health services, and participant satisfaction. We used standard Cochrane methods. We reported survival data as hazard ratios (HRs). For overall survival, we reported the HR of mortality, and for disease-free survival, we reported the combined HR of new disease, progression, and mortality; therefore, HRs below 1 indicated improvement in these outcomes. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We identified four new trials, bringing the total number of included trials to 15 (2820 participants randomised, 2583 participants analysed). For objective outcomes, we assessed four trials at high risk of bias, three at low risk, and eight at unclear risk. The trials evaluated nine comparisons; none compared different surgical approaches for excision of the primary tumour. Five trials evaluated elective neck dissection (ND) versus therapeutic (delayed) ND in people with oral cavity cancer and clinically negative neck nodes. Elective ND compared with therapeutic ND probably improves overall survival (HR 0.64, 95% confidence interval (CI) 0.50 to 0.83; I2 = 0%; 4 trials, 883 participants; moderate certainty) and disease-free survival (HR 0.56, 95% CI 0.45 to 0.70; I2 = 12%; 5 trials, 954 participants; moderate certainty), and probably reduces locoregional recurrence (HR 0.58, 95% CI 0.43 to 0.78; I2 = 0%; 4 trials, 458 participants; moderate certainty) and recurrence (RR 0.58, 95% CI 0.48 to 0.70; I2 = 0%; 3 trials, 633 participants; moderate certainty). Elective ND is probably associated with more adverse events (risk ratio (RR) 1.31, 95% CI 1.11 to 1.54; I2 = 0%; 2 trials, 746 participants; moderate certainty). Two trials evaluated elective radical ND versus elective selective ND in people with oral cavity cancer, but we were unable to pool the data as the trials used different surgical procedures. Neither study found evidence of a difference in overall survival (pooled measure not estimable; very low certainty). We are unsure if there is a difference in effect on disease-free survival (HR 0.57, 95% CI 0.29 to 1.11; 1 trial, 104 participants; very low certainty) or recurrence (RR 1.21, 95% CI 0.63 to 2.33; 1 trial, 143 participants; very low certainty). There may be no difference between the interventions in terms of adverse events (1 trial, 148 participants; low certainty). Two trials evaluated superselective ND versus selective ND, but we were unable to use the data. One trial evaluated supraomohyoid ND versus modified radical ND in 332 participants. We were unable to use any of the primary outcome data. The evidence on adverse events was very uncertain, with more complications, pain, and poorer shoulder function in the modified radical ND group. One trial evaluated sentinel node biopsy versus elective ND in 279 participants. There may be little or no difference between the interventions in overall survival (HR 1.00, 95% CI 0.90 to 1.11; low certainty), disease-free survival (HR 0.98, 95% CI 0.90 to 1.07; low certainty), or locoregional recurrence (HR 1.04, 95% CI 0.91 to 1.19; low certainty). The trial provided no usable data for recurrence, and reported no adverse events (very low certainty). One trial evaluated positron emission tomography-computed tomography (PET-CT) following chemoradiotherapy (with ND only if no or incomplete response) versus planned ND (before or after chemoradiotherapy) in 564 participants. There is probably no difference between the interventions in overall survival (HR 0.92, 95% CI 0.65 to 1.31; moderate certainty) or locoregional recurrence (HR 1.00, 95% CI 0.94 to 1.06; moderate certainty). One trial evaluated surgery plus radiotherapy versus radiotherapy alone and provided very low-certainty evidence of better overall survival in the surgery plus radiotherapy group (HR 0.24, 95% CI 0.10 to 0.59; 35 participants). The data were unreliable because the trial stopped early and had multiple protocol violations. In terms of adverse events, subcutaneous fibrosis was more frequent in the surgery plus radiotherapy group, but there were no differences in other adverse events (very low certainty). One trial evaluated surgery versus radiotherapy alone for oropharyngeal cancer in 68 participants. There may be little or no difference between the interventions for overall survival (HR 0.83, 95% CI 0.09 to 7.46; low certainty) or disease-free survival (HR 1.07, 95% CI 0.27 to 4.22; low certainty). For adverse events, there were too many outcomes to draw reliable conclusions. One trial evaluated surgery plus adjuvant radiotherapy versus chemotherapy. We were unable to use the data for any of the outcomes reported (very low certainty).

AUTHORS' CONCLUSIONS

We found moderate-certainty evidence based on five trials that elective neck dissection of clinically negative neck nodes at the time of removal of the primary oral cavity tumour is superior to therapeutic neck dissection, with increased survival and disease-free survival, and reduced locoregional recurrence. There was moderate-certainty evidence from one trial of no difference between positron emission tomography (PET-CT) following chemoradiotherapy versus planned neck dissection in terms of overall survival or locoregional recurrence. The evidence for each of the other seven comparisons came from only one or two studies and was assessed as low or very low-certainty.

Imaging of Neck Nodes in Head and Neck Cancers - a Comprehensive Update

Cervical lymph node metastases from head and neck squamous cell cancers significantly reduce disease-free survival and worsen overall prognosis and, hence, deserve more aggressive management and follow-up. As per the eighth edition of the American Joint Committee on Cancer staging manual, extranodal extension, especially in human papillomavirus-negative cancers, has been incorporated in staging as it is important in deciding management and significantly impacts the outcome of head and neck squamous cell cancer. Lymph node imaging with various radiological modalities, including ultrasound, computed tomography and magnetic resonance imaging, has been widely used, not only to demonstrate nodal involvement but also for guided histopathological evaluation and therapeutic intervention. Computed tomography and magnetic resonance imaging, together with positron emission tomography, are used widely for the follow-up of treated patients. Finally, there is an emerging role for artificial intelligence in neck node imaging that has shown promising results, increasing the accuracy of detection of nodal involvement, especially normal-appearing nodes. The aim of this review is to provide a comprehensive overview of the diagnosis and management of involved neck nodes with a focus on sentinel node anatomy, pathogenesis, imaging correlates (including radiogenomics and artificial intelligence) and the role of image-guided interventions.

The Sentinel Lymph Node in Treatment Planning: A Narrative Review of Lymph-Flow-Guided Radiotherapy

The sentinel lymph node technique is minimally invasive and used routinely by surgeons, reducing the need for morbid extensive lymph node dissections, which is a significant advantage for cancer staging and treatment decisions. The sentinel lymph node could also help radiation oncologists to identify tumor drainage for each of their patients, leading to a more personalized radiotherapy, instead of a probabilistic irradiation based on delineation atlases. The aim is both to avoid recurrence in unexpected areas and to limit the volume of irradiated healthy tissues. The aim of our study is to evaluate the impact of sentinel lymph node mapping for radiation oncologists. This concept, relying on sentinel lymph node mapping for treatment planning, is known as lymph-flow-guided radiotherapy. We present an up-to-date narrative literature review showing the potential applications of the sentinel lymph node technique for radiotherapy, as well as the limits that need to be addressed before its routine usage.

Current Treatment Strategies and Risk Stratification for Oral Carcinoma

Management of oral cavity squamous cell carcinoma (OSCC) involves a multidisciplinary team approach. Surgery is ideally the primary treatment option for nonmetastatic OSCC, and less invasive curative surgical approaches are preferred in early-stage disease to minimize surgical-related morbidity. For patients at high risk of recurrence, adjuvant treatment using radiation therapy or chemoradiation is often used. Systemic therapy may also be used in the neoadjuvant setting (for advanced-stage disease with the intent of mandibular preservation) or in the palliative setting (for nonsalvageable locoregional recurrence and/or distant metastases). Patient involvement in treatment decision is the key for patient-driven management, particularly in clinical situation with poor prognosis, for example, early postoperative recurrence before planned adjuvant therapy.

Diagnostic accuracy of combined optical- and radio-guided SNB for neck staging of oral squamous cell carcinoma lesions in the anterior oral cavity

PURPOSE

The purpose was to investigate the diagnostic performance of bimodal optical and radio-guided sentinel node biopsy (SNB) for oral squamous cell carcinoma (OSCC) sub-sites in the anterior oral cavity.

METHODS

Prospective study of 50 consecutive patients with cN0 OSCC scheduled for SNB was injected with the tracer complex Tc99m:ICG:Nacocoll. A near-infrared camera was applied for optical SN detection. Endpoints were modality for intraoperative SN detection and false omission rate at follow-up.

RESULTS

In all patients, a SN could be detected. In 12/50 (24%) of cases, the SPECT/CT showed no focus in level 1, but intraoperatively a SN in level 1 was optically detected. In 22/50 cases (44%), an additional SN was identified only due to the optical imaging. At follow-up, the false omission rate was 0%.

CONCLUSION

Optical imaging appears to be an effective tool to allow real-time SN identification comprising level 1 unaffected by possible interference of radiation site from the injection.

Traditional risk factors and nodal yield-still relevant with high-quality risk-adapted adjuvant treatment for locally advanced head and neck cancer?

OBJECTIVE

Patients with locally advanced head and neck cancer (LAHNC) often undergo multimodal therapy including radical resection of the primary tumor and neck dissection (ND) followed by risk-adapted adjuvant radio(chemo)therapy (R(C)T). Quality parameters influencing local control and survival of these patients have been postulated: resection status (R status), extranodal extension (ENE), interval to adjuvant treatment ≤6 weeks, R(C)T given when indicated, and nodal yield (NY) ≥18 lymph nodes per neck. For other solid tumors the trend is towards less extensive lymph node surgery to avoid toxicity such as lymphedema, damage to peripheral nerves, dysesthesia, or paresthesia. The present study aims to investigate whether the number of nodes removed during neck dissection for LAHNC is still predictive for outcome when patients receive risk-adapted adjuvant treatment according to current guidelines.

METHODS

Between 2008 and 2015, 468 patients with LAHNC undergoing R(C)T with curative intent were prospectively registered in a database (UICC III/IV). Among them, 359 patients received adjuvant treatment and 295 underwent neck dissection. There were 119 (40%) patients with an oropharyngeal primary, 49 (17%) with cancer of the larynx/hypopharynx, 88 (30%) of the oral cavity, and 39 (13%) of the nasal/paranasal sinuses and cancer of unknown primary (CUP). Median follow-up was 45.6 months. Histopathology revealed an R1 status in 65 (22%) cases and ENE in 93 (31%) cases. 150 (51%) patients received RCT; the median time to adjuvant treatment from the day of tumor resection was 44 days (35-54) and overall treatment time (OTT; time from surgery to the last day of R(C)T) was 90 days (82-101). Factors influencing disease-free survival (DFS) were adjusted and analyzed using CART analysis (removed nodes, number of positive nodes, body mass index (BMI), ENE, T and N classification, R status, and primary site). Local control (LC), distant metastases-free survival (DMFS), and overall survival (OS) were analyzed using Kaplan-Meier statistics and multivariate analysis (MVA) for factors predictive for DFS and OS.

RESULTS

CART analysis (Classification and Regression Trees) showed that T classification (T3/4) is the most important predictor for DFS, followed by age (> 61 years) and BMI (< 17.4). Primary site (OPC vs. other) and number of removed nodes (< 17) were shown to be less important for DFS, while ECE, N classification, and R status seem to be of little relevance. MVA revealed number of positive nodes, non-OPC, and T3/4 to be negative predictive factors for DFS. For OS, the number of positive nodes and non-OPC primary were predictive. Five-year rates were 86.1% for LC, 87.9% DMFS, 76.5% DFS, and 67.2% for OS.

CONCLUSION

In this patient cohort, the number of removed nodes is not relevant for DFS and OS, while the number of positive nodes and T classification have a negative impact on these endpoints. The high-risk factors positive resection margin and ECE seem to lose their negative impact on DFS and OS. High-quality care in head and oncology is only possible within a close multidisciplinary team and network.

Occult nodal metastases in T1-T2cN0 oral squamous cell carcinoma: Correlation between sentinel node positivity and completion neck dissection analysis

OBJECTIVES

Sentinel node procedure (SN) is a standard procedure that has shown its safety and effectiveness for T1/T2 cN0 oral squamous cell carcinoma (OSCC), with completion neck dissection (CND) for patients with positive SN. The aim of this study was to characterize the nodal involvement in a cohort of SN + OSCC.

MATERIALS AND METHODS

Patients with T1/T2 cN0 OSCC with positive SN with CND were included in this single-center, prospective cohort study between 2000 and 2013.

RESULTS

54/301 patients had at least one positive SN. In 43/54 (80 %) cases, only the SN(s) were invaded; with only one SN involved (SN+=1) in 36/54 (67 %) cases. No predictive factors of nodal involvement in the CND were found considering the followings: SN micro/macrometastases, primary tumor's depth of invasion (DOI), perineural spread, lymphovascular involvement, primary tumor location, T stage and extranodal extension. The SN micrometastatic involvement (n = 22) was significantly associated with only one SN + CND- (p = 0.017). In the group of patients with unique micrometastatic involvement in the SN (n = 20/54), there was a higher isolated nodal recurrence free time (p = 0.017).

CONCLUSION

80% of T1/T2 cN0 OSCC with positive SN had no other lymph node metastases in the CND, questioning the potential benefits of this procedure. Predictive factors such as the size of the SN metastasis need to be tested to stratify the risk of positive non-SN lymph nodes leading to a personalized treatment, lowering the therapeutic morbidity while maintaining the oncologic safety.

Macroscopic and multiple metastases in sentinel lymph node biopsy are respectively associated with poor prognosis in early oral cancer

BACKGROUND

A multicenter, randomized controlled phase III trial was conducted on sentinel lymph node biopsy (SLNB) and elective neck dissection for T1 (depth of invasion ≥ 4 mm)-T2N0M0 oral cavity squamous cell carcinoma. This study identified factors associated with poor prognosis in patients who underwent SLNB based on a subgroup analysis of this trial.

METHODS

We analyzed 418 sentinel lymph nodes (SLNs) from 132 patients who underwent SLNB. The metastatic SLNs were classified into three categories based on size-isolated tumor cells: < 0.2 mm, micrometastasis: ≥ 0.2 mm and < 2 mm, and macrometastasis: ≥ 2 mm. Three groups were formed based on the number of metastatic SLNs: no metastasis, 1 metastatic node, and ≥ 2 metastatic nodes. The size and number of metastatic SLNs on survival were evaluated using Cox proportional hazard models.

RESULTS

Patients with macrometastasis and ≥ 2 metastatic SLNs had worse overall survival (OS) and disease-free survival (DFS) after adjustment for potential confounders (HR for OS: macrometastasis, 4.85; 95% CI 1.34-17.60; ≥ 2 metastatic SLN, 3.63; 95% CI 1.02-12.89; HR for DFS: macrometastasis, 2.94; 95% CI 1.16-7.44; ≥ 2 metastatic SLN, 2.97; 95% CI 1.18-7.51).

CONCLUSIONS

In patients who underwent SLNB, a poorer prognosis was associated with macrometastasis or having ≥ 2 metastatic SLNs.

Management of the Contralateral Neck in Unilateral Node-Positive Oral Squamous Cell Carcinoma

INTRODUCTION

In lateralized oral squamous cell carcinoma (OSCC) with ipsilateral cervical lymph node metastasis (CLNM), the surgical management of the unsuspicious contralateral neck remains a matter of debate. The aim of this study was to analyze this cohort and to compare the outcomes of patients with and without contralateral elective neck dissection (END).

MATERIAL AND METHODS

A retrospective analysis of patients with lateralized OSCC, ipsilateral CLNM (pN+) and contralateral cN0-stage was performed. Patients were divided into two groups according to the surgical management of the contralateral neck: I: END; and II: no END performed. Adjuvant radiotherapy was applied bilaterally in both groups according to individual risk.

RESULTS

A total of 65 patients (group I: 16 (24.6%); group II: 49 (75.4%)) with a median follow-up of 28 months were included. Initially, there was no case of contralateral CLNM after surgery. During follow-up, 6 (9.2%) patients presented with recurrent CLNM. In 5 of these cases (7.7%), the contralateral neck (group I: 3/16 (18.8%); group II: 2/49 (4.1%)) was affected. Increased ipsilateral lymph node ratio was associated with contralateral CLNM (p = 0.07). END of the contralateral side showed no significant benefit regarding OS (p = 0.59) and RFS (p = 0.19).

CONCLUSIONS

Overall, the risk for occult contralateral CLNM in patients with lateralized OSCC ipsilateral CLNM is low. Our data suggest that END should not be performed routinely in this cohort. Risk-adapted radiotherapy of the contralateral neck alone seems to be sufficient from the oncological point of view.

Sentinel lymph node biopsy in early oral cancers: are we ready for it yet? Results from a survey among Indian surgeons treating oral cancers

OBJECTIVE

Emerging evidence has shown that sentinel node biopsy (SNB) is an oncologically safe option in patients with early oral cancer compared with elective neck dissection (END). However, its use on a routine basis could be associated with many challenges.

STUDY DESIGN

This online survey was conducted among the Indian surgeons treating patients with oral cancer to understand and comprehend the incidence and patterns of usage of SNB in their practice, their approach toward the use of SNB, and the possible challenges they face or perceive in its routine use in patients with early oral cancer.

RESULTS

We received 352 responses with a response rate of 47.63%. Most of the respondents (82.6%) were managing N-zero necks with END, only 15.1% (n = 53) respondents practiced SNB currently. Most respondents believed that SNB offered the advantage of better shoulder function compared with END (76.4% [n = 269]). The deterrents considered for routine use of SNB in early oral cancer were additional costs (71.9% [n = 253]), the unavailability of necessary expertise and infrastructure (87.2% [n = 307]), SLNB being a more time-consuming treatment (58.8% [n = 207]), a higher false negative rate (74.1% [n = 261]), and the possible need of a second surgery (82.4% [n = 290]).

CONCLUSIONS

Though SNB presently could be considered as an alternative treatment option, there seem to be various issues that need to be addressed before it can be adopted as a standard of care across centers.

Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update

Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.

Role of sentinel lymph node biopsy for oral squamous cell carcinoma: Current evidence and future challenges

Sentinel lymph node biopsy (SLNB) has been used across oncological specialties for prognostication, staging, and identification of occult nodal metastasis. Recent studies demonstrated the potential clinical utility of SLNB in oral cavity squamous cell carcinoma (OCSCC). Elective neck dissection is the current standard of care in early management of OCSCC with depth of invasion greater than 2-4 mm; however, majority of patients ultimately do not have nodal disease on final pathology. SLNB is an alternative procedure widely adopted in early cancer management in many oncological subspecialities. Several considerations such as depth of invasion, nodal mapping, histopathology methods, operator variability, postoperative complications, and advancement in preoperative and intraoperative imaging technology can guide the appropriate application to SLNB in OCSCC. The aim of this review is to discuss the current evidence for SLNB in the treatment of early stage OCSCC, imaging technologies that support SLNB procedures, and studies that are currently underway.

Neck and Shoulder Morbidity in Patients with Oral Cancer and Clinically Negative Node Neck Status: A Comparison between the Elective Neck Dissection and Sentinel Lymph Node Biopsy Strategies

The choice for the most optimal strategy for patients with a cT_1-2N₀ carcinoma of the oral cavity, sentinel lymph node biopsy (SLNB) or elective neck dissection (END), is still open for debate in many head and neck cancer (HNC) treatment centers. One of the possible benefits of the less invasive SLNB could be reduced neck and shoulder morbidity. Recent studies have shown a benefit in favor of SLNB the first year after intervention, but the long-term consequences and differences in neck morbidity remain unclear. This cross-sectional study aimed to research differences in neck and shoulder morbidity and Health-Related Quality of Life (HR-QoL) in patients with a cT_1-2N₀ carcinoma of the oral cavity, treated with either END or SLNB. Neck and shoulder morbidity and HR-QOL were measured with patient-reported questionnaires (SDQ, SPADI, NDI, NDII, EORTC-QLQ-C30, EORTC-QLQ-HN35) and active range of motion (AROM) measurements. In total 18 patients with END and 20 patients with SLNB were included. We found no differences between END and SLNB for long-term neck morbidity, shoulder morbidity, and HR-QOL. The significant differences found in the rotation of the neck are small and not clinically relevant.

AIRO GORTEC consensus on postoperative radiotherapy (PORT) in low-intermediate risk early stages oral squamous cell cancers (OSCC)

Evidence on the efficacy of postoperative radiotherapy (PORT) in low-intermediate risk squamous cell carcinoma of the oral cavity (OSCC) remains inconclusive. Members of a task force from two national radio-oncology Associations (AIRO and GORTEC) defined 14 clinically relevant questions to identify "gray areas" pertinent to the indication for PORT in this clinical setting. Consequently, a literature review was performed on the topic. The resulting statements were then rated by an Expert Panel (EP) using a modified Delphi method. Only radiation oncologists were part of the discussion and voting on the scenarios. There was agreement on the 14 statements at the first round of voting. The task force then decided to propose clinical cases for the two more controversial statements that had received a lower agreement to better capture the Experts' attitudes. The clinical cases highlighted a more significant decisional heterogeneity. However, the good level of consensus reached among the two Associations gives relevant support in informing clinical choices while acknowledging general indications cannot fit all clinical situations and do not replace multidisciplinary discussion.

Surgical Extent for Oral Cancer: Emphasis on a Cut-Off Value for the Resection Margin Status: A Narrative Literature Review

The optimal cut-off point of the resection margin was recently debated in oral cancer. To evaluate the current evidence of the dynamic criteria of the resection margin, a review of the available literature was performed. Studies were sourced from PubMed and EMBASE by searching for the keywords "mouth neoplasm", "oral cancer", "oral cavity cancer", "oral squamous cell carcinoma", "tongue cancer", "margins of excision", "surgical margin" and "resection margin". We found approximately 998 articles on PubMed and 2227 articles on EMBASE. A total of 3225 articles was identified, and 2763 of those were left after removing the duplicates. By applying advanced filters about the relevance of the subjects, these were narrowed down to 111 articles. After the final exclusion, 42 full-text articles were reviewed. The universal cut-off criteria of 5 mm used for determining the resection margin status has been debated due to recent studies evaluating the impact of different margin criteria on patient prognosis. Of note, the degree of the microscopic extension from the gross tumor border correlates with tumor dimensions. Therefore, a relatively narrow safety margin can be justified in early-stage oral cancer without the additional risk of recurrence, while a wide safety margin might be required for advanced-stage oral cancer. This review suggests a surgical strategy to adjust the criteria for risk grouping and adjuvant treatments, according to individual tumor dimensions or characteristics. In the future, it might be possible to establish individual tumor-specific surgical margins and risk stratification during or after surgery. However, the results should be interpreted with caution because there is no strong evidence (e.g., prospective randomized controlled studies) yet to support the conclusions. Our study is meaningful in suggesting future research directions and discussions.

Sentinel Lymph Node Identification in Cutaneous Head & Neck Cancer - Lymphoscintigraphy Late Phase

OBJECTIVE

Sentinel node (SN) biopsy following lymphoscintography is recommended for high-risk cutaneous malignancies. Herein, we investigate different lymphoscintography phases, focusing on the importance of the late static phase and the resultant discovery of distal echelon solitary positive sentinel nodes that would otherwise have been overlooked.

METHODS

In this retrospective cohort study, conducted in a tertiary referral medical center, we assessed SN localization and time from tracer injection to SN identification on lymphoscintigraphy. Findings on scan were compared with SN found in the surgical field, and with the final pathological investigation.

RESULTS

Seventy-three patients, undergoing SN biopsy for head and neck skin malignancies, were investigated. Most patients were male (n = 50). The average age was 65.7 (±15.7) years and the average follow-up time was 29.1 (±22.4) months. Overall, 101 SNs were histologically investigated, demonstrating 7 positive SN. Eleven patients (15%) benefited from the late lymphoscintigraphy phase. In four studies, an SN was identified only in the late static phase, one of which was positive for the disease. In seven patients, SN was identified in the early phase with additional, different, SN on the late phase, one of which was positive for the disease. Comparing the yield (positive SNs) of early versus late phases, demonstrated the same importance (p = 0.275).

CONCLUSIONS

The late lymphoscintigraphy phase has a crucial role in high-risk HN cutaneous cancer.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:2164-2168, 2022.

CT Lymphography Using Lipiodol® for Sentinel Lymph Node Biopsy in Early-Stage Oral Cancer

This study evaluated sentinel lymph node (SLN) identification with CT lymphography (CTL) following peritumoral administration of Lipiodol^® relative to conventional ^99mTc-nanocolloid lymphoscintigraphy (including SPECT/CT) in 10 early-stage oral cancer patients undergoing SLN biopsy. Patients first underwent early dynamic and static scintigraphy after peritumoral administration of ^99mTc-nanocolloid. Subsequently, Lipiodol^® was administered at the same injection sites, followed by fluoroscopy and CT acquisition. Finally, late scintigraphy and SPECT/CT were conducted, enabling the fusion of late CTL and SPECT imaging. The next day, designated SLNs were harvested, radiographically examined for Lipiodol^® uptake and histopathologically assessed. Corresponding images of CT, ^99mTc-nanocolloid lymphoscintigraphy and SPECT/late CTL fusion were evaluated. ^99mTc-nanocolloid lymphoscintigraphy identified 21 SLNs, of which 7 were identified with CTL (33%). CTL identified no additional SLNs and failed to identify any SLNs in four patients (40%). Out of six histopathologically positive SLNs, two were identified by CTL (33%). Radiographic examination confirmed Lipiodol^® uptake in seven harvested SLNs (24%), of which five were depicted by CTL. CTL using Lipiodol^® reached a sensitivity of 50% and a negative predictive value (NPV) of 75% (median follow-up: 12.3 months). These results suggest that CTL using Lipiodol^® is not a reliable technique for SLN mapping in early-stage oral cancer.

Ultrasound accurately assesses depth of invasion in T1‐T2 oral tongue cancer

Background

Depth of invasion (DOI) is important for the T‐classification of squamous cell carcinoma of the oral tongue (SCCOT) and incorporated in the TNM 8 classification of oral cavity cancer. To determine DOI clinical palpation is performed, but the preferred radiological modality remains controversial. The aim of this study was to investigate the assessment of DOI using ultrasound (US‐DOI).

Methods

The DOI was assessed in 40 patients with T1–T3 SCCOT by ultrasound, palpation, computed tomography and magnetic resonance imaging (MRI). Histopathological DOI (H‐DOI) was gold standard. Bland–Altman analysis was used to compare mean difference and 95% limits of agreement (LOA).

Results

The mean difference of US‐DOI was −0.5 mm (95% LOA −4.9–4.0) compared to H‐DOI and the mean difference for MRI was 3.9 mm (95% LOA −2.3–10.2). In the subgroup analysis of cT1‐T2 the US‐DOI mean difference was 0.1 mm and the 95% LOA limits −2.5–2.7.

Conclusions

Ultrasound seems to be the most accurate method to assess DOI in T1‐T2 SCCOT. MRI overestimates DOI and cannot assess a substantial proportion of the tumors.

Level of Evidence

2c.