Sentinel lymph node biopsy in head and neck squamous cell carcinoma

OBJECTIVES/HYPOTHESIS: Sentinel lymph node biopsy is a minimally invasive method to stage the regional lymphatics that has revolutionized the management of patients with intermediate-thickness cutaneous melanoma. Head and neck surgeons have been encouraged by the accuracy of sentinel lymph node biopsy in cutaneous melanoma and have applied the technique to patients with head and neck squamous cell carcinoma (HNSCC). The objectives of the study were 1) to study the feasibility and accuracy of sentinel lymph node biopsy as a method to stage the regional lymphatics in HNSCC and 2) to determine whether there are qualitative differences between the cutaneous and mucosal lymphatics that would affect the technique used in HNSCC. STUDY DESIGN: Two methods of investigation were employed: a prospective laboratory study using a feline model for sentinel lymph node biopsy and a retrospective review of patients who received lymphoscintigraphy before neck dissection and intraoperative identification of the sentinel lymph node. METHODS: Lymphoscintigraphy and a gamma probe were used in four felines to study the kinetics of technetium-labeled sulfa colloid (Tc-SC) in the mucosal lymphatics. In the second part of the feline study, eight subjects were studied intraoperatively. Tc-SC and isosulfan blue dye were used to study the injection technique for the mucosal lymphatics and to determine the time course of the dye and Tc-SC to the sentinel lymph node. In Part II of the present study, a retrospective review of 33 patients with HNSCC was conducted. Twenty patients (stage N0) whose treatment included elective neck dissection were studied with preoperative lymphoscintigraphy and underwent intraoperative identification of the sentinel lymph node to determine the accuracy and feasibility of sentinel lymph node biopsy. Eight patients with palpable neck disease and five patients with recurrent or second primary disease whose previous treatment included neck dissection were also studied with lymphoscintigraphy before neck dissection. RESULTS: In the feline study, both Tc-SC and isosulfan blue dye traversed the lymphatics rapidly, appearing in the sentinel lymph node in less than 5 minutes. Modification of the injection technique used for cutaneous melanoma was required to depict the sentinel lymph node of the base of tongue. In the human study, the sentinel lymph node was accurately identified in 19 of 20 (95%) N0 patients. On average, 2.9 sentinel lymph nodes (range, 1-5) were identified in 2.2 (range, 1-4) levels of the neck. Sentinel lymph nodes were bilateral in 4 of 19 patients. When the sentinel lymph node was identified, it accurately predicted the pathological nodal status of the regional lymphatics. Three of 20 patients had cervical metastases, and the sentinel lymph node was identified in 2 of 3 patients with pathologic nodes (pN+). Focal areas of radiotracer uptake were identified in seven of eight patients with palpable disease. These areas corresponded to the level with palpable disease in four patients. The lymphatics delineated by lymphoscintigraphy in the five patients with previous neck dissection were outside the levels that had been dissected. Lymphoscintigraphy depicted collateral patterns of lymphatic drainage. CONCLUSIONS: Sentinel lymph node biopsy is technically feasible and is a promising, minimally invasive method for staging the regional lymphatics in patients with stage N0 HNSCC. Lymphoscintigraphy alone may determine the levels that require treatment in patients with disrupted or previously operated cervical lymphatics.     

Sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma

The appearance of lymph node metastases represents the most important adverse prognostic factor in head and neck squamous cell carcinoma. Therefore, accurate staging of the cervical nodes is crucial in these patients. The management of the clinically and radiologically negative neck in patients with early oral and oropharyngeal squamous cell carcinoma is still controversial, though most centers favor elective neck dissection for staging of the neck and removal of occult disease. As only approximately 30% of patients harbor occult disease in the neck, most of the patients have to undergo elective neck dissection with no benefit. The sentinel node biopsy concept has been adopted from the treatment of melanoma and breast cancer to early oral and oropharyngeal squamous cell carcinoma during the last decade with great success. Multiple validation studies in the context of elective neck dissections revealed sentinel node detection rates above 95% and negative predictive values for negative sentinel nodes of 95%. Sentinel node biopsy has proven its ability to select patients with occult lymphatic disease for elective neck dissection, and to spare the costs and morbidity to patients with negative necks. Many centers meanwhile have abandoned routine elective neck dissection and entered in observational trials. These trials so far were able to confirm the high accuracy of the validation trials with less than 5% of the patients with negative sentinel nodes developing lymph node metastases during observation. In conclusion, sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma can be considered as safe and accurate, with success rates in controlling the neck comparable to elective neck dissection. This concept has the potential to become the new standard of care in the near future.     

Role of the head and neck surgeon in sentinel lymph node biopsy for cutaneous head and neck melanoma

OBJECTIVE: To determine the reliability of sentinel lymph node biopsy (SLNB) in head and neck cutaneous melanomas to accurately stage nodal basins, describe techniques for safe SLNB in the neck and parotid regions, and discuss treatments. STUDY DESIGN: Retrospective chart review with follow-up mean of 11 months. METHODS: The charts of 80 patients treated for head and neck cutaneous malignancies from January 2001 through June 2003 were reviewed for presentation, treatment, and outcome. RESULTS: All patients received lymphoscintigraphy and SLNB for melanoma with Breslow thickness greater than 1 mm. Accurate preoperative lymphoscintigraphy and blue dye injection along with facial nerve monitoring when indicated correlated with safe SLNB. Eleven (14%) patients required completion surgery after positive SLNB and underwent evaluation for adjuvant therapies. There were three cases with complications: two postoperative hematomas and one seroma. CONCLUSIONS: Safe and reliable SLNB depends on the knowledge of the anatomy in the head and neck region, reliability of preoperative lymph node mapping with lymphoscintigraphy, and possible additions of blue dye injection and facial nerve monitoring. Complete surgical treatment of positive SLNB cases along with adjuvant therapies potentially improves control of these cutaneous malignancies with manageable morbidity.     

Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck

OBJECTIVE: Our objective was to determine the proportion of patients disease free in the neck, with the primary site controlled, who have been treated with a selective neck dissection (SND) for squamous cell carcinoma (SCCa) of the upper aerodigestive tract, and who had cervical metastasis less than 3 cm. STUDY DESIGN: A cohort of patients who fit the inclusion/exclusion criteria was identified retrospectively. Then all surviving patients were followed for a minimum of 2 years. METHODS: A group of 52 patients who had 58 selective neck dissections for cervical metastases from SCCa of the upper aerodigestive tract were identified. The mean age was 56 years (range, 20-85 y), there were 40 males and 12 females, and mean follow-up was 24.5 months (range, 1-64 mo). Twenty-six patients had clinically negative (cNo) neck examinations and 26 had clinically positive neck examinations. Postoperative radiation was given for extracapsular spread, greater than 2 positive nodes, T3, T4, or recurrent disease if the patient had not received radiation before surgery. These radiation criteria excluded 18 patients from postoperative radiation treatment. RESULTS: Kaplan-Meier survival analysis showed that the regional control rate with the primary site controlled was 0.94. Six patients developed recurrent neck disease. Three of these 6 patientswere surgically salvaged. Four recurrences were in the dissected field and 2 were out of the dissected field (level V). CONCLUSIONS: With similar indications for radiation therapy, the regional control rate in this cohort is comparable to control rates obtained with modified radical neck dissection.     

前哨淋巴结检测在头颈部鳞状细胞癌中的应用

目的　评价前哨淋巴结 (sentinellymphnode ,SLN)检测在N0头颈鳞状细胞癌 (简称鳞癌 )中的可行性以及SLN对微小转移灶的诊断价值。方法　分析研究中国医学科学院肿瘤医院头颈外科 2 0 0 1年 8月～ 2 0 0 2年 2月收治的 10例头颈鳞癌患者 ,为未经治疗临床诊断为N0的患者。所有患者术前均在肿瘤周围的黏膜下注射锝标记的右旋糖酐胶体 (technetium 99m preparedwithdextrancolloid ,99mTc DX) ,约 30min后行单光子发射计算机断层显像术扫描 ,在相应的颈部皮肤上标记显像“热点” ;术中翻开皮瓣后用手提探测仪探测术野 ,以高于背景计数 4倍以上确定为SLN。将确定的SLN送病理学检查 ,并借助淋巴结连续切片和免疫组化法检测微小转移灶。结果　术前淋巴结显像及术中探测仪探测所识别的SLN行病理学检查 ,10例N0患者有 3例发现隐性转移 ,其隐性转移率为 30 % (3/ 10 ) ,SLN的阳性率为 2 2 .7% (5 / 2 2 ) ,非SLN的阳性率为 0 .4 % (1/ 2 4 7)。经病理证实为SLN阴性的患者的非SLN无阳性发现。结论　头颈鳞癌颈部N0的SLN检测对发现临床隐性转移灶是可行的。SLN检测技术可缩小手术范围 ,减少手术的创伤及并发症 ,该技术的进一步推广还需更多的研究。     

Histopathological features of occult metastasis detected by sentinel lymph node biopsy in oral and oropharyngeal squamous cell carcinoma.

OBJECTIVES: Sentinel lymph node biopsy has been introduced for head and neck cancer with promising results. Research in breast cancer has revealed different histopathological features of occult lymph node metastasis with possibly different clinical and prognostic implications. The aim of the study was to evaluate the histopathological features of occult metastasis detected by sentinel lymph node in oral and oropharyngeal squamous cell carcinoma. STUDY DESIGN: Prospective. METHODS: According to Hermanek (5), occult metastasis was differentiated into isolated tumor cells and infiltration of lymph node parenchyma smaller than 2 mm in diameter (micrometastasis) and larger than 2 mm in diameter (metastasis). RESULTS: Occult metastases were found in 6 of 19 (32%) sentinel lymph nodes. Three patients showed micrometastasis with a mean size of 1.4 mm (range, 1.2-1.5 mm), the first with three separate micrometastases within the same sentinel lymph node, the second with an additional cluster of isolated tumor cells within the same sentinel lymph node, and the third with an additional micrometastasis in one lymph node of the elective neck dissection. Two patients had macrometastasis (3.4 and 8 mm), both with multiple metastases in the elective neck dissection. One patient had two clusters of isolated tumor cells in the sentinel lymph node and an additional cluster of isolated tumor cells in one lymph node of the elective neck dissection. CONCLUSIONS: Occult metastasis can be subdivided histopathologically in isolated tumor cells, micrometastasis, and macrometastasis. We present the first study describing a great variety of these subtypes in sentinel lymph nodes from head and neck squamous cell carcinoma. Because the independent prognostic factor and clinical relevance of these subtypes is still unclear, we emphasize the importance of reporting these findings uniformly and according to well-established criteria.     

Sentinel lymph node biopsy staging for cutaneous malignant melanoma of the head and neck

Conclusion Sentinel lymph node biopsies (SLNBs) can be performed safely and with reasonable accuracy in HNM patients. The outcome provides important prognostic information concerning DFS and further treatment. However, one must recognize that SLNB is a multidisciplinary procedure with a learning curve for all. Objectives To evaluate efficacy of performing SLNBs in a series of consecutive patients with cutaneous head and neck melanoma (HNM)?≥?T1b from introduction of the procedure and 10 years onward. Method End-points comprised of SLNB outcome, disease-free survival (DFS), and overall survival (OS). Results SNs were harvested in 128 of 160 patients (median Breslow?=?2.0?mm, 29% ulcerated); success rate?=?80.0%, or 92.1% if excluding patients where SLNBs were omitted due to non-localization on pre-operative imaging or because of SN-location in the parotid basin. Ten patients (7.8%) had positive SLNBs and were offered early completion neck dissections. Of the 146 patients available for follow-up (median?=?27 months), 15.8% had recurrent disease. The risk of a regional nodal recurrence after a negative SLNB was 7.5%. SN-negative patients had improved DFS c.f. SN-positive patients (p?p?相似文献   

Perifacial lymph node metastasis in the submandibular triangle of patients with oral and oropharyngeal squamous cell carcinoma with clinically node-positive neck

OBJECTIVES: The objectives of this retrospective chart review were to investigate the rate of metastasis to the perifacial lymph node, which was defined as the nodal pads that lie anterior or posterior to the anterior facial vein on top of the facial artery in the submandibular triangle, and to identify its risk factors in patients with oral and oropharyngeal squamous cell carcinoma (OOSCC) with clinically node-positive neck. METHODS: Beginning in July 1999, we routinely removed the perifacial lymph node pads of the submandibular triangle (level Ib) from the main therapeutic comprehensive neck dissection (level I-V) specimen for evaluation of metastatic rate to this nodal group in patients with OOSCC with clinically node-positive neck. This study is a retrospective analysis of patients undergoing perifacial node sampling from July 1999 to March 2006. A total of 66 patients (17 patients with oral cavity cancer and 49 with oropharyngeal cancer) underwent perifacial lymph node dissections. Of these, three (two with oral cavity tumors and one with an oropharynx tumor) had clinically positive node in level I. RESULTS: The incidence rate of metastasis to the perifacial lymph node was 35% in oral cavity carcinoma (six of 17) and 8% in oropharynx carcinoma (four of 49). In addition, in patients without clinically positive level I node, the occult metastasis rate of the perifacial node was 27% in oral cavity carcinoma (four of 15) and 6% in oropharynx carcinoma (three of 48). Clinical or pathologic nodal staging above the N2b advanced lesion had a statistically significant association with perifacial lymph node metastasis (P < .05). CONCLUSION: Our data suggest that these nodal pads should be removed thoroughly for the treatment of node-positive neck in patients with oral cavity carcinoma. In contrast, however, complete removal may be unnecessary in comprehensive neck dissection of patients with oropharyngeal carcinoma with clinically node-positive neck, especially below nodal stage N2a.     

A review of clinical and histological parameters associated with contralateral neck metastases in oral squamous cell carcinoma

Oral squamous cell carcinoma(OSCC)bas a high incidence of cervical micrometastases and sometimes metastasizes contralaterally because of the rich lymphatic intercommunications relative to submucosal plexus of oral cavity that freely communicate across the midline,and it can facilitate the spread of neoplastic cells to any area of the neck consequently.Clinical and histopathologic factors continue to provide predictive information to contralateral neck metastases(CLNM)in OSCC,which determine prophylactic and adjuvant treatments for an individual patient.This review describes the predictive value of clinical-histopathologic factors,which relate to primary tumor and cervical lymph nodes,and surgical dissection and adjuvant treatments.In addition,the indications for elective contralateral neck dissection and adjuvant radiotherapy(aRT)and strategies for follow-up are offered,which is strongly focused by clinicians to prevent later CLNM and poor prognosis subsequently.     

Endoscopic sentinel lymph node biopsy in a porcine model

OBJECTIVE: The objective of this study was to investigate the feasibility of endoscopic sentinel lymph node biopsy in a porcine model. METHODS: One hundred microcuries of technetium-labeled sulfa colloid (Tc-SC) was injected into the right and left ventrolateral surfaces of the oral tongue of six adult Yorkshire pigs. A handheld gamma probe was used to locate the region of focal radioactivity on the neck that corresponded to the sentinel lymph node (SLN). Next, 0.25 mL of isosulfan blue dye was injected into the Tc-SC injection sites on the tongue. Endoscopic SLN dissection was then performed using a combination of balloon dissection and CO2 insufflation. The operative time, blood loss, and radioactivity of the SLN were measured for each animal. RESULTS: The SLN was detected transcutaneously with the gamma probe, and endoscopic SLN excision was successful. Endoscopic visualization and an endoscopic gamma probe confirmed the presence of both isosulfan blue dye and radiopositivity in the SLN in each pig. The procedure lasted 22 to 61 minutes (median duration, 35 minutes). There was no measurable blood loss in any of the animals. Mean radioactivity measured 14,466 counts/second per lymph node. CONCLUSIONS: Endoscopic SLN biopsy for oral tongue lesions is feasible and warrants further study.     

Sentinel lymph node mapping using SPECT–CT fusion imaging in patients with oral cavity squamous cell carcinoma

Lymphoscintigraphic planar imaging is commonly performed to locate the sentinel lymph nodes (SLN) preoperatively. The images are, however, obscure lacking anatomical information and only rough topographical orientation of the SLNs is possible. Image fusion of Single Photon Emission Computed Tomography (SPECT) and Computed Tomography (CT) has been suggested to be an anatomically more precise method for preoperative SLN mapping. In the present study, preoperative lymphoscintigraphic SLN mapping was performed by using a hybrid gamma-camera with CT system (SPECT–CT) in addition to conventional planar lymphoscintigraphy in 15 consecutive patients with squamous cell carcinoma (SCC) of the oral cavity. The planar images were compared to fused SPECT and CT images. SPECT–CT fusion images showed only one SLN that was not detected in planar images. Two SLNs suspected in planar images could be excluded by SPECT–CT. The location of the SLNs could be determined more accurately by SPECT–CT. SPECT–CT fusion imaging was found feasible for preoperative SLN identification in patients with oral cavity SCC. It enables more accurate localisation of the SLNs, but it rarely reveals SLNs, that are not detected on planar images.     

Soft tissue cervical metastases of squamous carcinoma of the head and neck

Some 497 of 3085 patients with squamous cell carcinoma of the head and neck treated between 1963 and 1990 had a later radical neck dissection at some time after initial treatment. The histological slides were all reviewed, firstly to confirm the presence of squamous cell carcinoma within the neck, and secondly to ascertain whether the metastasis was to soft tissue, to a lymph node or to both. The presence of extracapsular rupture in lymph node deposits was also assessed. Of the 497 patients, 138 had soft tissue deposits only, and 359 had nodal deposits only. Of the patients with nodal deposits 165 had extracapsular rupture and 194 did not. The 5-year survival of the 138 patients with soft tissue metastases was 27% compared with 33% for patients with extracapsular rupture and 50% for patients with no extracapsular rupture. Weighted logistic regression showed that soft tissue deposits were significantly more common in patients in poor general condition, plus poorly differentiated squamous cell carcinoma plus T₄ tumours (P < 0.005), and in patients with poorly differentiated squamous cell carcinoma plus T₄ tumours (P < 0.025). Cox's multivariate analysis with backward elimination showed that gender, histological differentiation, site of primary tumour and age of patient had no statistically significant effect on survival. The number of nodes (P < 0.0001), the presence of extracapsular rupture (P < 0.0001) and the presence of soft tissue free metastases (P < 0.001) were all highly significant. The N-status at recurrence also reached statistical significance (P < 0.0001).     

Sentinel lymph node biopsy in cutaneous melanoma of the head and neck using the indocyanine green SPY Elite system

Purpose

Lymph node status is the single most important prognostic factor for patients with early-stage cutaneous melanoma. Sentinel lymph node biopsy (SLNB) has become the standard of care for intermediate depth melanomas. Modern SLNB implementation includes technetium-99 lymphoscintigraphy combined with local administration of a vital blue dye. However, sentinel lymph nodes may fail to localize in some cases and false-negative rates range from 0 to 34%. Here we demonstrate the feasibility of a new sentinel lymph node biopsy technique using indocyanine green (ICG) and the SPY Elite near-infrared imaging system.

The impact of sentinel lymph node biopsy on the quality of life in patients with oral cavity squamous cell carcinoma

IntroductionSentinel lymph node biopsy is a proven method for staging the neck in patients with early oral cavity squamous cell carcinoma because it results in less comorbidity than the traditional method of selective neck dissection, with the same oncological results. However, the real effect of that method on the quality of life of such patients remains unknown.ObjectiveThe present study aimed to evaluate the quality of life of patients with oral cavity squamous cell carcinoma T1/T2N0 submitted to sentinel lymph node biopsy compared to those that received selective neck dissection.MethodsCross-sectional study including 24 patients, after a 36 month follow-up, 15 of them submitted to the sentinel lymph node biopsy and 9 to selective neck dissection. All patients answered the University of Washington quality of life questionnaire.ResultsThe evaluation of the questionnaires showed a late worsening of the domains appearance (p = 0.035) and chewing (p = 0.041), as well as a decrease of about 10% of general quality of life (p = 0.025) in patients undergoing selective neck dissection ??in comparison to those undergoing sentinel lymph node biopsy.ConclusionPatients with early-stage oral cavity squamous cell carcinoma undergoing sentinel lymph node biopsy presented better late results of general quality of life, mainly regarding appearance and chewing, when compared to patients submitted to selective neck dissection.     

Lymph node ratio as a prognostic factor for survival in patients with head and neck squamous cell carcinoma

Objective

The purpose of this study is to validate the concept of lymph node ratio (LNR) in head and neck squamous cell carcinoma (HNSCC).