Sentinel lymph node biopsy or elective neck dissection for patients with oral squamous cell carcinoma?

Sentinel lymph node biopsy (SNB) seems to be a promising method for staging clinically N0 neck in patients with oral squamous cell carcinoma (OSCC). In the present study, SNB was performed on 46 patients having elective neck dissection (END; six bilateral dissections) for T1–T3N0 OSCC. Sentinel lymph nodes (SLN) were first examined according to only slightly modified standard histopathologic protocol including sections at 1–2 mm intervals and H&E staining. SLN that appeared false negative (i.e. metastatic non-SLN without metastasis in a SLN) after the initial histopathologic examination were further assessed by step sectioning at 150 μm intervals and immunohistochemistry. Of the 47 neck sides with at least one SLN identified, nine contained metastasis in nine patients. After the initial histopathologic examination, SLNs were negative for malignant cells in four out of the nine metastatic neck sides. In one neck side, two metastatic SLNs were detected after the additional meticulous histopathologic work-up of the initially false negative SLNs. Therefore, in three neck sides the SLN did not contain metastasis although there was a metastasis in a non-SLN. In all these three cases with a false negative SLN, only one SLN had been identified. The sensitivity of the method (employing extensive histopathologic work-up) for detection of occult cervical metastasis was 67% (6/9 neck sides). The sensitivity of SNB for detection of occult metastasis seems to be poor in cases where only one SLN can be identified. The results of this study do not entitle us to entirely replace END by SNB in patients with OSCC.     

Recurrent advanced (T3 or T4) head and neck squamous cell carcinoma: is salvage possible?

BACKGROUND: Salvage surgery is often the only curative option for recurrent cancer. In patients whose initial tumor is stage T3 or T4, the primary therapy often makes salvage even more difficult. We therefore analyzed the outcome in patients who were originally treated for T3 or T4 squamous cell carcinoma of the oral cavity, larynx, oropharynx, or hypopharynx and who then had a recurrence and chose to undergo further therapy for cure. PATIENTS AND METHODS: From 1980 to 2000, a total of 940 patients were treated for stage T3 or T4 cancer. Forty-eight patients underwent salvage therapy for recurrence: 24 for primary site recurrence, 20 for regional recurrence, and 4 for locoregional recurrence. RESULTS: The mean time to recurrence was 14.0 months, and the mean survival time was 26.2 months. Among the 28 patients treated for primary site recurrence, the mean time to rerecurrence was 12.6 months, and the mean survival time was 27.3 months. Only 5 of the 28 patients had prolonged survival. The stage of the recurrent disease did not influence outcome. Among the 20 patients treated for neck recurrence, the mean time to recurrence was 14.0 months, and the mean survival time was 25.0 months. Six of the 20 patients had prolonged survival, but none had a recurrence in a previously dissected and irradiated neck. CONCLUSIONS: These results show the limited potential for survival in patients who have a recurrence after treatment for advanced primary site head and neck cancer. Patients who have not undergone all modalities of therapy have the potential for salvage, but even then the chances are limited. Given the morbidity of salvage therapy, and the limited chance for cure, physicians must cautiously counsel patients who are contemplating treatment of recurrent cancer after therapy for advanced disease.     

Is open surgery for head and neck cancers truly declining?

In the past two decades, major modifications in the way we treat head and neck cancers, due to advances in technology and medical oncology, have led to a decline in the use of open surgery as first-line treatment of cancers arising from several primary tumor sites. The incidence of tobacco- and alcohol-related squamous cell carcinoma of the pharynx and larynx has been steadily decreasing, with a rise in the incidence of human papillomavirus-related oropharyngeal tumors and the use of minimally invasive endoscopic surgery and non-surgical treatment modalities has increased in the treatment of all of these tumors. However, open surgery remains the initial definitive treatment modality for other tumors, including tumors of the skin, oral cavity, sinonasal cavities and skull base, salivary glands, thyroid and sarcomas. Selected group of nasal, paranasal, base of the skull and thyroid tumors are also candidates for minimally invasive procedures. For some indications, the rate of open surgery has actually increased in the past decade, with an increase in the incidence of oral cavity, thyroid and skin cancer, an increase in the number of neck dissections performed, and an increase in salvage surgery and free flap reconstruction. The use of minimally invasive, technology-based surgery—with the use of lasers, operating microscopes, endoscopes, robots and image guidance—has increased. Technology, epidemiology and advances in other domains such as tissue engineering and allotransplantations may further change the domains of competencies for future head and neck surgeons.     

Is there a role for neck dissection in T1 oral tongue squamous cell carcinoma? The UCLA experience

PurposeWe sought to examine prognostic and therapeutic implications, including cost-effectiveness, of elective neck dissection in the management of patients with clinically-determined T1N0 oral tongue carcinoma.Materials and methodsA retrospective review of patients with cT1N0 oral tongue squamous cell carcinoma who underwent surgical extirpation of primary tumor, with or without elective neck dissection, at UCLA Medical Center from 1990 to 2009 was performed. Cox proportional hazards regression was used to assess effects of variables on time to first loco-regional recurrence. A healthcare costs analysis of elective neck dissection was performed by querying the SEER-Medicare linked database.ResultsOf the 123 patients identified with cT1N0 squamous cell carcinoma of the oral tongue, 88 underwent elective neck dissection at the time of tumor resection while 35 did not. For all patients, disease-free survival at 3, 5, and 10 years was 93%, 82%, and 79%. Of the 88 patients undergoing elective neck dissection, 20 (23%) demonstrated occult metastatic disease. Male gender, tumor size, perineural invasion, and occult metastatic disease were individually associated with higher rates of loco-regional recurrence. There was no significant difference in loco-regional recurrence between those who underwent elective neck dissection and those who did not (HR = 0.76, p = 0.52). On cost analysis, neck dissection was not associated with any significant difference in Medicare payments.ConclusionsThe high rate of occult metastasis (23%) following elective neck dissection, which did not confer additional healthcare costs, leads to the recommendation of elective neck dissection in patients with cT1N0 oral tongue squamous cell carcinoma.     

Surgical margins in head and neck squamous cell carcinoma: what is ‘close’?

The aim of this systematic review is to evaluate the definition of close margin in head and neck squamous cell carcinoma (HNSCC), and its possible prognostic significance. An appropriate string was run on PubMed to retrieve articles discussing the ‘close’ surgical margin issue in HNSCC. A double cross-check was performed on citations and full-text articles retrieved. In total, 348 articles were identified. Further references were included by using the option “Titles in your search terms” option in PubMed. 15 papers were finally included for qualitative synthesis. In vocal cord surgery of HNSCC, a close margin could be considered to be ≤1 mm, in the larynx ≤5 mm, in the oral cavity ≤4 mm, and in the oropharynx ≤5 mm. In each patient, the choice of extent of close margin should be balanced against general condition, tumor stage, and functional issues to indicate appropriate adjuvant therapy.     

Is elective neck dissection necessary for the surgical management of T2N0 glottic carcinoma?

Objective

Evaluation of neck metastasis incidence in surgically treated T2N0M0 glottic carcinoma patients and discussion the necessity of elective neck dissection in this subset of larynx carcinomas.

Materials and methods

The patients who were staged clinically and radiologically as T2N0M0 glottic carcinoma having surgical intervention for their primary tumor and elective neck dissection between March 1996 and July 2009 with at least 2 years of follow up were included in the study. The recordings of patients were evaluated retrospectively for primary tumor location, vocal cord mobility, type of laryngectomy and neck dissection, results of histopathological examination, number of dissected lymph nodes for each specimen and for local and regional failure during the follow up.

Results

In the 13-year study period, 24 consecutive patients with a mean age of 56.4 were treated surgically with 20 frontolateral, three vertical laryngectomies and one cricohyoido-epiglottopexy; 19 lateral and 5 functional neck dissections were performed for the necks. Histopathological examinations of the neck dissection specimens revealed an average of 32 lymph nodes (8–65) and there was no metastasis in any of these specimens. After an average 58 months of follow-up, only one patient had local failure and no patients had regional failure.

Conclusion

As occult metastasis was not detected in any of the neck dissection specimens in cT2N0M0 patients and no regional failure was experienced during the follow-up period, it was concluded that the neck could be followed up without performing elective neck dissection in the surgical management of cT2N0M0 glottic carcinoma patients.     

Prospective analysis of 231 elective neck dissections in oral squamous cell carcinoma with node negative neck—To decide the extent of neck dissection

Objective

To evaluate the incidence of level IIB and IV lymph node metastases in patients of oral carcinoma with N0 necks. This study will help to decide the extent and need of routine comprehensive removal of these specific lymph node groups in selective neck dissection.

How long should we continue S-1 as adjuvant chemotherapy for squamous cell carcinoma of the head and neck?

Conclusion: It appears that patients with SCCHN should be recommended to take S-1 for more than 1 year and, if possible, more than 2 years, as adjuvant chemotherapy for SCCHN. Objectives: There is no established consensus on the duration of administration of S-1 as adjuvant chemotherapy for squamous cell carcinoma of the head and neck (SCCHN). Since it might be difficult to undergo prospective randomized study to identify the optimal duration of the administration period of S-1 without a standard, the authors have undergone a retrospective clinical study to decide the tentative standard of therapeutic duration of S-1 as adjuvant chemotherapy for SCCHN. Methods: The clinical records of 89 patients with SCCHN who underwent adjuvant chemotherapy with S-1 were investigated. Results: The median duration of S-1 administration as adjuvant chemotherapy for SCCHN was 7 months (range = 0.1–58 months). Disease-free survivals (DFSs) were generally longer when S-1 administration periods were longer. After adjusting for prognostic factors, S-1 administration periods of 24 months or longer showed significantly lower hazard ratios (HRs) than 0–12 months.     

Age as a prognostic factor for head and neck squamous cell carcinoma: should older patients be treated differently?

OBJECTIVE: In an aging society, one may expect to encounter more seniors with head and neck squamous cell carcinoma (HNSCC). The objective of this study was to question the appropriateness of feasible aggressive curative treatment for these older patients. DESIGN: A retrospective study. SETTING: A tertiary head and neck surgical oncology service. METHODS: A chart review of patients with HNSCC of the oral cavity, pharynx, and larynx, 75 years or older, who were primarily treated by our service from 1990 to 1999. MAIN OUTCOME MEASURES: Demographics, pretreatment comorbidities and treatment modalities, and their related morbidity and mortality were reviewed. Special attention was given to treatment decision making and long-term outcome. RESULTS: Twenty-six males and 14 females with an average age of 82.2 years were treated. Twenty-two had stage III and IV disease. All had at least one comorbidity. Four patients had palliative radiotherapy and were dead of disease within 6 months. Among the 36 patients who were treated for cure, there were 2 postoperative deaths, 11 recurrences, and 2 cases of distant metastasis. The average lifespan of the 34 survivors (until death or end of study) was 4.7 years. CONCLUSION: HNSCC is a serious disease that often necessitates aggressive treatment. All of the patients who were medically eligible received curative treatment, with age not serving as an exclusion criterion. The average survival almost approached the expected lifespan of a normal cohort (4.7 vs 6.3 years, respectively). Seniors with HNSCC may benefit from curative treatment, and exclusion should be based, as for younger subjects, on an individual basis.     

Is extended selective supraomohyoid neck dissection indicated for treatment of oral cancer with clinically negative neck?

Oral cavity tumors may develop occult metastases to the cervical lymph nodes. Current imaging techniques and routine histopathologic methods may fail to detect lymph node micrometastases, but the surgeon has to electively dissect a neck at risk of developing clinical disease. Supraomohyoid neck dissection has been the elective surgery for treating a clinically negative neck in patients with oral cavity primaries. A literature review revealed that level IV nodes can be significantly affected by occult disease with and without metastases in level I-III lymph nodes. This means that level IV nodes have to be included in the supraomohyoid neck dissection, resulting in a more extensive surgical procedure to ensure a margin of oncological safety.     

Why do patients with head and neck squamous cell carcinoma experience distant metastases: can they be prevented?

PURPOSE OF REVIEW: This article will examine recent publications that enhance our understanding of this process, and current areas of investigation for therapeutic intervention in preventing and treating metastatic disease. RECENT FINDINGS: Recent investigations have led to insights into the mechanisms of cellular adhesion, invasion, and angiogenesis. E-cadherin, integrins, and selectins are all pivotal in cell-cell adhesion and communication. Recent advances in the area of tumor angiogenesis have led to our discovery of endostatin, an anti-angiogenic peptide that has potential in treating metastatic head and neck cancer. Current trials looking at sentinel node mapping may allow us to evaluate the nodal status of early head and neck cancer and identify a subset of patients at risk for distant metastasis. SUMMARY: As our understanding of metastatic disease increases, so will our ability to intervene in the various pathways involved in metastatic evolution. Metastatic cells are likely to respond differently to chemotherapeutic agents. Agents inhibiting specific aspects of invasion, adhesion, and angiogenesis will need to be combined to intervene at these key steps. Continued investigation into the biology of the epidermal growth factor receptor has led to an increased understanding of the mechanisms of abrogation of apoptosis, increased cellular motility, and metastasis. Inhibition of the epidermal growth factor receptor pathway with the monoclonal antibody C-255 has been shown to inhibit these processes and will likely be effective in reducing the development of distant metastasis.     

Initial staging of head and neck squamous cell carcinoma. What is the place of bronchoscopy and upper GI endoscopy?

European Archives of Oto-Rhino-Laryngology - To determine the place of bronchoscopy and upper GI endoscopy in the initial staging of head and neck squamous cell carcinoma (HNSCC). A 10-year...