Cervical lymph node metastasis from early-stage squamous cell carcinoma of the oral tongue (original) (raw)
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Journal of Clinical Oncology, 2019
PURPOSE The volume treated with postoperative radiation therapy (PORT) is a mediator of toxicity, and reduced volumes result in improved quality of life (QOL). In this phase II trial, treatment volumes were reduced by omitting PORT to the pathologically negative (PN0) neck in patients with primary head and neck squamous cell carcinoma. METHODS Patients with head and neck squamous cell carcinoma who underwent surgical resection and neck dissection with a PN0 neck and high-risk features mandating PORT to the primary and/or involved neck were eligible. The primary end point was greater than 90% disease control in the unirradiated neck. QOL was evaluated using the MD Anderson Dysphagia Inventory and the University of Michigan patient-reported xerostomia questionnaire. RESULTS Seventy-three patients were enrolled, and 72 were evaluable. Median age was 56 years (range, 31 to 81 years); 58 patients were male, and 47 (65%) had a smoking history. Sites included oral cavity (n = 14), oropharynx (n = 37), hypopharynx (n = 4), larynx (n = 16), and unknown primary tumor (n = 1). According to the American Joint Committee on Cancer Staging Manual (7 th edition), 67 patients (93%) had stage III/IV disease, and 71% of tumors involved or crossed midline. No patient had contralateral neck PORT. In 17 patients (24%), only the primary site was treated. At a median follow-up of 53 months, two patients experienced treatment failure of the PN0 unirradiated neck; they also experienced treatment failure locally. Unirradiated neck control was 97% (95% CI, 93.4% to 100.0%). Five-year rates of local control, regional control, progression-free survival, and overall survival were 84%, 93%, 60%, and 64%, respectively. QOL measures were not significantly different from baseline at 12 and 24 months post-PORT (P. .05). CONCLUSION Eliminating PORT to the PN0 neck resulted in excellent control rates in the unirradiated neck without long-term adverse effects on global QOL.
American Journal of Otolaryngology, 2012
Patients with surgically treated head and neck cancer and clinical N0 neck with high risk of occult lymph node metastasis undergo elective neck dissection (ND). Late lymph node metastasis may appear in those patients with pN0 neck. The aim of the present study was to analyze the incidence and clinical relevance of late lymph node metastasis in patients with head and neck cancer. Materials and Methods: The clinical data of 61 patients with head and neck cancer who had undergone elective ND with pN0 neck were retrospectively analyzed. Only patients without local failure, second primary, or radiochemotherapy were included in the study. Results: Late lymph node metastasis could be observed in 4 (6.5%) cases at the margin or outside the initially dissected lymph node levels. In those patients, the primary tumor was localized in the oral cavity (n = 3) or oropharynx (n = 1) and was classified in all cases as T1 or T2. Lymph node metastasis could be found in levels I (n = 2), II (n = 1), and IV (n = 1), respectively. Conclusion: Even in the case of pN0 neck after an elective ND, the appearance of late lymph node metastases must be expected. The low proportion of patients with late lymph node metastases after a selective ND in clinical and histologic N0 does not justify an extended form of neck surgery.
Head & Neck, 1991
An analysis of 508 patients (660 heminecks) with head and neck squamous cell carcinoma and clinically positive neck nodes who were treated with radiotherapy alone to the primary lesion (with or without a neck dissection) was conducted to determine if open neck-node biopsy before definitive treatment adversely affected the probability of control of neck disease, the risk of distant metastasis, or the cause-specific survival rate. The prognostic factors analyzed included biopsy status of the neck, N stage, neck treatment, node mobility, node location, T stage, primary site, and control of disease above the clavicles. Sixty-six patients who had undergone an open neck-node biopsy before definitive radiotherapy were compared with a control group of 442 patients who did not undergo a neck-node biopsy; no detrimental effect of the biopsy on neck control, distant metastasis, or cause-specific survival was demonstrated. We conclude that the potential adverse effect of violating the neck before definitive treatment cannot be demonstrated if radiotherapy is the next step in the patient's management. HEAD &
Management of the node-positive neck in oral cancer
Oral and maxillofacial surgery clinics of North America, 2008
Surgery continues to play a prominent role in the management of patients with loco-regionally advanced squamous cell carcinoma of the upper aerodigestive tract. Most evidence supports the use of comprehensive neck dissection for node-positive disease and suggests that planned neck dissection following definitive radiation therapy and chemoradiation therapy is unnecessary in the great majority of patients with node-positive neck disease who exhibit a complete response. Evidence for less aggressive therapy is much less compelling in patients with bulky adenopathy. For such patients, there is growing enthusiasm for selective or even super-selective neck dissection for surgical salvage. Finally, when cervical disease is so advanced as to involve the carotid artery, evidence continues to portend a dismal prognosis.
Management of the Clinically Negative Neck in Oral Squamous Cell Carcinoma: A Systematic Review
Journal of Cancer Research and Therapeutic Oncology, 2013
The decision regarding treatment of the clinically negative neck has been debated extensively. The aim of the current review was to answer the following questions: What is the optimal pre-treatment modality for diagnosing the cervical lymph nodes metastasis? Should a patient with a cN0 neck treated now or wait and see? Should the patient receive an elective neck dissection or should they be treated with elective neck radiation'? Are there prognostic factors that can guide us in our decisions in treating the neck? Which modality should be used for treating the neck? What are the future trends? Material and Methods: A computer literature search in MEDLINE, EMBASE, the Cochrane library and CENTRAL databases followed by extensive hand searching for identification of the relevant studies. The inclusion criteria include the following: the study should include patients treated for clinically negative neck of OSCC, report the management of the initial OSCC, include a comparison of the diagnostic methods for the neck metastasis in OSCC, and include comparison of different methods for treatment of the clinically negative neck of OSCC. 27 studies were eventually identified and systematically reviewed. Results: 27 studies fulfilled the inclusion criteria. A total of 3867 patients were reviewed (neck dissection= 2291 with recurrence in 148 patients, wait and see = 1523 with recurrence in 406 patients, radiotherapy = 11 with recurrence in 6 patients, combined therapy 42 with recurrence in 9 patients). Conclusion: based on the results of the current study, its seem the neck dissection superior to wait and see policy. Sentinel lymph node biopsy superior to Ultrasonography-guided cytology.
Laryngoscope, 1997
Optimal management of advanced neck metastases as part of an organ preservation treatment approach for head and neck squamous carcinoma (HNSC) is unclear. Since 1989, our management paradigm for patients on organ preservation was modified to incorporate planned early neck dissection before radiation therapy for patients who did not achieve a complete response (CR) of neck nodes after induction chemotherapy (IC). The purpose of this study was to determine if planned early neck dissection is a safe and effective approach in the management of advanced nodal disease as part of organ preservation. Fifty-eight consecutive patients with advanced HNSC who were entered in organ preservation trials using induction chemotherapy and radiation with surgical salvage were studied. Median follow-up was 26 months. Of the 68 patients, 71% were stage IV. Patients were grouped by nodal response to chemotherapy and N class, and were analyzed with respect to patterns of recurrence, complications, and survival. Overall, the rate of CR of neck nodes was 4 W. Fifty-one percent had less than a complete response of neck nodes after IC and required planned early neck dissection. There were no significant differences in patterns of recurrence, complications, interval time to start of radiation, recurrence, or survival rates between the CR and less than CR groups. These data suggest that planned early neck dissection for patients with less than CR in the neck after IC is not detrimental From the Head and Neck Tumor Biology Section (G.R.T.), and the Epidemiology, Statistics and Data System Branch (K.-T.w.), NIDCD/NIH,
Elective neck dissection in oral carcinoma: a critical review of the evidence
Acta otorhinolaryngologica Italica: organo ufficiale della Società italiana di otorinolaringologia e chirurgia cervico-facciale
more than 50% of patients with squamous cell carcinoma of the oral cavity have lymph node metastases and histological confirmation of metastatic disease is the most important prognostic factor. among patients with a clinically negative neck, the incidence of occult metastases varies with the site, size and thickness of the primary tumour. The high incidence rate of occult cervical metastases (> 20%) in tumours of the lower part of the oral cavity is the main argument in favour of elective treatment of the neck. The usual treatment of patients with clinically palpable metastatic lymph nodes has been radical neck dissection. This classical surgical procedure involves not only resection of level I to V lymph nodes of the neck but also the tail of the parotid, submandibular gland, sternocleidomastoid muscle, internal jugular vein and spinal accessory nerve. It is a safe oncological surgical procedure that significantly reduces the risk of regional recurrences, however it produces significant postoperative morbidity, mainly shoulder dysfunction. aiming to reduce morbidity, Ward and roben described a modification of the procedure sparing the spinal accessory nerve to prevent post-operative shoulder morbidity. Several clinical and pathological studies have demonstrated that the pattern of metastatic lymph node metastases occurs in a predictable fashion in patients with oral and oropharyngeal carcinoma. The use of selective supraomohyoid neck dissection as the elective treatment of the neck, in oral cancer patients, is now well established. However, its role in the treatment of clinically positive neck patients is controversial. Some authors advocate this type of selective neck dissection in patients with limited neck disease at the upper levels of the neck, without jeopardizing neck control. The main factors supporting this approach are the usually good prognosis in patients with single levels I or II metastasis independent of the extent of neck dissection, and the low rates of level V involvement in oral cavity tumours. Furthermore, the high incidence of clinically false-positive lymph nodes in oral cavity cancer patients is well recognized. In selected cases, supraomohyoid dissection could be extended to level IV, and followed by radiotherapy when indicated. Several reports have confirmed the usefulness of minimally invasive sentinel lymph node biopsy in melanoma and breast tumours. However, only preliminary data testing the feasibility of the method exist regarding the management of oral and oropharyngeal squamous cell carcinoma. The complexity of lymphatic drainage and the presence of deep lymphatics of the neck make application of this method difficult. This attractive concept has recently been explored by several investigators who examined the feasibility of identifying the sentinel lymph node in primary echelons of drainage from oral cavity squamous carcinoma. The current knowledge of sentinel lymph node biopsy does not allow avoiding the indication of elective neck dissection in clinical practice. Sentinel lymph node biopsy cannot be considered the standard of care at this time. However, there are multiinstitutional clinical trials testing this approach. management of occult neck node metastasis continues to be a matter of debate. The role of imaging methods such as ultrasound-guided needle biopsy, sentinel node biopsy and positron emission tomographycomputed tomography are still being evaluated as alternatives to elective neck dissections. Whether one of these techniques will change the current management of cervical node metastasis remains to be proved in prospective multi-institutional trials.
Squamous cell carcinoma of the head and neck: Management of the NX neck
International Journal of Radiation Oncology*Biology*Physics, 1991
Purpose: The judiciousness of open biopsy of lymph node mestastases in the neck is controversial. A retrospective review of treatment results at the University of Florida in patients who underwent excisional biopsy of a solitary metastatic neck node followed by radiotherapy was undertaken to determine whether the approach resulted in increased rates of regional and distant recurrence or wound complications. Methods and Materials: Between October 1964 and September 1987, 41 patients were referred for radiotherapy after excisional biopsy of a solitary cervical node containing metastatic squamous cell carcinoma from a known mucosal site (19 patients) or unknown primary (22 patients) in the head and neck. None had known gross residual neck disease. The neck stage (based on N stage before surgery or size of the excised node) was unknown in seven patients, Nl in 15 patients, N2A in 18 patients, and N3A in one patient. All patients received radiotherapy to the neck and two had a planned neck dissection after radiotherapy. Doses to the nodal bed ranged from 5485 cGy to 8100 cGy (median, 6675 cGy). Results: The probability of control of neck disease was 95% at both 5 and 10 years. Five-year probability of disease control above the clavicles was 90%. Distant metastasis occurred in 0 of 36 patients whose disease was controlled above the clavicles vs. 3 of 5 patients who suffered failure above the clavicles. Conclusion: Excisional biopsy of a solitary neck node followed by radiotherapy produced excellent regional control and no apparent increased rate of distant metastasis. Head and neck neoplasms, Lymphatic metastasis, Lymph node excision, Squamous cell carcinoma, Radiotherapy.