Lymphatic drainage of the tongue and the soft palate

Potential of preoperative fluorodeoxyglucose-positron emission tomography/computed tomography to diagnose contralateral lymph node metastases in patients with oral cancer

OBJECTIVE

To establish a decision tree using preoperative PET/computed tomography (CT) parameters for detecting contralateral lymph node metastasis (CLNM) in oral cancer patients.

METHODS

In total, 140 patients with a confirmed histopathological diagnosis of oral carcinoma showed fluorodeoxyglucose accumulation of contralateral lymph nodes in PET images. Of 260 lymph nodes, eight were metastatic. We compared metastatic and non-metastatic nodes using Fisher-Freeman-Halton exact and Fisher's exact and Mann-Whitney U tests. The diagnostic performance was analyzed using receiver operating characteristic curves. We established a decision tree using exhaustive chi-squared automatic interaction detection algorithm.

RESULTS

Five PET/CT parameters were significantly different between metastatic and non-metastatic nodes: the longest ( P  = 0.015) and shortest ( P  = 0.023) diameter, and the maximum standardized uptake values (SUVmax) of the contralateral node ( P  = 0.030), primary tumor ( P  < 0.001), and ipsilateral node ( P  < 0.001). The area under the curves of SUVmax of the primary tumor (0.887), ipsilateral node (0.886), and longest diameter (0.752) were the largest and these three parameters were used as predictive criteria in the decision tree. The accuracy of the decision tree was 97.7% with 100% sensitivity and 97.6% specificity.

CONCLUSION

Preoperative PET/CT imaging with a decision tree has the potential to diagnose CLNM in patients with oral cancer.

Three-Dimensional Tumor Margin Demarcation Using the Hybrid Tracer Indocyanine Green-99mTc-Nanocolloid: A Proof-of-Concept Study in Tongue Cancer Patients Scheduled for Sentinel Node Biopsy

For radical resection of squamous cell carcinoma of the oral cavity, a tumor-free margin of at least 5 mm is required. Unfortunately, establishing in-depth margins is a surgical conundrum. Knowing that the hybrid sentinel node (SN) tracer indocyanine green (ICG)-^99mTc-nanocolloid generates temporary tattoolike markings at the site of administration, we studied the ability to apply this tracer for tumor margin demarcation combined with SN biopsy. Methods: Nineteen patients with clinical T1-T2 oral tongue tumors received the traditional superficial 3 or 4 deposits of ICG-^99mTc-nanocolloid (0.1 mL each), and in 12 patients additional deposits were placed deeply using ultrasound guidance (total of 6; 0.07 mL each). SN mapping was performed using lymphoscintigraphy and SPECT/CT. Before and directly after tumor excision, fluorescence imaging was performed to monitor the tracer deposits in the patient (fluorescent deposits were not used to guide the surgical excision). At pathologic examination, primary tumor samples were studied in detail. Results: The number of tracer depositions did not induce a significant difference in the number of SNs visualized (P = 0.836). Reproducible and deep tracer deposition proved to be challenging. The fluorescent nature of ICG-^99mTc-nanocolloid supported in vivo and ex vivo identification of the tracer deposits surrounding the tumor. Pathologic examination indicated that in 66.7% (8/12), all fluorescence was observed within the resection margins. Conclusion: This study indicates that tumor margin demarcation combined with SN identification has potential but that some practical challenges need to be overcome if this technique is to mature as a surgical guidance concept. Future studies need to define whether the technology can improve the radical nature of the resections.

Squamous cell carcinoma of the uvula: an analysis of factors affecting survival

OBJECTIVES/HYPOTHESIS

Uvular squamous cell carcinoma (SCC) is usually considered with soft palate tumors as an oropharyngeal cancer subsite. This investigation aims to determine whether the uvula itself is a high-risk subsite in the oropharynx for primary squamous cell carcinomas.

STUDY DESIGN

Retrospective analysis of a large population database.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified patients with T1 and T2 SCC of the oropharynx. Patients were categorized into two groups based on primary site: 1) uvula; and 2) oropharynx not otherwise specified. Clinicopathologic characteristics and disease-specific survival (DSS) were compared between the two groups.

RESULTS

Of the 9,833 patients we identified, 129 (1.3%) had primary uvular tumors. Primary tumors of the uvula were more likely to be smaller lesions at diagnosis (P < .001) and to present at a lower anatomical stage (P < .001). They also presented with less concurrent nodal metastasis (P < .001) and lower histological grade (P < .001). There was no evidence that size of uvular SCC lesion had any effect on nodal disease (P = .54), and survival was the same for T1 and T2 uvular SCC patients (P = .14). DSS was similar between the two groups as well (P = .7629).

CONCLUSIONS

Our data indicate that primary SCC of the uvula does not have a worse prognosis, and tends to be recognized earlier and treated more definitively than SCC found in other oropharyngeal regions. However, survival being equivalent between two distinctive groups is perplexing, and may indicate an underlying aggressiveness to uvular cancers.

T1-T2 Squamous Cell Carcinoma of the Uvula

Objective. No specific epidemiology data are available for carcinoma of the uvula. This study aims to analyze the epidemiological characteristics and treatment outcomes of carcinoma of the uvula at the authors’ institution.

Study Design. Case series with chart review.

Setting. Service of ENT–Head and Neck Surgery, University Hospital Complex of Santiago de Compostela (CHUS), Spain.

Subjects and Methods. Retrospective epidemiological study of 21 male patients, mean age 57.52 years, diagnosed with squamous cell carcinoma of the uvula in the CHUS between January 1990 and June 2009.

Results. Most patients presented with odynophagia and exophytic lesions microscopically consistent with moderately differentiated squamous cell carcinoma. Despite the size of the lesions (T1 and T2), more than half of the patients had lymph node metastases at diagnosis. More than 90.0% of patients with lesions larger than 1 cm presented with lymph node metastases. Although more than 70.0% of patients underwent a neck dissection in the first year after diagnosis, only 25.0% were free of metastatic disease. Recurrences occurred at a mean of 14 months from baseline in more than 50.0% of cases. Of the patients, 52.4% died, with a median survival of 38.15 months after diagnosis. The overall 5-year survival was 39.0%. According to tumor size, 5-year survival was 53.0% for T1 and 27.0% for T2.

Conclusion. According to the data, clinical features of carcinoma of the uvula correspond with aggressive tumors, with rapid onset and a major negative impact regardless of tumor size at diagnosis. Early stage patients benefit significantly from surgical treatments with neck dissections.