Lymphoscintigraphy and radioguided sentinel node biopsy in oral cavity squamous cell carcinoma: same day protocol

A Systematic Review of Oral Biopsies, Sample Types, and Detection Techniques Applied in Relation to Oral Cancer Detection

Background: Early identification of the stage of oral cancer development can lead to better treatment outcomes and avoid malignant transformation. Therefore, this review aims to provide a comprehensive overview that describes the development of standardized procedures for oral sample collection, characterization, and molecular risk assessment. This can help investigators to choose the appropriate sampling method and downstream analyses for different purposes. Methods: This systematic review was conducted according to the PRISMA guidelines. Using both PubMed and Web of Science databases, four independent authors conducted a literature search between 15 and 21 June 2021. We used key search terms to broaden the search for studies. Non-conforming articles were removed using an EndNote-based and manual approach. Reviewers used a designed form to extract data. Results: This review included a total of 3574 records, after eliminating duplicate articles and excluding papers that did not meet the inclusion criteria. Finally, 202 articles were included in this review. We summarized the sampling methods, biopsy samples, and downstream analysis. The biopsy techniques were classified into tissue and liquid biopsy. The common sequential analysis of tissue biopsy includes histopathological examination such as H&E or IHC to identify various pathogenic features. Meanwhile, liquid samples such as saliva, blood, and urine are analyzed for the purpose of screening to detect mutations in cancer. Commonly used technologies are PCR, RT-PCR, high-throughput sequencing, and metabolomic analysis. Conclusions: Currently, tissue biopsies provide increased diagnostic value compared to liquid biopsy. However, the minimal invasiveness and convenience of liquid biopsy make it a suitable method for mass screening and eventual clinical adoption. The analysis of samples includes histological and molecular analysis. Metabolite analysis is rising but remains scarce.

Radioguided sentinel node biopsy to avoid unnecessary neck dissection in T1-T2N0 oral cavity squamous cell carcinoma: personal experience with same day protocol

PURPOSE

Data from literature show a mean incidence of occult metastases of 33% in early OCSCC. The gold standard for most authors is a selective neck dissection and a routine pathological examination. 60-70% of unnecessary neck dissections with associated morbidity, can be avoided by using SNB. The aim of this study is to present the results of one of the major Italian centres for the SNB procedure, reserving neck dissection only for proven positive lymphatic metastases.

METHODS

From July 2004 to March 2015, 48 patients with transorally resectable cT1-T2N0 oral SCC were submitted to a lymphoscintigraphic examination one-three hours before surgery and a radio-guided SNB (same day protocol). Patients with a negative SNB were checked every 3 months by ultrasound examination. The minimum follow-up was 5 years.

RESULTS

Sentinel nodes were found in all cases, with 71% localized in the ipsilateral neck only in levels I-II. Metastases were found in 15 out of 48 cases (31.2%), on levels I, II and III. Further metastatic nodes were found in 6 cases in the neck dissection specimen. In the cohort of 33 patients with SNB negative at 5 years, no-one had a recurrence on the ipsilateral neck.

CONCLUSION

This study confirms the accuracy of SNB in predicting the presence of occult metastases, sparing the need for unnecessary neck dissection in 70% of cases. The same day protocol is designed to detect sentinel nodes, which are almost always on neck level I-II, thereby limiting the number of nodes examined and the extension of the surgical approach.

Usefulness of Sentinel Lymph Node Biopsy for Oral Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

We assessed the diagnostic accuracy of sentinel lymph node biopsy (SLNB) for detecting neck nodal metastasis in early oral squamous cell carcinoma (OSCC) as an alternative to elective neck dissection.

STUDY DESIGN

A systematic search for relevant literature was conducted in the PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases.

METHODS

Two reviewers individually searched the five databases up to November 2019. For studies that met inclusion criteria, data on patient diagnoses were pooled, including true positives, true negatives, false positives, and false negatives. Methodological quality was checked with the Quality Assessment of Diagnostic Accuracy Studies (version 2) tool.

RESULTS

In total, 98 observational or retrospective studies were included. The diagnostic odds ratio of SLNB was 326.165 (95% confidence interval [CI]: 231.477-459.587; I²  = 0%). The area under the summary receiver operating characteristic curve was 0.982. Sensitivity was 0.827 (95% CI: 0.804-0.848), and specificity was 0.981 (95% CI: 0.975-0.986). The correlation between sensitivity and the false positive rate was -0.076, which indicates that heterogeneity did not exist. Subgroup analyses were performed with the subgroups reference test type, publication year, and study type. No significant difference was found within the reference test type subgroup. However, differences within the publication year and study type subgroups were significant, where the retrospective study subgroup was significantly more sensitive and specific than the prospective study subgroup.

CONCLUSION

Results of this meta-analysis imply that the high specificity of SLNB supports its role as a diagnostic tool for patients with clinical tumor stage (CT)1-2 clinically negative (N0) OSCC. More studies should be done to further verify the results of this study.

LEVEL OF EVIDENCE

2a Laryngoscope, 131:E459-E465, 2021.

Intraoperative sentinel node imaging versus SPECT/CT in oral cancer - A blinded comparison

INTRODUCTION

Sentinel node biopsy (SNB) is gaining popularity as a staging tool in oral cancer. Protocol mandates radiotracer injection and pre-operative imaging (LSG ± SPECT/CT) in the nuclear medicine department. This approach limits application to accessible tumours and to centres with nuclear medicine. New technology, freehand single photon emission computed tomography (fhSPECT), has proved a useful adjunct in intraoperative imaging and localisation of sentinel nodes. This study investigates fhSPECT as an alternative to traditional imaging, an approach that would widen the remit of SNB.

METHODS

Fifty consecutive cT1-T2 N0 oral cancer patients received radiotracer followed by lymphoscintigraphy and SPECT/CT. Surgery was undertaken using fhSPECT by a surgeon blinded to pre-operative imaging. Prior to biopsy completion, results of pre-operative imaging were reviewed and any additional nodes removed. The accuracy of LSG, SPECT/CT and fhSPECT were compared.

RESULTS

Nineteen patients had positive sentinel nodes. Disease free survival for sentinel node positive versus negative was significant (p < 0.005). All modalities missed positive nodes in at least one patient. The false negative rate for lymphoscintigraphy, SPECT/CT and fhSPECT was 26.3%, 15.8% and 5.3% respectively.

DISCUSSION

These data show a surgeon naïve to the results of traditional pre-operative sentinel node imaging can use fhSPECT in the operating theatre to accurately locate sentinel nodes in oral cancer. Freehand SPECT showed excellent sensitivity and a low false negative rate offering the possibility of a streamlined intraoperative sentinel node protocol.

Diagnostic value of sentinel lymph node biopsy for cT1/T2N0 tongue squamous cell carcinoma: a meta-analysis

The aim of this study was to systematically evaluate the diagnostic value of the sentinel lymph node biopsy (SLNB) for cT1/T2N0 tongue squamous cell carcinoma (TSCC) patients. A comprehensive and systematic literature review was performed by searching the Embase and PubMed databases for English language articles published up to December 2016. The pooled overall sentinel lymph node (SLN) detection rate, sensitivity and negative predictive value (NPV) were used to evaluate the diagnostic value of SLNB which used neck dissection or follow-up as a reference test. The Q test and I ² statistic were used to assess the heterogeneity across the studies. Subgroup analyses were performed in consideration of higher contribution of different clinical characteristics on the SLNB diagnostic value. Begg's linear regression and Egger's regression tests were conducted to evaluate the publication bias. Thirty-five studies (with 1084 patients) were included. The pooled SLN detection rate was 98% (95% CI 97-100%). The pooled overall sensitivity and NPV of SLNB were 0.92 (95% CI 0.88-0.95) and 0.96 (95% CI 0.94-0.97), respectively. The subgroup analyses demonstrated that higher extracted number of patients (n ≥ 30) from the included studies achieved a more stable NPV than lower number of patients. SLNB can effectively predict the status of regional lymph nodes in cT1/T2N0 TSCC patients. With high sensitivity and NPV, SLNB can guide the treatment of SLNB-positive patients with neck dissections and those with negative SLNBs with follow-ups in order to avoid unnecessary surgical morbidity.

Effectiveness of Preoperative Lymphoscintigraphy for the Detection of Cervical Lymph Node Metastasis in Patients with Oral Squamous Cell Carcinoma

Background:

Oral squamous cell carcinoma (OSCC) is one of the most common malignant tumor. OSCC is the malignancy of squamous epithelium of oral cavity, which is the sixth most common malignancy reported worldwide and one with highest mortality rate among all malignancies.

Aims:

The aims of this study is to assess the diagnostic performance of lymphoscintigraphy (LSG) for the detection of cervical lymph node metastasis in patients with OSCC.

Materials and Methods:

This was a prospective study done in Oral and Maxillofacial Surgery Department and National Institute of Nuclear Medicine and Allied Science, Bangabandhu Sheikh Mujib Medical University during July 2015–June 2016. Thirty-six patients with OSCC were included in this study. Radioisotope technique was used in the detection of cervical metastases in patients with histologically proven OSCC. Patients were assessed by LSG after diagnosis of OSCC, and then, it was compared with postoperative histopathology report.

Results:

Lymphoscintigraphically out of 36 patients, 23 had lymphatic channel obstruction where histologically 20 patients had lymph node metastasis. There were 20 true positive cases, 13 true negative cases, and 3 false positive cases but no false negative case was found. The test of validity result reveals that sensitivity 100.0%, specificity 81.25%, accuracy 96.66%, positive predictive value 86.96%, and negative predictive value 100.0%.

Conclusion:

LSG for the detection of cervical lymph node metastasis has an important role for the management of OSCC. It is also cost-effective and decreases the morbidity.

Diagnostic Efficacy of Sentinel Lymph Node Biopsy in Early Oral Squamous Cell Carcinoma: A Meta-Analysis of 66 Studies

OBJECTIVES

The diagnostic efficacy of sentinel lymph node biopsy(SLNB) in early oral squamous cell carcinoma(OSCC) still remains controversial. This meta-analysis was conducted to assess the diagnostic value of SLNB in clinically neck-negative T1-2 OSCC.

METHODS

A systematic literature search for relevant literature published up to September 11, 2016 was conducted in PubMed, Embase, Web of Science, Cochrane Library and ClinicalTrials, and the reference lists of eligible studies were examined. Data from different studies were pooled to estimate the summary sentinel lymph node(SLN) identification rate, sensitivity, negative predictive value. Summary receiver operator characteristic curve(SROC) was plotted and area under the SROC curve (AUC) was calculated to evaluate the overall diagnostic efficacy. Threshold effect was assessed with use of the spearman correlation coefficient. Between-study heterogeneity was tested using the Q tests and the I2 statistics. Subgroup analyses were conducted in view of the greater effect of different study characteristics on diagnostic efficacy of SLN. Deeks' funnel plot asymmetry test was performed to evaluate publication bias. Sensitivity analysis was evaluated through omitting studies one by one and comparing the pooled results of random-effects model and fixed-effects model. All analyses were performed using Review Manager (version 5.3.5), Meta-DiSc (version 1.4), Comprehensive Meta Analysis (version 2.0) and STATA (version 12).

RESULTS

66 studies comprising 3566 patients with cT1-2N0 OSCC were included in this meta-analysis. The pooled SLN identification rate was 96.3%(95% CI: 95.3%-97.0%). The pooled sensitivity was 0.87 (95% CI: 0.85-0.89), pooled negative predictive value was 0.94 (95% CI: 0.93-0.95), and AUC was 0.98 (95% CI: 0.97-0.99). Subgroup analyses indicated that SLN assessment with immunohistochemistry(IHC) achieved a significantly higher sensitivity than without IHC.

CONCLUSIONS

This meta-analysis suggests that SLNB has a high diagnostic accuracy in cT1-2N0 oral squamous cell carcinoma, and is an ideal alternative to elective neck dissection. Furthermore, the use of IHC can significantly improve SLNB diagnostic sensitivity for early OSCC.

Sentinel Node in Oral Cancer: The Nuclear Medicine Aspects. A Survey from the Sentinel European Node Trial

PURPOSE

Nuclear imaging plays a crucial role in lymphatic mapping of oral cancer. This evaluation represents a subanalysis of the original multicenter SENT trial data set, involving 434 patients with T1-T2, N0, and M0 oral squamous cell carcinoma. The impact of acquisition techniques, tracer injection timing relative to surgery, and causes of false-negative rate were assessed.

METHODS

Three to 24 hours before surgery, all patients received a dose of Tc-nanocolloid (10-175 MBq), followed by lymphoscintigraphy. According to institutional protocols, all patients underwent preoperative dynamic/static scan and/or SPECT/CT.

RESULTS

Lymphoscintigraphy identified 723 lymphatic basins. 1398 sentinel lymph nodes (SNs) were biopsied (3.2 SN per patient; range, 1-10). Dynamic scan allowed the differentiation of sentinel nodes from second tier lymph nodes. SPECT/CT allowed more accurate anatomical localization and estimated SN depth more efficiently. After pathological examination, 9.9% of the SN excised (138 of 1398 SNs) showed metastases. The first neck level (NL) containing SN+ was NL I in 28.6%, NL IIa in 44.8%, NL IIb in 2.8%, NL III in 17.1%, and NL IV in 6.7% of positive patients. Approximately 96% of positive SNs were localized in the first and second lymphatic basin visualized using lymphoscintigraphy. After neck dissection, the SN+ was the only lymph node containing metastasis in approximately 80% of patients.

CONCLUSIONS

Best results were observed using a dynamic scan in combination with SPECT/CT. A shorter interval between tracer injection, imaging, and surgery resulted in a lower false-negative rate. At least 2 NLs have to be harvested, as this may increase the detection of lymphatic metastases.

Diagnostic evaluation of sentinel lymph node biopsy in early head and neck squamous cell carcinoma: a meta-analysis

BACKGROUND

The purpose of this study was to evaluate the efficacy of sentinel lymph node biopsy (SLNB) in early head and neck squamous cell carcinoma (HNSCC).

METHODS

The PubMed database was searched for studies published before October 31, 2012. Pooled values for the sentinel lymph node identification rate, sensitivity, false-negative rate, negative predictive value, and accuracy were calculated.

RESULTS

A total of 16 studies (987 patients) was included. The pooled identification rate, sensitivity, false-negative rate, negative predictive value, and accuracy were 95.2%, 86.3%, 13.7%, 94.2%, and 95.0%, respectively. The subgroup with high methodological quality showed a mean identification rate of 95.4% for SLNB validation trials and 94.2% for SLNB alone trials, and mean sensitivity of 91.0% for SLNB validation trials and 84.2% for SLNB alone trials.

CONCLUSION

The SLNB procedure has shown a high sensitivity rate, but the pooled sensitivity and false-negative rate were worse in SLNB alone trials than in SLNB validation trials.

Diagnostic value of sentinel lymph node biopsy in head and neck cancer: a meta-analysis

This study aimed to evaluate the diagnostic reliability of sentinel lymph node biopsy in patients with squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, and larynx by reviewing the published literature. A systematic literature review was performed using MEDLINE from 1970 to 2011. With Boolean search strings, search terms included sentinel node, supraglottic, supraglottis, tongue, head and neck, oral, pharynx, laryngeal, and larynx. Additional studies were identified through article references. Duplicate data and articles were excluded based on treating institution and study inclusion time period. Additional studies were excluded if the head and neck subsite or tumor stage was not specifically identified or if the sentinel lymph node biopsy occurred in previously treated necks. All patients had sentinel lymph node biopsy performed followed by a concurrent neck dissection. Twenty-six studies met our inclusion criteria (n = 766 patients). The pooled sensitivity and negative predictive value of SLNB for all head and neck tumors was 95 % (95 % CI 91-99 %) and 96 % (95 %CI 94-99 %), respectively. The overall sensitivity and negative predictive value of SLNB in the subset of oral cavity tumors (n = 631) was 94 % (95 % CI 89-98 %) and 96 % (95 % CI 93-99 %), respectively. One-hundred percent of oropharyngeal (n = 72), hypopharyngeal (n = 5), and laryngeal (n = 58) tumor sentinel lymph biopsy results correlated with subsequent neck dissections giving a negative predictive value of 100 %, showing that, sentinel lymph node biopsy is a valid diagnostic technique to correctly stage regional metastases in patients with head and neck squamous cell carcinoma.

Platinum concentration in sentinel lymph nodes after preoperative intra-arterial cisplatin chemotherapy targeting primary tongue cancer

CONCLUSION

We conclude that intra-arterially injected cisplatin passed via lymph flow into sentinel nodes (SNs) as the platinum concentration in the SNs was higher than that in the non-sentinel nodes (NSNs). It is possible that preoperative intra-arterial chemotherapy targeting primary cancer also has a therapeutic effect on subclinical metastatic SNs.

OBJECTIVES

Intra-arterial chemoradiotherapy has been reported to be effective against not only primary tumors but also nodal metastases. We considered the hypothesis that intra-arterially injected cisplatin passed via lymph flow into regional nodes. This study aimed to investigate intra-arterially injected cisplatin distribution to regional nodes by comparing platinum concentrations in SNs and NSNs.

METHODS

Five patients with T1-2 N0 tongue cancer were treated with preoperative intra-arterial chemotherapy (cisplatin, 100 mg/m(2)) targeting primary cancer. Partial glossectomy together with SN biopsy and elective neck dissection were performed 2 weeks after intra-arterial chemotherapy. Platinum concentrations in the lymph nodes were measured using a Zeeman atomic absorption spectrometer.

RESULTS

Thirteen SNs were harvested together with eight NSNs from the areas adjacent to the SNs. Platinum concentrations were then measured, revealing a significant difference in platinum concentration between the SNs and the NSNs (mean ± SD, 0.682 ± 0.246 µg/g vs 0.506 ± 0.274 µg/g; p = 0.049).

A comprehensive overview of radioguided surgery using gamma detection probe technology

The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.