Sentinel Node Biopsy as Staging Tool in a Multimodality Treatment Approach to Cancer of the Oral Cavity and the Oropharynx

A retrospective analysis of 5-year post surgery recurrence of N0 neck and the role of methylene blue in sentinel lymph node biopsy

The aim of this study is to perform a retrospective analysis of the feasibility of the clinical application of SLNB using methylene blue dye (MBD) for the identification of SLN followed by frozen section biopsy to detect occult metastasis in clinically N0 necks. Hence, to know the reliability of MBD in reducing the need for extensive surgery.

Methods

We retrospectively analyzed the clinic pathological data of 48 patients with early oral cancer.The SLN identification rate (IR) was calculated in SLNB with MBD and the false-negative rate (FNR). Intra operative frozen section biopsy was done for all patients was compared with post-operative paraffin histopathology report and the prognosis of patients was analyzed.

Results

Analysis of the 48 SLNB cases showed that there were significant differences in SLN successful detection rate among patients with different site (p = 0.043) and clinical presentation (p = 0.007). Similar significant results (p < 0.05) were observed with intra-operative frozen and post-operative paraffin histopathology sections. SLNs were successfully detected in 37(77.1%) patients out of 48. The intra operative frozen histopathology completely matched with the post-operative paraffin histopathology showing 39 (81.2%) negative and 09 (18.8%) positive cases. A prognostic analysis of SLN detection based on 48 patients showed that the 5-year survival rate was 100%.

Conclusion

MBD has acceptable SLN identification rate and a low FNR(false negative report) in frozen sections. Stained SLNs with no SLN metastasis are associated with disease-free survival (DFS). Hence, MBD-SLN biopsy has significantly reduced the need for extensive neck dissection in N0 neck with less morbidity.

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.

Advances in diagnostic modalities to detect occult lymph node metastases in head and neck squamous cell carcinoma

Regional metastasis is a prominent feature of head and neck squamous cell carcinoma (HNSCC) and is an important prognostic factor. The currently available imaging techniques for assessment of the neck have limitations in accuracy; thus, elective neck dissection has remained the usual choice of management of the clinically N0 neck (cN0) for tumors with significant (≥20%) incidence of occult regional metastasis. As a consequence, the majority of patients without regional metastasis will undergo unnecessary treatment. The purpose of this review was to discuss new developments in techniques that potentially improve the accuracy of the assessment of the neck in patients with HNSCC. Although imaging has improved in the last decades, a limitation common to all imaging techniques is a lack of sensitivity for small tumor deposits. Therefore, complementary to improvements in imaging techniques, developments in more invasive diagnostic procedures, such as sentinel node biopsy (SNB) will add to the accuracy of diagnostic algorithms for the staging of the neck.

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.

High-Risk Cutaneous Squamous Cell Carcinoma without Palpable Lymphadenopathy: Is There a Therapeutic Role for Elective Neck Dissection?

PURPOSE

The beneficial role of elective neck dissection (END) in the management of high-risk cutaneous squamous cell carcinoma (CSCC) of the head and neck remains unproven. Some surgical specialists suggest that END may be beneficial for patients with clinically node-negative (N0) high-risk CSCC, but there are few data to support this claim. We reviewed the available literature regarding the use of END in the management of both CSCC and head and neck SCC (HNSCC).

METHODOLOGY

The available medical literature pertaining to END in both CSCC and HNSCC was reviewed using PubMed and Ovid Medline searches.

RESULTS

Many surgical specialists recommend that END be routinely performed in patients with N0 HNSCC when the risk of occult metastases is estimated to exceed 20%; however, patients who undergo END have no proven survival benefit over those who are initially staged as N0 and undergo therapeutic neck dissection (TND) after the development of apparent regional disease. There is a lack of data regarding the proper management of regional nodal basins in patients with N0 CSCC. In the absence of evidence-based data, the cutaneous surgeon must rely on clinical judgment to guide the management of patients with N0 high-risk CSCC of the head and neck.

CONCLUSIONS

Appropriate work-up for occult nodal disease may occasionally be warranted in patients with high-risk CSCC. END may play a role in only a very limited number of patients with high-risk CSCC.

The diagnostic role of radioactivity in sentinel nodes in oral and oropharyngeal cancer

Sentinel lymph node biopsy (SNB), using radioactive tracers, is a novel, interesting tool in the staging of patients with oral and oropharyngeal squamous-cell carcinoma (OOSCC), which could lead to a reduced rate of elective neck dissections. The aim of the study was to evaluate the ranking of measured radioactivity in the sentinel lymph nodes (SLNs) and to correlate these findings with histopathological results to assess the number of SLN being sufficient for exact staging of the neck. In 77 consecutive patients with T1-4 OOSCC clinically and positron emission tomography-staged N0, between 15 and 55 MBq of Tc- 99m-labeled albumin-microcolloids were injected peritumorally and 213 SLNs were excised by small skin incisions using a gamma probe 2-3 hours later. The counts per second (cps) were measured ex vivo and excised SLNs were ranked according to their cps defining the LN with the highest activity as primary SLN, followed by a 2nd, 3rd, and so forth, SLN. Elective neck dissections were not performed. Median activity was 213 cps. All levels harbored SLNs with a maximum (43%) in level II and a minimum in level V (1%). SLNs in level II had significantly higher tracer accumulation (median, 289 cps) than those in levels I (144 cps) and IV (149 cps), but distant levels did not have significantly lower counts, compared to proximal. Eight (8) pathologically positive SLNs in 7 patients (7/77 = 9%; median activity, 157 cps) were detected. The median counts of the positive SLNs were not significantly different from those of the 205 negative SLNs (235 cps). The positive SLN was the one with the highest tracer accumulation in 4 cases, with the second highest in 1 case, and with the third highest tracer accumulation in 2 cases. Three (3) positive SLN were in level IB, 4 in level IIA, and 1 in level III. One (1) patient had 2 positive SLNs: a SLN with the third highest activity in level IIB and a SLN with the fifth highest activity in level III. In OOSCC, excision of only 1 SLN is not feasible. The positive SLNs were not necessarily the hottest nodes. Utilizing radiotracer lymphatic mapping, the 3 SLNs with the highest activity should be excised for exact staging of the neck in patients with T1-3 tumors. Excision of all radioactive nodes is recommended until further studies will prove this result. Large T4a tumors should not be staged using SNB.

Sentinel lymph node biopsy in squamous cell carcinomas of the lips and the oral cavity—A single center experience

BACKGROUND AND OBJECTIVES

Despite the availability of initial data on sentinel lymph node biopsy (SLNB) in OSCC, its value in clinical practice remains unclear. The aim of this study is to evaluate the feasibility and potential of SLNB as a reliable staging procedure in early stage SCC of the lips and the oral mucosa.

METHODS

From 2001 to 2004, 40 patients with early stage SCC of the lips and oral cavity were enrolled. The main inclusion criteria were: cN0 category by MRI and ultrasound, tumor category T1-T2, for certain sites also T3. Patients with positive SLN underwent MRND and/or radiation. Patients with negative SLN were monitored monthly.

RESULTS

In eight patients, the SLN were positive. Two patients with negative SLN subsequently developed nodal disease (5% false negatives). Twenty-one patients have a follow-up longer than 24 months. Five patients died (one from nodal disease, one from local recurrence, and three from unrelated causes). One patient developed a second primary tumor, the remaining patients are free of disease.

CONCLUSIONS

SLNB may contribute to more targeted lymph node dissection strategies. Further studies will have to ensure the safety of this procedure in comparison to selective neck dissection.

Head and Neck Squamous Cell Carcinoma: Sentinel Node or Selective Neck Dissection

Improved knowledge about the metastatic behavior of mucosal squamous cell cancer of the head and neck made it possible to reduce the extension of elective and even therapeutic neck dissections by sparing selected levels, thereby reducing morbidity. The diagnostic question of when to treat a clinically negative neck to avoid unnecessary overtreatment, even through selective neck dissections, might be answered with sentinel lymph node biopsy. A thorough and sophisticated evaluation of this technique is necessary when defining suited patients.

Comparison of early telescope loading of non-submerged ITI implants in irradiated and non-irradiated oral cancer patients

OBJECTIVE

To compare early dental implant loading in irradiated and non-irradiated oral cancer patients in order to accelerate masticatory function improvement and quality of life.

PATIENTS AND METHODS

One hundred and fourteen non-submerged interforaminal ITI implants were early loaded in 30 patients after 3 weeks in situ (telescoped overdenture). Nineteen patients received 72 implants (63%) after local irradiation; 11 non-irradiated patients received 42 implants (37%) with a 24-month follow-up.

RESULTS

At 24 month follow-up, one early failure had occurred in an irradiated patient (=99% functioning implants in situ). Peri-implant bleeding and plaque index were similarly high in both groups (40 to 68% average). The Results of other measured parameters were as follows (values for mean; irradiated; non-irradiated patients with respective standard deviations; significance of comparison): bone loss (0.9+/-0.9; 1.4+/-0.9; 0.4+/-0.5 mM; P<0.01); Periotest score (-2.7+/-2.7; -2.4+/-2.2; -3.1+/-3.3; P<0.2); gingival recession (0.6+/-0.7 mM; 0.8+/-0.9 mM; 0.4+/-0.5 mM, P<0.02); and peri-implant probing depths (3+/-1.2; 2.6+/-0.6; 3.4+/-1.7 mM; P<0.002).

CONCLUSION

The results suggest reliable non-submerged implantation and early loading. However, bone loss in irradiated mandibles, combined with higher average Periotest values and gingival recession in an oral environment of altered saliva quantity, quality, microflora and local scarring, requires extended follow-up.

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

The routine use of a sentinel node biopsy (SNB) protocol in oral cavity squamous cell carcinomas (SCC) has been challenged on the basis of the elevated number of sentinel nodes (SNs) detected (>2.5) and on the multiply neck level involvement reported in several studies. These data limit the practical application of the protocol, because in such cases, it seems easier and safer to perform a selective neck dissection. The aim of our study is to perform radioguided surgery 1-3 h after lymphoscintigraphy (same day protocol) to detect the lymph nodes closest to the tumour site. In our study, 12 patients affected by cT1-2 N0 SCC of the oral cavity were submitted to a same day protocol of a lymphoscintigraphic examination (1-3 h before surgery) and a radioguided SNB. We used a hand-held gamma probe and performed an elective neck dissection on all patients. The SNs were found in all cases with 83% localised in the ipsilateral neck in only levels I-II. The mean number of SN detected was 2.1, with a mean pathological size of 13.8 mm measured on pathological specimen. Metastases were found in 5/12 cases (41.6%), on levels I, II and III and all were identified by step serial sectioning and routine H&E staining. This study confirms the accuracy of SNB in predicting the presence of occult metastases. This protocol is designed to detect SNs, which are almost always on neck level I and II, thereby limiting the number of nodes examined and the extension of the surgical approach.

[Organ-preserving treatment in inoperable patients with primary oral and oropharyngeal carcinoma: chances and limitations]

INTRODUCTION

The aim of this study was to demonstrate the chances of nonoperative therapy in those patients from an unselected population suffering from primary previously untreated squamous cell carcinomas of the oral cavity and the oropharynx who did not seem to be operable.

PATIENTS AND METHODS

Following interdisciplinary counseling and extensive individual discussion, 72 (21%) of 340 consecutive patients (1997-2004) did not or did not reasonably seem to be operable; three other patients with stage II disease refused surgery. Of the inoperable patients, 95%suffered from far-advanced stage IV disease, 8% had distant metastases, 14% had synchronous malignancies, 9% were aged over 85 years combined with advanced malignant disease, and nearly 50% were limited in their activity or were even bedridden. Depending on fitness and tumor extent, three therapy regimens were used: intra-arterial (i.a.) high-dose chemotherapy with systemic antagonization for palliation, induction with this i.a. high-dose chemotherapy followed by additional radiotherapy, and induction with the i.a. high-dose chemotherapy followed by additional radiochemotherapy.

RESULTS

Thirty-two patients were treated with i.a. chemotherapy alone for palliation with few acute side effects. The response rate was 34%, and a further growth of the tumour could be inhibited in 49%. The 1- and 2-year survival rates were 21 and 14%, respectively. The three patients who refused surgery experienced complete clinical remission and survived 8, 6, and 2 years, respectively, to date. Twenty-three patients were fit enough to receive additional radiotherapy, and 17 an additional radiochemotherapy. Of the patients, 22% had to cut short additional radiotherapy and 47% had to discontinue concomitant chemotherapy. The 1- and 2-year survival rates were 41 and 25%, respectively; 14 of these irradiated patients experienced long-lasting complete clinical remission >2 years.

CONCLUSION

About 20% of the patients classified as inoperable could achieve long-lasting remission. Viewed with caution, sex (male), performance state (ECOG) <3, and positive response to i.a. chemotherapy could be regarded as predictors for therapeutic success. The combination of i.a. chemotherapy and radiochemotherapy seemed to be most successful. Conversely, the therapies offered could not achieve a substantial improvement of survival in 80% of patients classified as inoperable; the most successful therapy combination could be offered to merely 23% of patients as classified inoperable due to reduced general condition. The i.a. high-dose chemotherapy has to be regarded as a well tolerated and effective palliation. This descriptive analysis must be followed by specific studies to establish clinical treatment recommendations.

Sentinel node biopsy and head and neck tumors—Where do we stand today?

BACKGROUND

Sentinel lymph node sampling may be studied profitably in series of patients with 1 tumor type, such as breast carcinoma, in 1 anatomic locale. The present work analyzes the efficacy of sentinel node sampling in a pathologically diverse group of lesions from an anatomically diverse region such as the head and neck; however, there are risks conflating the findings in different tumors with radically different behaviors, in the process producing muddled data. This report reviews the head and neck experience with sentinel sampling and concludes that certain tumor types that have a known propensity for aggressive behavior are the best candidates for trials employing sentinel node sampling; candidates include many cutaneous melanomas of the head and neck, oropharyngeal squamous carcinomas, and selected thyroid carcinomas. Despite the growing popularity of sentinel node sampling in a variety of regions of the body, however, at this juncture this technique remains an investigational procedure, pending demonstration of a tangible improvement in patient outcome through its use. It is recommended that studies of the efficacy of this technique strive, whenever possible, to segregate results of different tumor types in different head and neck locales from one another so as to produce more focused findings for discrete types of malignancies, and not group together tumor types that may in reality exhibit different biological behaviors.

Clinical photodynamic therapy of head and neck cancers-A review of applications and outcomes

As local control is tantamount to cure in head and neck cancer, an aggressive regimen of surgery and radiation remains the standard of care for most patients. Despite significant technical advances, these treatments are highly morbid. Further, patients who fail treatment have limited salvage options. Photodynamic therapy (PDT) and photodiagnosis (PD) of head and neck cancer offer significant potential for improved outcomes in a myriad of clinical indications ranging from in situ to recurrent disease. However, despite promising results, these modalities remain at the fringe of head and neck treatment options. Photofrin(®), Photosan and Foscan(®) are photosensitizers used clinically in head and neck PD/PDT. In addition, aminolevulinic acid (ALA), which gives origin to Protoporphyrin IX, an endogeneous photosensitizer, is also used for PD/PDT. We review the clinical literature on these photosensitizers to assist in the integration of these important modalities into the mainstream of head and neck oncological therapy.