Value of sentinel lymphonodectomy in head and neck cancer patients without evidence of lymphogenic metastatic disease

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.

SPECT-CT and intraoperative portable gamma-camera detection protocol for sentinel lymph node biopsy in oral cavity squamous cell carcinoma

OBJECTIVE

The aim of this study was to evaluate a multimodality approach to sentinel lymph node biopsy (SLNB) detection with lymphoscintigraphy and single-photon emission computed tomography (SPECT)/computed tomography (CT). When combined with intraoperative imaging by a portable gamma camera (PGC), improved SLNB accuracy and detection rate may result.

MATERIAL AND METHODS

A total of 42 patients selected for SLNB in node-negative T1 and T2 oral squamous cell carcinoma were retrospectively analyzed. The detection protocol consisted of preoperative lymphoscintigraphy and SPECT/CT performed the day before surgery. Intraoperative sentinel lymph node (SLN) detection was done with the aid of a PGC in association with hand-held gamma probe.

RESULTS

All SLN detected in the preoperative study could be harvested except for one case. A total of 131 SLN were resected. This number was higher than the SLN depicted on lymphoscintigraphy (119 SLNs) and SPECT/CT (123 SLNs). Sublingual SLNs were observed in two cases (4.76%). These SLNs were detected by SPECT/CT but not by lymphoscintigraphy. Five (3.8%) additional SLNs not previously visualized on lymphoscintigraphy or on SPECT/CT were detected intraoperatively with the aid of the PGC. Positive SLNs were detected in eight cases (19%). Micrometastases were detected in five cases (62%) and macrometastases in three cases (38%).

CONCLUSION

The SLNB detection protocol described contributes to more accurate study and detection.

Validity of Sentinel Lymph Node (SLN) Detection following Adjuvant Radiochemotherapy (RCT) in Head and Neck Squamous Cell Carcinoma (HNSCC)

The effect of preoperative radio chemotherapy on lymphatic drainage and intraoperative gamma probe-guided sentinel lymph node detection has yet not been investigated. In this study, we study 13 patients with SCC. Sentinel lymph node (SLN) imaging of the patients was performed using SPECT-CT. Special care was taken to use identical injection sites for both studies. Imaging comprised planar and SPECT, iterative reconstruction and were viewed with the co-registered CT image. The results were validated by comparison with the histological results of intraoperative gamma probe detection and histology of the completed neck dissection. Identical SLNs were found in 6/13 patients. In 2/13 cases SLN biopsies were false-negative. In 4/13 patients preoperative SLN imaging identified more/additional nodes than the initial imaging, whereas fewer nodes were seen in 3/13 patients. Neither the primary tumor site nor the TNM stage was predictive for changes in the lymphatic drainage pattern. No constant effect of irradiation could be demonstrated. Preoperative radio chemotherapy has an unpredictable influence on the lymphatic drainage pattern in HNSCC. Consequently, the intraoperative gamma probe-guided sentinel lymph node detection after radio chemotherapy does not reveal the SLN of carcinogenesis. Thus, we advise fused functional/anatomical imaging (SPECT-CT) before and after radiochemotherapy if the SLN concept is utilized in HNSCC.

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

OBJECTIVES: Feasibility of sentinel lymph node (SLN) biopsy in head and neck cancer as a staging tool embedded in a multimodality regimen including neoadjuvant intraarterial chemotherapy.

STUDY DESIGN AND SETTING: 39 patients with oral and anterior oropharyngeal cancer classified N0 by [18F]FDG-PET underwent SLN scintigraphy. Selective SLN biopsy without elective neck dissection (ND) was performed, immediately followed by radical resection of the primary tumor. Histopathology included step-serial sections and immunocyto-chemistry.

RESULTS: Lymphoscintigraphy detected 104 spots. In 15 patients there was bilateral drainage. 114 SLN were excised due to additional intraoperative discrimination. 95% of visualised SLN could be removed. Histology was positive in 3 patients (8%), all underwent ND which yielded another positive node in 2 cases. Median observation time was 30 months. Two patients (5%) had a neck relapse in combination with a second primary.

CONCLUSIONS: SLN biopsy as only surgical staging tool seems to be feasible.

SIGNIFICANCE: Method promises reduction of elective ND and morbidity in N0 patients.

Comparative study of sentinel lymph node biopsy in clinically N0 oral tongue squamous cell carcinoma: Long-term oncologic outcomes between validation and application phases

OBJECTIVE

This study tested the long-term outcomes of sentinel lymph node biopsy (SLNB) for oral tongue squamous cell carcinoma (SCC) during the transition from validation to application phase.

MATERIALS AND METHODS

Sensitivity, negative predictive value (NPV), neck control rate, disease-specific survival (DSS), disease-free survival (DFS), and overall survival (OS) were compared in cN0 oral tongue SCC patients from different phases.

RESULTS

A total of 133 SLNs from 61 patients (21 in the validation phase, 40 in the application phase) were harvested. Fourteen SLNs of 12 patients (6 in each phase) were positive for metastasis (occult metastasis rate, 19.6%). Regional recurrences developed from 5 negative SLNs (one in the validation phase, 4 in the application phase), of whom 3 patients were successfully salvaged. Sensitivity and NPV of the validation phase were both 100%, with 60.0% and 88.2% in the application phase. False omission rates were 6.6% (1/15) in the validation group, and 11.7% (4/34) in the application group, respectively. The neck control rate was 95.2% in the validation phase and 97.5% in the application phase (p=0.52). No differences were evident in DSS, DFS, and OS between the two phases (DSS: 92.5% vs 95.2%, p=0.69; DFS: 85.0% vs 90.4%, p=0.40; OS: 90% vs 85.5%, p=0.62). Subgroup analyses between negative- and positive-SLNs within each phase revealed no significant differences in all endpoints.

CONCLUSION

Given higher false negative cases in the application phase, stringent strategy of follow-up and salvage treatment is mandatory to maintain acceptable outcomes.

Sentinel lymph node biopsy in clinically N0 T1-T2 staged oral cancer: the Dutch multicenter trial

OBJECTIVES

Results of the Dutch multi-institutional trial on sentinel lymph node (SLN) biopsy in oral cancer.

PATIENTS AND METHODS

Patients were consecutively enrolled from 4 institutions, with T1/T2 oral cancer and cN0 neck based on palpation and ultrasound guided fine needle aspiration cytology. Lymphatic mapping consisted of preoperative lymphoscintigraphy. For intraoperative SLN detection a gamma-probe was used and in some patients additional blue dye. SLN negative patients were carefully observed, SLN positive patients were treated by neck dissection, radiotherapy or a combination of both. Endpoints of the study were risk of occult lymp node metastases, neck control, accuracy, 5-year disease-free survival (DFS), overall survival (OS) and disease-specific survival (DSS).

RESULTS

Twenty of 62 patients (32%) had positive SLNs. Macrometastases were found in 9 patients, micrometastases in 8, and isolated tumour cells in 3 patients. Median follow-up was 52.5 months. Of the 42 SLN negative patients, 5 developed a regional recurrence of whom 4 patients could be successfully salvaged. DFS, OS and DSS of SLN negative patients were 72.0%, 92.7% and 97.4%, and for SLN positive patients these numbers were 73.7%, 79.7%, 85.0%, respectively (DFS: p=0.916, OS: p=0.134, DSS: p=0.059, respectively). Neck control rate was 97% in SLN negative and 95% in SLN positive patients. Sensitivity was 80% and negative predictive value 88%.

CONCLUSION

SLN biopsy is able to reduce the risk of occult lymph node metastases in T1/T2 oral cancer patients from 40% to 8%, and enables excellent control of the neck.

Usefulness of sentinel node navigation surgery in the management of early tongue cancer

OBJECTIVE

To determine the validity of sentinel node navigation surgery (SNNS) in early stage tongue cancer, the occurrence rate of postoperative cervical metastasis (POCM) after lead plate technique (LPT) introduction and survival rates in patients who underwent SNNS were analyzed.

METHODS

SNNS was performed in 29 patients (stage I: 14, stage II: 15) from 2000 to 2007. Tc-labeled phytate was prepared as a radiotracer a day before SNNS. The sentinel node (SN) was then examined pathologically during surgery. For cases where metastasis in SN was positive, neck dissection was performed. Occurrence of POCM after LPT introduction was compared with that before LPT introduction. 'Wait and see' policy was performed in 52 patients (stage I: 27, stage II: 25) from 1987 to 1999 as a historical control. The observation period of SNNS cases and 'wait and see' policy cases ranged from 10 months to 165 months (median: 91 months) and from 7 months to 268 months (median: 87 months), respectively.

RESULTS

Six of the 29 SNNS cases (21%) were proven metastatic SNs. Before LPT introduction, POCM occurred in 2 of the 15 cases, while we had no occurrences after LPT introduction. The 5-year overall survival rate of the 29 patients who underwent SNNS and the 52 patients with 'wait and see' policy were 96% and 84%, respectively, and there was statistical significance in the two groups (p<0.05).

CONCLUSIONS

As the survival rate of the patients with the SNNS tended to be better than that with the 'wait and see' policy in our cases, SNNS could avoid unnecessary neck dissection. SNNS provides useful information regarding decision-making for neck dissection in early stage tongue cancer.

Occult metastases detected by sentinel node biopsy in patients with early oral and oropharyngeal squamous cell carcinomas: impact on survival

BACKGROUND

Analysis of the lymphatic drainage pattern, the reliability of a negative sentinel lymph node biopsy (SLNB), as well as the impact of sentinel lymph node (SLN) metastases on regional control and survival in patients with early stage oral and oropharyngeal squamous cell carcinoma (SCC).

METHODS

A prospective consecutive cohort analysis was conducted which included 111 patients diagnosed between 2003 and 2010. Endpoints of the study were neck control rate, overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS), depending on the size of occult metastases.

RESULTS

Forty-nine of 111 patients (38%) had positive SLNs, 10 had isolated tumor cells (ITCs), 19 had micrometastases, and 13 had macrometastases. OS, DSS, and DFS at 3 years for SLN-negative and SLN-positive patients was 98% and 71%, 95% and 76%, and 98% and 73%, respectively. Furthermore, there was a statistically significant difference between the SLN-negative group and ITCs in DSS as well as between the SLN-negative group and patients with micrometastases in OS and DSS and between the SLN-negative group and patients with macrometastases in all 3 survival estimates.

CONCLUSION

Our study is the first to demonstrate that even small tumor deposits only detectable by the extensive histopathologic workup of the SLNB protocol have a significant impact on tumor control and survival in early Oropharyngeal SCC. Whether these findings will translate into different treatment strategies based on the upstaged neck has to be further investigated.

Implications of a positive sentinel node in oral squamous cell carcinoma

BACKGROUND

The role of sentinel node biopsy in head and neck cancer is currently being explored. Patients with positive sentinel nodes were investigated to establish if additional metastases were present in the neck, their distribution, and their impact on outcome.

METHODS

In all, 109 patients (n = 109) from 15 European centers, with cT1/2,N0 tumors, and a positive sentinel lymph node were identified. Kaplan-Meier and univariate and multivariate logistic regression analysis were used to identify variables that predicted for additional positive nodes and their position within the neck.

RESULTS

A total of 122 neck dissections were performed in 109 patients. Additional positive nodes were found in 34.4% of cases (42/122: 18 same, 21 adjacent, and 3 nonadjacent neck level). Additional nodes, especially if outside the sentinel node basin, had an impact on outcome.

CONCLUSIONS

The results are preliminary but suggest that both the number and the position of positive sentinel nodes may identify different prognostic groups that may allow further tailoring of management plans.

Long-term experience in sentinel node biopsy for early oral and oropharyngeal squamous cell carcinoma

OBJECTIVE

Long-term results of sentinel node biopsy (SNB) in early (T1/T2) oral and oropharyngeal squamous cell carcinoma (OSCC) in a single-institution experience.

METHODS

Prospective consecutive cohort analysis of 79 patients (67% male, median age 60 years, age range 34-87 years) included between 2000 and 2006. Lymphatic mapping consisted of preoperative lymphoscintigraphy, single photon emission computed tomography (SPECT/CT), and intraoperative use of a handheld gamma probe. Endpoints of the study were neck control rate, overall (OS), disease-specific (DSS), and disease-free survival (DFS).

RESULTS

Twenty-nine of 79 patients (37%) had positive sentinel nodes (SN). Six of 29 (21%) patients showed isolated tumor cells, 14/29 (48%) micrometastases, and 9/29 (31%) macrometastases. OS, DFS, and DSS at 5 years for the entire cohort were 80, 85, and 87%, for SN-negative patients were 88, 96, and 96%, and for SN-positive patients were 74, 73, and 77%, respectively. Only the difference in DSS achieved statistical significance. The neck control rate after 5 years was 96% in SN-negative and 74% in SN-positive patients. This difference was statistically significant.

CONCLUSIONS

SNB is a safe and accurate staging modality to select patients with clinically stage I/II OSCC with occult lymph node disease for elective neck dissection (END). The promising reported short-term results have been sustained by long-term follow-up. Patients with negative SN and no END achieve an excellent neck control rate which compares favorably with reports on primary END. The neck control rate in SN-negative patients is superior to that in SN-positive patients, which is reflected in superior DSS.

Sentinel node biopsy in head and neck squamous cell cancer: 5-year follow-up of a European multicenter trial

BACKGROUND

Sentinel node biopsy (SNB) may represent an alternative to elective neck dissection for the staging of patients with early head and neck squamous cell carcinoma (HNSCC). To date, the technique has been successfully described in a number of small single-institution studies. This report describes the long-term follow-up of a large European multicenter trial evaluating the accuracy of the technique.

METHODS

A total of 227 SNB procedures were carried out across 6 centers, of which 134 were performed in clinically T1/2 N0 patients. All patients underwent SNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with hematoxylin and eosin (H&E) staining, step-serial sectioning (SSS), and immunohistochemistry (IHC). There were 79 patients who underwent SNB as the sole staging tool, while 55 patients underwent SNB-assisted elective neck dissection.

RESULTS

Sentinel nodes were successfully identified in 125 of 134 patients (93%), with a lower success rate observed for floor-of-mouth tumors (FoM; 88% vs. 96%, P = 0.138). Also, 42 patients were upstaged (34%); of these, 10 patients harbored only micrometastatic disease. At a minimum follow-up of 5 years, the overall sensitivity of SNB was 91%. The sensitivity and negative predictive values (NPV) were lower for patients with FoM tumors compared with other sites (80% vs. 97% and 88% vs. 98%, respectively, P = 0.034).

CONCLUSIONS

Sentinel node biopsy is a reliable and reproducible means of staging the clinically N0 neck for patients with cT1/T2 HNSCC. It can be used as the sole staging tool for the majority of these patients, but cannot currently be recommended for patients with tumors in the floor of the mouth.

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.

Sentinel lymph node radiolocalization in clinically negative neck oral cancer

BACKGROUND

The sentinel node concept has become one of the most interesting topics in the treatment of head and neck cancer. The aim of this article is to report the results of our feasibility study and clinical application of sentinel lymph node (SLN) radiolocalization and biopsy in patients with clinically negative neck oral cancer.

METHODS

Individuals with previously untreated N0 oral cancer participated in the study. The radioactive tracer used was 99m Tc phytate. Lymphoscintigrams were taken in the feasibility study, and fusion images of SPECT and CT were obtained in the clinical SLN biopsy (SLNB) group. In the feasibility study, metastases to SLNs and other nodes were analyzed in permanent specimens. In the clinical application group, we investigated the comparative effectiveness of multi-slice frozen section analysis and imprint cytology for the intraoperative diagnosis of SLNB.

RESULTS

Fifteen individuals participated in the feasibility study. Six SLNs in five patients were cancer-positive, and two thirds of the SLNs were micrometastases. The SLN concept was established, and SLNs with the highest to the third highest radioactivity reflected the patients' neck status accurately. Twelve patients participated in the clinical application group of SLNB. Intraoperative diagnosis of the three hottest SLNs correctly predicted the neck status of 10 patients. Three patients underwent modified radical neck dissection on the basis of the intraoperative diagnosis of cancer metastasis to SLNs, whereas neck dissections were spared in patients with no evidence of such metastases. There were two false-negative cases. One involved a failure of the intraoperative diagnosis of SLNB, and the other had cancer-negative SLNs and cancer-positive non-SLNs. Considering intraoperative diagnosis, multi-slice frozen section analysis was found to be superior to imprint cytology in its sensitivity, specificity, and overall accuracy on a lymph node basis. No differences were found in any of these indices of intraoperative SLNB on a patient basis. The fusion images of SPECT and CT proved very useful during intraoperative SLNB.

CONCLUSIONS

The sentinel node concept was established in the head and neck region. Analyzing the three hottest SLNs suffices to predict a patient's neck status. Multi-slice frozen section analysis was shown to be superior to imprint cytology for detecting micrometastasis to SLN. Intraoperative SLNB based on fusion images of SPECT and CT proved to be an easy, accurate, and reliable method.

Radiolocalized Sentinel Lymph Node Biopsy in Squamous Cell Carcinoma of the Oral Cavity and Analysis of Various Parameters

BACKGROUND

Sentinel lymph node (SLN) biopsy seems to be a method that solves the problem of neck management with oral squamous cell carcinoma. Using blue dye methods for detection of neck SLNs from the surface of the operative field seems difficult; therefore, we used radiolocalization alone to detect and extract sentinel nodes. Aside from the various histological and clinical parameters examined in this procedure, we also determined whether they had any clinical significance in relation to the detection of SLNs during the operation.

METHODS

Enrolled subjects had preoperative clinical N0 stage squamous cell carcinoma of the oral cavity and had received an unfiltered (99m)Tc sulfur colloid peritumoral injection. Localization of the SLNs was performed by using lymphoscintigraphy and a handheld gamma probe.

RESULTS

In total, 28 oral squamous cell carcinoma patients were included in this prospective study. Sixty-four SLNs in 27 patients were identified by this method. The identification rate was 96.4%. No false-negative predictions of SLN were noted among any of the patients studied. The numbers of the SLNs found during the operation were larger in patients with positive findings than those with negative findings (P < .05 by the Mann-Whitney U-test).

CONCLUSIONS

SLN radiolocalization provided an acceptable identification rate. The cases of positive findings for metastasis seemed to statistically have more SLNs than did those with negative findings, but more evidence is needed to prove this point. Therefore, SLN biopsies for extracting all possible high-risk nodes may be conducive for oral squamous cell carcinoma surgery.

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.

The nodal neck level of sentinel lymph nodes in mucosal head and neck cancer

Sentinel node biopsy is emerging as a successful means of identifying subclinical lymph node disease in mucosal head and neck cancer. Sentinel node studies in melanoma and breast cancer have identified sentinel nodes at unusual sites and the technique is redefining our understanding of dynamic lymphatic flow. In this study, the sentinel nodes in mucosal head and neck malignancies were mapped according to their site within the neck and this was correlated with tumour site within the oral cavity. Fifty-two necks were explored for sentinel nodes from tumours located in the tongue (23 cases), floor of mouth (12 cases), palate (six cases), retromolar trigone (five cases), alveolus (three cases), buccal mucosa (two cases), tonsil (two cases) and lip (one case). In total, 124 sentinel nodes were found in levels I-V. Two hot spots were found in the tonsils and were not excised, two nodes were located in level IIB, four nodes were found in level IV, three in the contralateral neck and one in level V. The sentinel nodes located at unusual sites would not have been excised in a supraomohyoid neck dissection and the study has improved our understanding of dynamic lymph flow from tumours.

Sentinel lymph node biopsy in oral cancer: validation of technique and clinical implications of added oblique planar lymphoscintigraphy and/or tomography

PURPOSE

To validate lymphatic mapping combined with sentinel lymph node biopsy as a staging procedure, and to evaluate the possible clinical implications of added oblique lymphoscintigraphy and/or tomography and test the intra- and interobserver reproducibility of lymphoscintigraphy.

MATERIAL AND METHODS

Forty patients (17 F and 23 M, aged 32-90) with 24 T1 and 16 T2 squamous cell carcinoma of the oral cavity. Planar lymphoscintigraphy, emission and transmission tomography were performed. Detection and excision of the sentinel nodes were guided by a gamma probe. The sentinel nodes were step-sectioning and stained with hematoxylin and eosin and cytokeratin (CK 1). Histology and follow-up were used as "gold standard". Tumor location, number of sentinel lymph nodes, metastasis, and recurrences were registered. Two observers evaluated the lymphoscintigraphic images to assess the inter-rater agreement.

RESULTS

Eleven (28%) patients were upstaged. The sentinel lymph node identification rate was 97.5%. Sentinel lymph node biopsy significantly differentiated between patients with or without lymph node metastasis (P = 0.001). Lymphatic mapping revealed 124 hotspots and 144 hot lymph nodes were removed by sentinel lymph node biopsy. Three patients developed a lymph node recurrence close to the primary tumor site during follow-up. Added oblique lymphoscintigraphic images and/or tomography revealed extra hotspots in 15/40 (38%) patients. In 4/40 (10%), extra contralateral hotspots were detected.

CONCLUSION

Sentinel lymph node biopsy upstaged 28% of the patients. Sentinel lymph nodes close to the primary tumor were difficult to find. Added oblique planar images and/or tomographic images revealed extra clinical relevant hotspots in 38% of patients. Reproducibility proved excellent.

Sentinel-Lymphonodektomie als Staging-Methode bei Kopf-Hals-Karzinomen

BACKGROUND

The excision of sentinel lymph nodes has a growing relevance in the diagnosis of oral and oropharyngeal cancer in cases of N0 necks. The validity of sentinel node biopsy (SNB) was examined as a single surgical staging tool.

PATIENTS AND METHODS

Within the framework of a multi-modal treatment scheme, SNB without elective neck dissection was carried out on 70 previously untreated patients in the same session as the surgery for the primary cancer. Control of accuracy was via observation of the manifestation of neck node metastases in 45 patients who were postoperatively irradiated.

RESULTS

A total of 94% of sentinel nodes could be excised; 9 patients (13%) had positive nodes and were treated with a therapeutic neck dissection (ND). There were 2 neck node metastases as second primaries, all other patients remained regionally inconspicuous (median observation time 26 months).

CONCLUSION

As a staging tool for N0 necks and T1-3 tumors, SNB could lead to a considerable reduction in the number of elective NDs. It could be well integrated into a multi-modal treatment scheme.

Reliability of sentinel lymph node biopsy with squamous cell carcinoma of the oral cavity

OBJECTIVES

Although sentinel lymph node biopsy (SLNB) may reduce surgery-related complications related to unnecessary lymph node dissection and is now widely used for many patients with cutaneous melanoma and breast cancer, its use for oral cancer patients remains controversial. One of the main reasons for the reluctance to initiate SLNB for oral cancer is that the frequency of skip metastasis has not been clarified. The objectives of this study are to examine the frequency of skip metastasis and to evaluate SLNB for oral cancer.

STUDY DESIGN

To shed light on these concerns, we first conducted a retrospective study of 296 patients with squamous cell carcinoma of the oral cavity who underwent neck dissection. Next, the accuracy of lymph node biopsy with and without detecting sentinel lymph node was examined.

RESULTS

Ten patients showed skip neck metastasis in the level III-V region without level I-II involvement. Of these patients, 7 underwent neck dissection when their initially N0 neck progressed to N+, 2 underwent neck dissection when local recurrence occurred, and only 1 underwent surgery as an initial therapy. Most patients who underwent neck dissection as the initial therapy showed skip metastasis. Intraoperative lymph node biopsy without any attempt to detect sentinel lymph nodes by means of blue dye or lymphoscintigraphy was performed on 68 patients with oral cancer. Sixty-one (90%) were diagnosed correctly, whereas 7 diagnosed as N- actually had neck metastasis. SLNB with blue dye was performed on 21 patients. In 17 of them, sentinel lymph node was easily detected, resulting in a correct diagnosis for 16 patients (94%), while 1 with a false negative result actually had micrometastasis.

CONCLUSION

These findings seem to suggest that SLNB is useful and can be applied to patients with oral cancer who undergo surgery as the initial therapy.

Pattern of drainage in sentinel lymph nodes after intra-arterial chemotherapy for oral and oropharyngeal cancer

PURPOSE

Prerequisite for lymphoscintigraphy-guided sentinel lymph node (SLN) biopsy in head and neck cancer patients has been a previously untreated primary tumor to avoid disturbance of the lymphatic flow. We evaluated the feasibility in a multimodality treatment approach to oral and oropharyngeal cancer comprising presurgical intra-arterial chemotherapy of the primary tumor.

PATIENTS AND METHODS

In a prospective study of 35 consecutive patients with primary oral and anterior oropharyngeal cancer T1-4N0 treated with superselective intra-arterial chemotherapy with high-dose cisplatin, SLN scintigraphy was performed on the day of surgery, including gamma camera imaging before and hand-held gamma probe identification of the SLN during surgery. SLN biopsy was performed in 50 neck sides, followed by radical resection of the primary in the same session. Elective neck dissection was not carried out. The pattern of lymphatic drainage was recorded and compared with the literature on well-known patterns found in lymphographic studies and metastatic disease in neck dissection specimens of patients without presurgical treatment.

RESULTS

Drainage patterns of SLN related to different primary locations mapped the mentioned comparison patterns. SLN drainage patterns gave strong evidence that there are SLN in levels 3 and 4 with direct drainage from the primary. After a median observation time of 24 months, no patients had a neck relapse.

CONCLUSIONS

The results suggest that intra-arterial chemotherapy of the primary tumor does not significantly alter lymphatic drainage and that SLN biopsy following intra-arterial chemotherapy is feasible and offers valid results comparable to those obtained from patients without presurgical treatment.

A preliminary study on sentinel lymph node biopsy: feasibility and predictive ability in oral cavity cancer

The main factor that affects the prognosis of patients with head and neck cancer (HNC) is regional lymph node metastases. For this reason, the accurate evaluation of neck metastases is required for neck management. This study investigates the sentinel lymph node identification and the accuracy of the histopathology of the sentinel lymph node in patients with HNC. Eleven patients with histologically proven oral squamous cell carcinoma accessible to radiocolloid injection were enrolled in this study. Using both lymphoscintigraphy and a handheld gamma probe, the sentinel lymph node could be identified in all 11 patients. Subsequently, the sentinel lymph nodes and the neck dissection specimen were examined for lymph node involvement due to tumor. The histopathology of sentinel lymph nodes was consistent with the pathological N classification in all 11 patients. Furthermore, the histopathology of sentinel lymph nodes was superior to physical examination, computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) scan. The results of this study indicate that sentinel lymph node identification is technically feasible and predicts cervical metastases in patients with oral cavity cancer. This may be a useful diagnostic technique for identifying lymph node disease in staging lymph node dissection.

Sentinel Node Biopsy in Head and Neck Cancer: Preliminary Results of a Multicenter Trial

BACKGROUND

The aim was to determine the reliability and reproducibility of sentinel node biopsy (SNB) as a staging tool in head and neck squamous cell carcinoma (HNSCC) for T1/2 clinically N0 patients by means of a standardized technique.

METHODS

Between June 1998 and June 2002, 227 SNB procedures have been performed in HNSCC cases at six centers. One hundred thirty-four T1/2 tumors of the oral cavity/oropharynx in clinically N0 patients were investigated with preoperative lymphoscintigraphy (LSG), intraoperative use of blue dye/gamma probe, and pathological evaluation with step serial sectioning and immunohistochemistry, with a follow-up of at least 12 months. In 79 cases SNB alone was used to stage the neck carcinoma, and in 55 cases SNB was used in combination with an elective neck dissection (END).

RESULTS

In 125/134 cases (93%) a sentinel node was identified. Of 59 positive nodes, 57 were identified with the intraoperative gamma probe and 44 with blue dye. Upstaging of disease occurred in 42/125 cases (34%): with hematoxylin-eosin in 32/125 (26%) and with additional pathological staging in 10/93 (11%). The sensitivity of the technique with a mean follow-up of 24 months was 42/45 (93%). The identification of SNB for floor of mouth (FOM) tumors was 37/43 (86%), compared with 88/91 (97%) for other tumors. The sensitivity for FOM tumors was 12/15 (80%), compared with 30/30 (100%) for other tumor groups.

CONCLUSION

SNB can be successfully applied to early T1/2 tumors of the oral cavity/oropharynx in a standardized fashion by centers worldwide. For the majority of these tumors the SNB technique can be used alone as a staging tool.

Value of sentinel lymphadenectomy in head and neck cancer

The increasing interest in the so-called sentinel node concept, which has recently been adapted to squamous cell carcinomas of the upper aerodigestive tract, can be explained by encouraging results in other tumor entities. Although the publications on this topic do not yet allow a final judgment on the significance of sentinel lymphadenectomy in head and neck squamous cell carcinoma, early results emphasize the importance of this new diagnostic and therapeutic concept. The basic prerequisite is a detailed knowledge of the existing method-specific limitations in this anatomic region. Critical and careful evaluation of the sentinel node concept is mandatory prior to its application to other tumor entities. Sentinel lymphadenectomy for head and neck cancer may prove helpful if the indications for its use are clearly defined.

Rationale for Sentinel Node Biopsy to Stage N0 Head and Neck Squamous-Cell Carcinoma

Sentinel node biopsy is an evolving staging tool in the management of patients with squamous-cell carcinoma of the head and neck. This tool provides a more detailed understanding of the lymphatic pathways within the head and neck and the role of these pathways regarding tumor spreading. By targeting nodes that are most likely to harbor disease, a more detailed pathological evaluation of sentinel nodes is possible-thus improving staging by the identification of micrometastases. The rationale behind the use of sentinel node biopsy to stage the N0 neck are discussed within this paper.

Sentinel lymph node biopsy in head and neck cancer

In the past decade, the technique of sentinel lymph node biopsy (SLNB) has been applied to a vast array of primary neoplasms, ranging from head and neck melanoma to vulvar carcinoma. At present, experience with SLNB is greatest in patients with melanoma and breast cancer. In view of the well known complications associated with cervical node dissection, it has been suspected for some time that cervical SLNB, if successful, might reduce the morbidity associated with the definitive care of patients with head and neck cancers. This report assesses the current status of SLNB in the treatment of head and neck cancers; while formal investigations of the efficacy of this technique are recommended, SLNB has not yet been demonstrated to possess the same level of utility seen in SLNB in melanoma and breast cancer patients. As a consequence, the application of SLNB to head and neck cancers remains an experimental technique--one which has not yet acquired the status of the standard of patient care.

Functional anatomy of the lymphatic drainage system of the upper aerodigestive tract and its role in metastasis of squamous cell carcinoma

BACKGROUND

Although there is a significant understanding of the vascular anatomy of the upper aerodigestive tract (UADT), there is less detailed knowledge of the architecture and drainage patterns of the lymphatic system. Detailed knowledge of the lymphatic system is critical for understanding the role of sentinal node identification in the management of different cancers.

METHODS

We have combined microscopic techniques with in vivo and in vitro lymphographic studies to survey the architecture and drainage patterns of the lymphatic system of the UADT in 850 organ specimens.

RESULTS

These studies show an interaction of superficial and deep lymphatic networks that vary in density but have a constant distribution characterized by predictable patterns of lymph drainage into the regional lymph nodes.

CONCLUSIONS

Detailed knowledge of the lymphatic system of the UADT contributes to a better understanding of the patterns of metastatic spread of carcinomas of the UADT and provides a strong rationale for the practice of sentinel node identification in the management of these tumors.

The ability of lymphoscintigraphy to direct sentinel node biopsy in the clinically N0 neck for patients with head and neck squamous cell carcinoma

This study aimed to evaluate the ability of lymphoscintigraphy (LSG) to direct sentinel node biopsy (SNB) in the identification of occult metastases in the clinically N0 neck for patients with head and neck squamous cell carcinoma (HNSCC). 57 clinically N0 neck sides in 48 patients were assessed using the triple diagnostic approach of pre-operative LSG, intra-operative use of a gamma probe and blue dye. SNB was performed after radiocolloid and blue dye injection. Pre-operative LSG and the intra-operative use of a gamma probe identified radioactive sentinel nodes, and visualization of blue stained lymphatics identified blue sentinel nodes. 104 sentinel nodes were harvested from 43 patients. The identification rate was 90% (43 of 48). Of the 104 nodes harvested, 17 of 62 (27%) nodes identified as both radioactive and blue were positive for occult metastases compared with 5 of 42 (12%) nodes identified as hot or blue only (p<0.05). Sentinel nodes were identified in 39 of 48 (81%) patients using LSG. Of 39 patients in whom sentinel nodes were identified using LSG, 37 of 39 (95%) had radioactive sentinel nodes harvested intra-operatively. In patients who had no sentinel nodes identified on LSG, 4 of 9 (44%) had radioactive sentinel nodes harvested intra-operatively. This difference was statistically significant using the t-test (p<0.05). LSG directs SNB and is essential in the identification of occult metastases within the clinically N0 neck for patients with HNSCC.

Lymphatic mapping and sentinel node identification in squamous cell carcinoma and melanoma of the head and neck

AIM

The aim of our study was to evaluate the role of scintigraphy in lymphatic mapping and in the identification of the sentinel lymph node (SLN) in patients with head and neck cancer.

METHODS

Between September 1999 and February 2001 we enrolled 22 consecutive patients with cancer in the head and neck region: five squamous cell carcinomas, one Merkel cell tumor of the cheek, and 16 malignant melanomas. Lymphoscintigraphy was performed three hours before surgery after injection of 30-50 MBq of 99mTc -Nanocoll in 0.3 mL; the dose was fractionated by injecting the radiotracer at two points around the lesion. Static acquisition (anterior and/or lateral views, 512 x 512 matrix, 5 mins pre-set time) was started immediately after the injections so as to visualize the pathways of lymphatic drainage. The skin projection of the SLN was marked with ink. Intraoperative SLN detection was performed with perilesional injection of patent blue.

RESULTS

SLNs were found with lymphoscintigraphy in all patients. Thirty-three SLNs were identified: one occipital node, three nodes at the base of the tongue, 10 superficial lateral nodes (external jugular), five submandibular nodes, five submental nodes, three mastoid nodes and six supraclavicular nodes. Biopsy was performed in 21/22 patients. In 20/22 patients the first lymph nodes were visualized in the proximal cranial regions (retroauricular, jugular and submandibular) at five minutes post injection. The SLN positivity rate was 13.6% (three patients). All patients with tumor-positive SLNs were submitted to radical dissection. Poor concordance in the detection of sentinel nodes was observed with patent blue.

CONCLUSIONS

The flow of nanocolloid in the lymph vessels of the head is rapid. In our experience immediate scintigraphic imaging was essential to visualize the pathways of lymphatic drainage and the first SLN. Radioguided SLN biopsy is therefore recommended within three hours. Injection of patent blue is inadvisable because of the poor concordance with lymphoscintigraphy and the risk of permanent tattooing of the face.