Pathogenesis of Metastatic Recurrences on the Operative Field after Radical Neck Dissection for Oropharyngeal Cancer

Failures (Cause and Time) of Radiotherapy in Oral Cancer

The results of a retrospective clinical evaluation concerning 434 cases of oral carcinomas treated with radiotherapy from January 1959 to December 1967 are presented. The analysis of the results obtained shows that radiotherapy alone may offer a reasonable possibility of success in limited lesions (68.3% 5-year survival of Stage I patients). In more advanced local cases, and especially those with regional adenopathies, radiotherapy alone cannot consistently control the disease for a long period of time; 5-year survival from the onset of treatment was respectively 36.5% and 24.5% for Stage II and III cases. Moreover, if controlateral or bilateral metastatic adenopathies or fixed lymph nodes are present, the prognosis becomes dramatic (2.6% 5-year survival of Stage IV patients). Among the irradiation techniques currently available, curietherapy (interstitial applications or surface molds) presumably offers the best possibility of success, since the observed failures, both overall and stage by stage, are inferior. Radiotherapy alone may generally be of proven efficacy if the local or locoregional extension is limited. In more advanced cases a combined surgery-chemotherapy treatment method is recommended. The criteria for a combined therapeutic approach for these tumors are also discussed.

Therapeutic implications of sentinel lymph node biopsy in the staging of oral cancer

The most powerful prognostic factor in patients with oral cancer is the presence of lymph node metastases. The management of the neck at diagnosis in the absence of adenopathy is still controversial, but sentinel lymph node biopsy (SLB) may help resolve this issue. At the National Cancer Institute in Naples, we performed SLB in 41 patients with T1 to T2 oral cancer. All patients underwent lymphoscintigraphy. Intraoperative blue dye and gamma probe examination identified a sentinel node (SN) in 39 patients. Four patients (10%) had double drainage, and 7 (18%) had drainage beyond the expected anatomical site. Complete concordance between the pathology of the SN and nodes obtained from radical dissection confirmed SLB as a reliable staging procedure. Since January 2001, seven patients with T1 to T2 oral cancers have been staged with SLB only; modified radical neck dissection was carried out only in cases with a positive SN. The rate of SN identification was 100%, and all five cases with negative SNs were free of disease after a median follow-up of 10 months. Lymphoscintigraphy plus SLB seems to be a good staging system for guiding neck management in patients with oral cancer. A larger number of patients and a longer follow-up in a randomized trial will confirm the potential staging value of this procedure and determine which patients might benefit from a conservative approach that avoids radical neck dissection.

Retrospective comparison of conservative and radical neck dissection in laryngeal cancer

A retrospective comparison of radical and conservative technique for neck dissection in cancer of the larynx was made, starting from analysis of 98 patients operated on with the conservative procedure (128 cervical neck fields at risk of recurrence) at the Istituto Nazionale Tumori of Milan. Furthermore, a series of 162 patients was selected from more than 500 radical neck dissections performed in the past to set up a series as comparable as possible as far as several parameters were concerned. No significant difference was found between radical and conservative neck dissection with regard to the incidence of recurrences in the operative field, either considering the whole series (2.5% versus 1.6%), or cases with histologically proven metastases (9.4% versus 4.5%). Conservative neck dissection seems as safe as radical neck dissection, at least within the limits set in the present study for the indication of the former procedure, ie, nonsuspect nodes or metastatic mobile nodes not greater than 2.5 cm.