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Dr. Serena WongDr. Serena Wong
Queen Elizabeth HospitalQueen Elizabeth Hospital
IntroductionIntroductionBackgroundCurrent debates in neck management◦Why is neck treatment so
controversial?◦What are the options for neck
treatment?◦What is the evidence on neck
treatment?
BackgroundBackground
BackgroundBackgroundIncidence: 1.7 per 100000 108 new cases in 20110.7% of all new cancer cases 6th leading cancer worldwide32-40% of all head and neck
cancers
HK Cancer registry
How early is early?How early is early?
N0 N1 N2 N3
T1 I
T2 II
T3 III
T4a IVa
T4b IVb
IVC: M1
AJCC Cancer Staging Manual. 7th ed, 2010
T stagingT staging
Head and Neck Cancer Guide
N stagingN staging
Head and Neck Cancer Guide
N stagingN staging
Merritt et al. Arch Otolaryngol Head Neck Surg 1997; 123: 149-152
Giancarlo et al. Anticancer Res 1998; 18: 2805-9
Akoglu et al. J Otolaryngol 2005; 34: 384-94
Fan et al. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2014;49(1):39-43
Sensitivity
Specificity
Ultrasound 72-80% 59-96%
CT 78-83% 80-96%
MRI 50% 75%
PET-CT 67% 85%
N stagingN staging
Increased risk of occult metastasisIncreased risk of occult metastasis◦Tumor thickness / depth of invasion (> 3 or
4mm)◦Higher T stage◦Perineural and angiolymphatic invasion◦Poor tumor differentiation
Yuen et al. Am J Surg. 2000; 180: 139-143Sparano et al. Otolarngol Head Neck Surg 2004; 131: 472-6
N stagingN staging• Incidence of occult neck
metastasis–T1: 16-38%–T2: 21-57%–T3: 77%Kaya et al. Am J Otolaryngol 2011;22:59-64
• Presence of LN mets: most important prognostic factor– Woolgar JA: Oral Oncol 26. 42(3): 229-239
Current Debates in Current Debates in Neck ManagementNeck Management
Debates in neck Debates in neck managementmanagement
Probability of Probability of neck neck
metastasismetastasis
Prognostic Prognostic implicationsimplications
ComplicatioComplications of neck ns of neck dissectiondissection
Options for neck Options for neck managementmanagement1. Elective Neck Dissection (END)
2. Watchful waiting3. Other options:
◦Neck irradiation◦Sentinel LN biopsy
Which level?Which level?
•95% metastatic nodes are in ipsilateral levels I-III
•Skip metastasis: 16%
Liu et al. Oral Oncol 47 (2011) 136-141
Byers et al. Head Neck, 19 (1997) 14–19
Elective neck dissectionElective neck dissection
1. Supraomohyoid neck dissection (I-III)
2. Modified radical neck dissection (I-V)
Brazilian Head and Neck Cancer Study Group. Am J Surg. 1998 Nov;176(5):422-7
http://emedicine.medscape.com/article/1894829-overview
Elective neck dissectionElective neck dissection
Options for neck Options for neck managementmanagement1. Prophylactic Elective Neck Dissection (END)
2. Watchful waiting2. Watchful waiting3. Other options:
◦Neck irradiation◦Sentinel LN biopsy
ObservationObservationCompliance is crucialMRND for salvage of regional
recurrencesMany neck recurrences will be of
advanced stage with poor prognostic factors such as extracapsular spread◦ Andersen et al. Am J Surg 1996; 172:689-
691
END vs ObservationEND vs Observation
Authors Duration
Country Study population
T stage
Tumor location
Survival Benefit
Vandenbrouck et al (1980)
1966-1973
France 75 T1-3 Oral cavity
No
Fakih et al (1989)
1985-1988
India 70 T1-2 Tongue No
Kligerman et al (1994)
1987-1992
Brazil 67 T1-2 Oral cavity
Yes
Yuen et al (2009)
1996-2004
Hong Kong
71 T1-2 Tongue No
Vandenbrouck C et al. Cancer; 1980: 46: 386-90Fakih AR et al. Am J Surg 1989; 158: 309-313Kligerman J et al. Am J Surg 1994; 168: 391-4
Yuen AP et al. Head Neck 2009; 31: 765-72
Prospective randomized study of selective neck Prospective randomized study of selective neck dissection versus observation for N0 neck of early dissection versus observation for N0 neck of early
tongue carcinomatongue carcinomaYuen PW, Ho CM, Chow TL, Tang LC, Wei W et alYuen PW, Ho CM, Chow TL, Tang LC, Wei W et al
Outcomes: Outcomes: -Node related mortality: 0%-Salvage rate: 100% -5 year Disease specific survival:
- END: 89%- Observation: 87% (Not statistically
significant)
A meta-analysis of the RCTs on elective neck A meta-analysis of the RCTs on elective neck dissection versus therapeutic neck dissection in dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative oral cavity cancers with clinically node-negative
neckneckFasunla AJ, Greene BH, Timmesfeld N et al. Fasunla AJ, Greene BH, Timmesfeld N et al.
Do we have the answer Do we have the answer yet?yet?
Elective Neck Dissection
Observation
Pros • Less nodal recurrence
• Less surgical morbidity than radical or MRND
• Accurate N staging
• Avoid unnecessary neck dissection in truly N0 patients
Cons • Shoulder morbidities • Strict compliance to FU• Poor prognostic factors
on recurrence
Options for neck Options for neck managementmanagement1. Prophylactic Elective Neck Dissection (END)
2. Watchful waiting3. Other options: 3. Other options:
◦Neck irradiation◦Sentinel LN biopsy
IrradiationIrradiationElective irradiation of the N0 neck
produces results equivalent to that of neck dissection◦ G.H. Fletcher. Cancer, 29 (1972), pp. 1450–1454◦ Bataini et al. Eur Arch Otorhinolaryngol, 250
(1993), 442–445
Disadvantages: ◦No histopathological staging◦complications of radiation◦Secondary neoplasms
Sentinel LN biopsySentinel LN biopsy
Atula T et al. Eur Arch Otorhinolaryngol. 2008;265 Suppl 1:S19-23 Tschopp et al. Otolaryngol Head Neck Surg, 132 (2005), 99–102
Paleri et al. Head Neck, 27 (2005), 739–747Kovacs AF. Surg Oncol Clin N Am 16 (2007), 81-100
s
Sensitivity: 93%
Negative predictive value: 94%
Upstaging rate: 13-60%
ConclusionConclusionManagement of the N0 neck in
stage I and II tongue cancer is controversial◦Main options for management: Elective
neck dissection vs observationStringent follow up is crucial in
detection of early nodal metastasis for successful salvage surgery
Further developments: Sentinel LN biopsy
The EndThe End
ReferencesReferences http://www.intechopen.com/books/melanoma-from-early-detection-to-treatment/sentinel-lymph-node-biopsy-
for-melanoma-and-surgical-approach-to-lymph-node-metastasi (figure on slide 25) Keski-Santti et al. Sentinel lymph node biopsy or elective neck dissection for patients with oral squamous cell
carcinoma. Eur Arch Otorhinolaryngol 2008: 265 (suppl): S13-S17 Govers et al. Sentinel lymph node biopsy for SCC of the oral cavity: A diagnostic meta-analysis. Oral Oncol
2013: 49; 726-732 Fasunla AJ et al. A meta-analysis of the RCTs on elective neck dissection versus therapeutic neck dissection
in oral cavity cancers with clinically node negative neck. Oral Oncol 2011: 47: 320-324 Kovacs AF. Head and neck squamous cell carcinoma: Sentinel node or selective neck dissection. Surg Oncol
Clin N Am 2007; 16: 81-100 Fan SF et al. Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2N0 oral tongue
SCC. Oral Pathol Oral Radiol 2014; 117: 186-190 Melkane AE, et al. Sentinel Node biopsy in early oral squamous cell carcinomas: A 10 year experience.
Laryngoscope 2012; 122: 1782-1788 Amaral TMP et al. Predictive factors of occult metastasis and prognosis of clinical stages I and II squamous
cell carcinoma of the tongue and floor of mouth. Oral Oncol 2004; 40: 780-786 Yuen APW et al. A comparison of the prognostic significance of tumor diameter, length, width, thickness,
area, volume and clinicopathological features of oral tongue carcinoma. Am J Surg 2000; 180: 139-143 Sparano A et al. Multivariate predictors of occult neck metastasis in early oral tongue cancers. Otolaryngol
Head Neck Surg 2004; 131: 472-6 Yuen APW et al. Prospective randomized study of selective neck dissection versus observation for N0 neck of
early tongue carcinoma. Head Neck 2009; 31: 765-772 Kligerman et al. Supraomohyoid neck dissection in the treatment of T1/2 squamous cell carcinoma of oral
cavity. Am J Surg 1994; 168: : 391-4
Prognostic implications◦Regional recurrence is the most
common cause of treatment failure Yuen et al. Head Neck 1997; 19:583-588
◦Recurrence rate: 23.7-42% Brugere et al 1996; Khahf et al. 1991;
Okamoto et al 2002
◦Poor salvage surgery outcomes◦Accurate N staging (diagnostic
limitation)
Elective neck dissectionElective neck dissectionOccult metastasis rate > 20%
◦Weiss et al. Arch Otolaryncol Head Neck Surg 1994, 120(7): 699-702
PrognosisPrognosis
5 year survival relative rateT1: 71%T2: 59%T3: 47%T4: 37%
American Cancer Society
Elective Neck Elective Neck DissectionDissectionWhich side?Which side?Contralateral LN metastasis: 4%
◦ Lim et al. Laryngoscope 2006; 116: 461-465
Higher risk of contralateral neck involvement:
positive ipsilateral nodesadvanced stage primary tumors tumors crossing midlineKoo et al. Head Neck. 2006 Oct;28(0):896-901