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.

A retrospective analysis of histological prognostic factors for the development of lymph node metastases from auricular squamous cell carcinoma.

AIMS: Squamous cell carcinoma (SCC) of the auricle has a high risk of metastatic spread, which is associated with high mortality. Identification of patients with a high risk of lymph node metastases would allow prophylactic treatment to the draining lymph nodes, but there are no established clinical or histopathological criteria to predict which tumours have a high risk of metastasis. The aim was to determine such criteria. METHODS AND RESULTS: The study was a retrospective analysis of the clinical and histological features of 229 cases of SCC of the auricle, with a minimum of 2 years' clinical follow-up. Overall, lymph node metastases were present in 24 cases (10.5%). Of the patients with metastatic disease 66.7% died, despite multi-modality treatment. Tumours with a depth of invasion >8 mm or a depth of invasion between 2 and 8 mm in conjunction with evidence of destructive cartilage invasion, lymphovascular invasion or a non-cohesive invasive front had a high risk of metastasis (56% and 24%, respectively). CONCLUSIONS: Patients with high-risk tumours, as assessed histopathologically, should be considered for prophylactic therapy to or staging of the regional lymph nodes.

Does tumor depth affect nodal upstaging in squamous cell carcinoma of the head and neck?

PURPOSE: The aim of this study was to determine whether tumor depth affects upstaging of the clinically node-negative neck, as determined by sentinel lymph node biopsy with full pathologic evaluation of harvested nodes including step-serial sectioning (SSS) and immunohistochemistry (IHC). PATIENTS AND METHODS: One hundred seventy-two patients with cT1/2 N0 squamous cell carcinoma (SCC) of the oral cavity/oropharynx undergoing primary resection and either sentinel node biopsy (SNB) or SNB-assisted neck dissection as a staging tool for the cN0 neck. Harvested nodes were examined with hematoxylin-eosin staining, SSS, and IHC. Patients upstaged by SSS/IHC were denoted pN1mi. RESULTS: One hundred one of 172 patients were staged pN0, with 71 (41%) patients upstaged. Increasing tumor depth was associated with higher likelihood of upstaging (P < .001). Tumor depth showed a positive correlation with nodal stage according to TNM classification (P < .001). Tumor depth greater than 4 mm appears to be the most appropriate cutoff for risk stratification, although tumors in the oropharynx may require a lower value. CONCLUSION: Tumor depth is an important prognostic factor for patients with SCC of the oral cavity or oropharynx. Tumors greater than 4 mm are associated with greater risk of upstaging; however, this optimum cutoff value may vary between primary tumor sites.

The use of sentinel node biopsy to upstage the clinically N0 neck in head and neck cancer.

OBJECTIVE: To investigate the possible role of sentinel node biopsy (SNB) alone to upstage the clinically N0 neck in patients with oral and oropharyngeal squamous cell carcinoma. DESIGN: Prospective clinical study. SETTING: Head and neck referral center. PATIENTS: Patients with primary untreated oral and/or oropharyngeal squamous cell carcinoma accessible to injection and with clinically N0 necks were enrolled in the study. INTERVENTION: An SNB was performed after radiocolloid and blue dye injection. Preoperative lymphoscintigraphy and the perioperative use of a gamma probe identified radioactive sentinel nodes and visualization of blue-stained lymphatics identified blue sentinel nodes. If the sentinel node was found negative, there was no further treatment to the neck. If the sentinel node tested positive, a therapeutic neck dissection was performed. All patients underwent regular follow-up at the outpatient clinic to identify possible recurrence. MAIN OUTCOME MEASURES: Upstaging of the clinically N0 neck by SNB and development of subsequent disease in SNB-negative necks. RESULTS: An SNB was performed on 57 clinically N0 necks in 48 patients. Sentinel nodes were harvested in 43 (90%) of 48 patients. Fifteen (35%) of 43 patients were upstaged by SNB and 28 (65%) of 43 were staged SNB negative. There was a mean follow-up of 18 months. One patient developed subsequent disease after having been staged negative with SNB. The overall sensitivity of the procedure using the full pathologic protocol was 94% (15/16). CONCLUSIONS: Sentinel node biopsy can be used to upstage the N0 neck in patients with early subclinical nodal disease. However, before it becomes the standard of care in head and neck squamous cell carcinoma, longer follow-up observational trials are needed.

Objective assessment of speech after surgical treatment for oral cancer: experience from 196 selected cases.

In 1992, a personal computer-based workstation for speech-digitized analysis was developed in conjunction with Canniesburn Hospital and Edinburgh University to measure all dispersion in speech after surgery for oral cancer. The voices of 196 patients with tumor of the oral cavity were recorded preoperatively and postoperatively. Surgical resection was carefully mapped out on standard diagrams of the oral cavity. Patients' recordings were assessed for conversational understandability by two referees. Patients also self-scored their speech using the Functional Intraoral Glasgow Scale self-questionnaire. Many patients had similar if not identical resections; therefore, 12 homogeneous groups were identified. Functional outcome for speech was correlated with the site and size of resected tissue and with the reconstruction modalities. The original association of an objective, computer-based tool and two subjective assessment tools proved to be the most suitable investigation method for speech. The general pattern was for consistently better speech quality with smaller excisions. The reconstruction modalities did not seem to influence the overall speech quality, as it was related mainly to the extent of surgical demolition. The authors present a detailed correlation between site and size of excision and functional outcome using color multiple-view diagrams for immediate appreciation. Positive and negative prognostic factors were identified in surgery for oral cancer.

Chewing and swallowing after surgical treatment for oral cancer: functional evaluation in 196 selected cases.

One hundred ninety-six patients treated for oral cancer between 1992 and 1999 self-scored their speech, chewing, and swallowing using a new self-questionnaire (Functional Intraoral Glasgow Scale) developed at Canniesburn Hospital, Glasgow, to assess the functional efficiency of patients treated for intraoral cancer. The patients were distributed into 12 homogeneous groups, according to the site and size of surgical resection, carefully mapped out on standard diagrams of the oral cavity. The functional outcome for chewing and swallowing was correlated to the site and size of resected tissue, to the reconstruction modality, and to radiotherapy and compared with the speech quality. The general trend is very similar for both chewing and swallowing; the smaller the resections, the better the functional outcome. Chewing was mostly affected by resections of the floor of the mouth, whereas swallowing was mostly affected by demolition of the base of the tongue and of the retromolar trigone. Speech showed a better postoperative recovery than chewing and swallowing. The reconstruction modality did not influence the eventual outcome for either function. Radiotherapy in combination with surgery is a negative functional prognostic factor. A correlation between site and size of excision and functional outcome is presented using color multiple-view diagrams for immediate appreciation to identify positive and negative prognostic factors.

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.

How many sentinel nodes should be harvested in oral squamous cell carcinoma?

The number of harvested lymph nodes when performing sentinel lymph node (SLN) biopsy remains controversial. The aim of this study was to examine the maximum number of nodes to be harvested for histopathological analysis. We also wanted to determine if the level of radioactivity within a SLN or its size were indicators for the likelihood of nodal metastases. The SLNs from 34 neck dissection specimens from patients with T1/T2 N0 oral and oropharyngeal carcinomas were included. Altogether 76 SLNs were measured for radioactivity and lymph node dimensions and volume. Tumour was identified in 16 of 76 nodes (positive nodes), and the remaining 60 nodes were free from tumour (negative nodes). In 9 of 16 cases, metastases were in the hottest node. Two patients had more than one positive SLN: the first and fourth hottest in one and the second and fourth hottest nodes in another contained tumour. However, all patients would have been staged accurately if only the hottest three sentinel nodes had been retrieved. Lymph nodes that contained tumour had a greater maximum diameter than non-metastatic SLNs. To stage the neck accurately, only the three hottest lymph nodes required sampling.

Predictive factors for failure to identify sentinel nodes in head and neck squamous cell carcinoma.

BACKGROUND: The aim of this study was to ascertain which factors determine success of sentinel node biopsy (SNB). METHODS: We conducted a retrospective review of 121 patients with head and neck squamous cell carcinoma undergoing SNB to stage the neck. All patients underwent the triple-diagnostic procedure of preoperative lymphoscintigraphy, intraoperative blue dye, and a gamma probe. Factors contributing to failure of SNB were identified. RESULTS: SNB was unsuccessful in 12 of 121 patients (10%). Seven of the 12 patients had cT1/cT2 tumors, and 6 of these were located in the floor of mouth. SN identification was more likely to be successful in patients with cN0 necks, but this did not reach statistical significance (92% vs 84%, p = .268). Factors associated with failure included T classification (p = .01), tumor site (p = .05), and negative preoperative lymphoscintigraphy (p = .0174). CONCLUSION: Successful sentinel lymph node harvest is related to primary tumor site, T classification, and the presence of nodes on preoperative lymphoscintigraphy.

Potential for efficacy of the oncolytic Herpes simplex virus 1716 in patients with oral squamous cell carcinoma.

BACKGROUND: : Herpes simplex virus (HSV) 1716 is a selectively replicating oncolytic virus. Our objective was to assess the potential efficacy of HSV1716 in patients with oral squamous cell carcinoma (SCC) by intratumoral injection. METHODS: : Twenty patients with oral SCC had a single intratumoral injection of HSV1716 at a dose of 105 pfu (plaque forming unit) or 5 x 105 pfu. Injections were done at 1, 3, or 14 days before surgical resection. The tumors were assessed for evidence of viral replication and necrosis. Immunologic response to virus and toxicity was also assessed. RESULTS: : Intratumoral injections were well tolerated with no adverse effects. Evidence of biological activity was lacking, with no increase in detectable virus in tumor samples. CONCLUSION: : Intratumoral injection of HSV1716 is safe but with little evidence for viral replication or efficacy. Further studies at higher doses are required to determine the potential efficacy of this virus in head and neck cancer.

Sentinel node in head and neck cancer: use of size criterion to upstage the no neck in head and neck squamous cell carcinoma.

BACKGROUND: Anatomical imaging tools demonstrate poor sensitivity in head and neck squamous cell carcinoma (HNSCC) patients with clinically node-negative necks (cN0). This study evaluates nodal size as a staging criterion for detection of cervical metastases, utilizing sentinel node biopsy (SNB) and additional pathology (step-serial sectioning, SSS; and immunohistochemistry, IHC). METHODS: Sixty-five patients with clinically N0 disease underwent SNB, with a mean of 2.4 nodes excised per patient. Nodes were fixed in formalin, bisected, and measured in 3 axes before hematoxylin-eosin staining. Negative nodes were subjected to SSS and IHC. SNB-positive patients underwent modified radical neck dissection. RESULTS: Maximum diameter was larger in levels II and III (13.1 and 13.2 mm) when compared with level I (10.5 mm; p = .004, p = .018), while minimum diameter was constant. Positive nodes were larger than negative nodes (p = .007), but nodes found positive by SSS/IHC were not significantly larger than negative nodes for either measurement (p = .433). Sensitivity and specificity were poor for all measurements. CONCLUSIONS: Nodal size is an inaccurate predictor of nodal metastases and should not be regarded as an accurate means of staging the clinically N0 neck.

The effect of surgical resection in the region of the retromolar trigone.

Tumours in the mucosa of the retromolar trigone (RMT) are rare, but develop insidiously and spread rapidly into surrounding structures. Resection may require radical dissection beginning usually on the medial side of the mandible. Such surgery can put important structures at risk. The normal anatomy of the RMT and its relations has been studied together with simulated surgical incisions and resections. Tissue removed was processed by histological techniques in order to demonstrate structures excised or damaged by the operation. The simulated incision showed that the lingual nerve, submandibular duct and palatoglossus were at particular risk. This could affect sensation, speech, swallowing and movements of the tongue. The findings pose immediate concerns for surgeons operating in this area. Although cancer surgery often involves sacrificing tissue, care should be taken to preserve structures vital to the patient's oral function without compromising oncological principles.

The functional intraoral Glasgow scale (FIGS) in retromolar trigone cancer patients.

BACKGROUND: Surgical incisions in the retromolar trigone (RMT) cause injury to underlying structures. The functional intraoral Glasgow scale (FIGS) is used to determine the ability of patients to speak, chew and swallow. FIGS could be used to investigate whether there is a correlation between clinical tumour stage and the function of the oral cavity following surgery in the RMT. MATERIALS AND METHODS: FIGS scores for 58 patients speech, chewing and swallowing collected pre-operatively, then at 3 and 20 weeks post-operatively, were used to calculate a total 'Global Oral Disability' value and compared with the clinical tumour size using the TMN staging method. RESULTS: Patients with RMT cancer who undergo surgical resection can expect a degree of functional impairment which is proportional to the clinical tumour size. DISCUSSION: FIGS is a simple and reproducible way of assessing a patient's functional impairment following surgery in the RMT, especially when using the new global oral disability value.

Evidence of significant sternocleidomastoid atrophy following modified radical neck dissection type III.

BACKGROUND: Although modified radical neck dissection type III preserves the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle, the authors believe there is a significant morbidity to retained structures after neck dissection. Although the effects on accessory nerve function and internal jugular vein patency have been documented, there is little information about sternocleidomastoid morphology and function following modified dissection. METHODS: Using a SonoSite ultrasound machine, the authors assessed sternocleidomastoid muscle morphology, at rest and during contraction, in a cohort of 45 patients who underwent modified radical neck dissection type III with no radiotherapy. All patients had head and neck cancers and received unilateral neck dissection as part of their primary treatment. Static and dynamic measurements were performed at three different levels of the muscle, with the neck in the neutral position. The contralateral neck of the same patient was used as a control. Local muscle asymmetry patterns were calculated using the Absolute Asymmetry Index. RESULTS: Significant sternocleidomastoid atrophy was noted on the side of modified radical neck dissection type III (p < 0.05). The atrophy was particularly marked in the caudal and middle portions of the sternocleidomastoid muscle and was likely related to damage to the segmental blood supply in the caudal and middle portions of the muscle as well as injury to the innervation. CONCLUSION: Despite evidence of significant atrophy, the muscle still underwent morphological changes during contraction that were comparable to those on the normal control side.

A comparison of temporalis transfer and free latissimus dorsi transfer in lower facial reanimation following unilateral longstanding facial palsy.

The ultimate goal in the treatment of facial palsy is the restoration of voluntary and spontaneous movement to the paralyzed side of the face, symmetrical to the normal side. We report our experience treating 40 patients with established facial palsy over a 4-year period. All patients underwent either temporalis transfer or free latissimus dorsi transfer as a single stage to improve lower facial symmetry. We believe that both techniques reliably achieve an increase of movement in facial reanimation after oncological, traumatic, or congenital facial palsy.

The second international conference on sentinel node biopsy in mucosal head and neck cancer.

BACKGROUND: The Second International Conference on Sentinel Node Biopsy in Mucosal Head and Neck Cancer was hosted by the Department of Otorhinolaryngology, Head and Neck Surgery of the University Hospital in Zurich, Switzerland, from September 12 to 13, 2003. The aims of this conference were to present the results of validation studies and to achieve a consensus on methodological requirements. METHODS: More than 80 delegates from 20 countries attended the conference. The presented validation studies were summarized and compared with the literature. Consensus was achieved concerning requirements for lymphatic mapping and histopathologic work-up. RESULTS: Twenty centers presented results on 379 patients with cN0 disease. Sentinel nodes were identified in 366 (97%) of 379. Of these 366, 103 (29%) were positive for occult metastasis, and 263 (71%) were negative. Of those 263 patients, 11 patients (4%) showed nodal disease not revealed by the sentinel lymph node biopsy (SNB). The negative predictive value of a negative sentinel node for the remaining neck was 96%. The consensus conference resulted in the use of a radiotracer, lymphoscintigraphy, and a handheld gamma probe for lymphatic mapping as minimal requirements. The use of conventional hematoxylin and eosin staining and immunohistochemistry for cytokeratin is mandatory. Step-sectioning of the entire node at intervals of 150 mum is recommended. CONCLUSIONS: The conference attracted delegates from all over the world, thus underscoring the high interest in the topic. With regard to the presented data and the data from the literature, SNB for early oral and oropharyngeal cancer is sufficiently validated. The consensus conference resulted in the definition of minimal methodological requirements for accurate SNB.

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.