Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2N0 oral tongue squamous cell carcinoma.

OBJECTIVE: This study aimed to compare the value of sentinel lymph node biopsy (SLNB) with that of elective neck dissection (END) for the prediction of cervical lymph node metastasis in patients with clinically diagnosed T1-2N0 (cT1-2N0) oral tongue squamous cell carcinoma (OTSCC), and it aimed to examine the prognostic value of individualized treatment in sentinel lymph node (SLN)-negative patients. STUDY DESIGN: The study entailed a retrospective review of 82 patients with cT1-2N0 OTSCC. Thirty patients underwent SLNB, and 52 patients underwent END. RESULTS: There was a significant difference between the SLNB and END groups in the incidence of occult cervical lymph node metastasis in initial specimens (30% vs 11.5%; P = .037). However, there were no significant differences between the groups for 10-year overall and cervical recurrence-free survival rates and 10-year overall survival rate. CONCLUSIONS: SLNB is superior to END for the prediction of cervical lymph node metastasis in patients with cT1-2N0 OTSCC. Neck dissection may be reduced for SLN-negative patients, owing to the comparable prognosis of SLNB.

Immediate reconstruction of maxillectomy defects using anterolateral thigh free flap in patients from a low resource region.

OBJECTIVES/HYPOTHESIS: To report the reliability and reconstructive outcome of using anterolateral thigh (ALT) flap with or without titanium mesh to repair maxillectomy defects in a patient from a low resource region (LRR). STUDY DESIGN: Retrospective review. METHODS: Clinical data of patients with oral-maxillofacial cancers who underwent maxillectomy and reconstruction using ALT flap in two tertiary cancer centers in southern China were retrospectively reviewed. Reconstructive techniques, flap survival, postoperative oral functions, and surgical complications were reported. RESULTS: Apart from one total flap loss, 18 of the 19 free ALT flaps survived. Titanium mesh was used in two patients with total maxillectomy defects. Eighteen of the 19 patients resumed a normal oral diet. Fourteen patients had good speech, except one patient with poor pronunciation, and four patients had average speech. One patient presented with postoperative palatal fistula. No other complications were observed. CONCLUSIONS: The application of ALT flaps with or without titanium mesh to repair maxillectomy defects is straightforward and reliable and has an acceptable reconstructive outcome. It might be a suitable procedure for patients from an LRR.

[Sentinel lymph node radiolocalization in squamous cell carcinoma of the oral tongue].

BACKGROUND & OBJECTIVE: At present, there is no clinical examination that can accurately assess the lymph node metastasis status of oral tongue carcinoma with clinically negative neck lymph node (cN0) before operation. Therefore, the treatment of cN0 neck is still controversial. Sentinel lymph node (SLN) biopsy may be the evidence for individual treatment of cN0 neck. This study was to explore the feasibility of SLN radiolocalization, and to investigate the clinical value of SLN detection in squamous cell carcinoma of the oral tongue. METHODS: Twenty-one oral tongue squamous cell carcinoma patients with cN0 necks were recruited, among which 1 had received primary dissection before. 99mTc-SC, as the tracer, was injected into the submucosa around primary tumor before operation. Lymphoscintigraphy was performed immediately in 5 cases. The gamma probe was used to identify SLNs for all cases before and during operation. All patients received supraomohyoid neck lymph node dissection. The pathologic results were considered as golden standard to evaluate the effectiveness of SLN radiolocalization. SLNs that had been reported as negative by routine pathologic examination were examined by immunohistochemistry. RESULTS: The detection rate of SLNs was 100%. Among the 21 patients, the pathologic results of SLNs for 21 patients accorded with the pathologic results of neck lymph node dissection; the accuracy rate was 95%. In 1 patient, the pathologic result of SLNs was negative, but that of neck lymph node dissection was positive. Micrometastases were found in 3 of 41 detected lymph nodes by immunohistochemstry. CONCLUSIONS: SLN radiolocalization in squamous cell carcinoma of the oral tongue is feasible. SLN biopsy can well predict the cervical lymph node metastasis status of oral tongue carcinoma, but further investigation is necessary to determine its clinical value.

[Research of modified rat laryngeal transplantation model].

OBJECTIVE: To study modified rat laryngeal transplantation model. METHODS: Eighty isogeneic histocompatible F344 rats were randomized into control and experimental groups. Strome model of laryngeal transplantation was established in the the control group, and in the experimental group, the ascending pharyngeal artery was preserved and the base of the tongue, larynx and pharyngolarynx were harvested as a complex allograft followed by end-to-end anastomosis of the both allograft common carotid arteries with the recipient common carotid artery and the anterior jugular vein, respectively. The arterial and nenous patency rate and allograft viability rate were compared between the two groups. RESULTS: The artery and vein patency rates and graft survival rate were 30%, 15%, and 30% in the control group, and 75%, 65%, and 80% in the experimental group, respectively, showing significant difference between the two groups (P<0.05). CONCLUSION: In modified rat laryngeal transplantation model, the allograft viability rate and vessel patency rate are improved, which provides a good model for immunological study of larynx transplantation.

[In vitro preservation of laryngeal allograft for larynx transplantation].

BACKGROUND & OBJECTIVE: As a complex organ, laryngeal allograft cannot endure more than 3 hours during preservative time in vitro. This study was to explore the best preservation method and time limit of laryngeal allograft. METHODS: During transplantation experiment of the larynx, HCA solution and UW's solution was used to perfuse laryngeal allograft on original position separately. The sequential morphologic changes of the allograft after cold preservation were observed to compare the effects of the 2 solutions. RESULTS: After preservation in HCA solution for 20 h, ultrastructure changes, including mitochondrial edema or collapse and chromatin agglutination, appeared in mucosa, capillary and intrinsic laryngeal muscle cells of the laryngeal allograft; nuclear pyknosis was observed after 22 h and followed by apoptosis. While ischemic and necrosis changes of the laryngeal allograft appeared after preservation in UW's solution for 24 h. CONCLUSIONS: UW's solution can preserve laryngeal allograft for 24 h in vitro, and has better effect than HCA solution.

[Treatment and prognosis of stage T3 glottic laryngeal cancer--a report of 65 cases].

BACKGROUND & OBJECTIVE: Clinical treatment of stage T3 glottic laryngeal cancer still remains controversial. This study was to explore the influences of different treatment modalities, lymph node metastasis, and positive margin on prognosis of stage T3 glottic cancer. METHODS: Records of 65 stage T3 glottic cancer patients, treated in Cancer Center of Sun Yat-sen University from Jan. 1, 1990 to Dec. 30, 1998, were retrospectively analyzed. The influences of different treatments, lymph node metastasis, and positive margin on survival of the patients were analyzed. RESULTS: The 3- and 5-year overall survival rates were 75.47% and 65.07%. No significant difference was found among surgery alone, radiotherapy alone, and surgery plus adjuvant radiotherapy groups (P=0.914), between partial laryngectomy and total laryngectomy groups (P=0.710), and between positive margin and negative margin groups (P=0.176). The lymph node metastasis rate was 18.5%, and the occult lymph node metastasis rate was 10.8%. Lymph node metastasis was a poor prognostic factor (P<0.001). CONCLUSIONS: The influences of different treatments on survival of stage T3 glottic cancer patients are similar, and the effects of partial laryngectomy and total laryngectomy are also similar. Lymph node metastasis affects prognosis, and wait-and-see is recommended to cN0 patients. The survival of patients with positive margin after postoperative radiotherapy is similar to that of patients with negative margin.

[Surgical management for occult cervical metastasis of oral tongue squamous cell carcinoma].

BACKGROUND & OBJECTIVE: In oral tongue squamous cell carcinoma (SCC), the management for clinically negative (cN0) neck remains controversial. This study was to explore rational neck management for cN0 cases. METHODS: Clinical data of 187 patients with oral tongue SCC of cN0, who received surgery alone, were retrospectively reviewed. Rules of occult nodal metastasis, factors that impact cervical node metastasis, and prognostic factors were analyzed. Neck recurrences of different treatment groups were compared. RESULT: Incidence of occult nodal metastasis in all patients was 23.0% (43/187). The most common site of occult nodal metastases was ipsilateral level II. About 83.0% of occult nodal metastases were found in ipsilateral levels I, II, and III. Pathologic grade was an independent influencing factor for occult neck metastases. Occult neck metastasis was an independent prognostic factor for oral tongue SCC. Supraomohyoid neck dissection (SOHND) was an effective therapeutic method for oral tongue SCC of cN0; the neck recurrence rate after SOHND was only 6.7%. CONCLUSIONS: SOHND is the effective and safe treatment for oral tongue SCC.

[Establishment of a modified larynx transplantation model with inbred F344 rat].

BACKGROUND & OBJECTIVE: As a non-vital organ, transplantation of larynx lags behind that of the other organs, but it is supposed that if induction of immunologic tolerance of the host to the allograft comes true, larynx transplantation would be an optimal approach for management of advanced laryngeal cancer as well as functional reconstruction of the larynx. This study was designed to establish a modified rat model of larynx transplantation to improve survival rate of the recipients and vitality of the allografts, and provide an optimal rat model for further research on immunology and induction of immunologic tolerance in larynx transplantation. METHODS: A Strome's model of larynx transplantation was repeated with inbred F344 rats (40 rats in Stroma model A and 40 rats in Stroma model B). A modified model of larynx transplantation was developed (40 rats), in which both superior thyroid arteries and ascending pharyngeal arteries were preserved, combining with the hyoid, base of the tongue, hypopharynx, larynx, thyroid, part of the cervical trachea and cervical esophagus as an allograft complexity. The blood supply of the allograft was reconstructed through end-to-end anastomosis of the donors' carotid arteries with the recipients' carotid artery and anterior jugular vein. The recipients were injected with 15 ml of 5% glucose normal saline (GNS) through contralateral external jugular vein intraoperatively, and injected subcutaneously with 5 ml of 5% GNS daily for 3-5 days postoperatively. Morphology of the allografts and patency of the arteries and veins were observed under microscope 7 days after operation, and vitality of the allogafts was assessed pathologically. Survival of the recipients and vitality of the allografts in Strome model and modified model were compared. RESULTS: Survival rates of the recipient rats were 70% in Strome model A, 85% in Strome model B, and 95% in modified model; the survival rates of the allografts were 30% in Strome model A, 40% in Strome model B, and 80% in modified model, respectively. CONCLUSIONS: Compare with Strome models, the modified model of larynx transplantation reduces mortality of the recipients through enhancing perioperative care, improves vitality of the allografts through including both ascending pharyngeal arteries and superior thyroid arteries in the allograft complexity, which increases blood supply of the allografts and reduces micro-circulation resistance, therefore, reduces the micro-circulation malfunction of the allografts.

[Management option for cervical metastases in tongue squamous cell carcinoma with clinically N0 neck].

OBJECTIVE: This study was designed to explore the optimal management option for cervical metastases in tongue squamous cell carcinoma (SCC) with clinically N0 neck in order to avoid excessive or inadequate treatment in clinical practice. METHODS: Clinical data of 327 cases of tongue SCC with cN0 neck were retrospectively analyzed. Neck control rates affected by different pathoclinical parameters were compared. Prognosis analysis and death analysis were also performed. RESULTS: Overall 3-year survival was 69.7% (228/327), 3-year survival of neck recurrent group and non-recurrent group was 39.1% (25/64) and 77.2% (203/263), and 51.5% (51/99) of the death related to neck failure. Overall neck control rate was 80.4% (263/327); neck control rate of wait and watch group, level I neck dissection, level I + II neck dissection, supraomohyoid neck dissection, radical neck dissection, functional neck dissection, was 67.5% (27/40), 72.7% (24/33), 60.0% (15/25), 84.9% (45/55), 86.8% (131/151), 84.0% (21/25), respectively. Treatment modality and cervical lymph node involvement were independent factors for neck control. CONCLUSIONS: Neck control is a key for prognosis of tongue SCC with cN0 neck. Supraomohyoid neck dissection is the first choice in management of cervical metastases in tongue SCC with cN0 neck, during which the suspected involved lymph nodes should be sent for frozen section to determine whether comprehensive neck dissection required. Multimodal metastasis and/or capsular spread are the indications for postoperative irradiation.

[Clinical research of sentinel node biopsy in oral tongue carcinoma].

OBJECTIVE: This study was designed to evaluate whether sentinel node (SN) biopsy can accurately assess the cervical lymph node status of oral tongue carcinoma, as well to research the best method and indications of SN biopsy. METHODS: Preoperative lymphoscintigraphy with (99m)Tc-SC and intraoperative sentinel node mapping with methylene blue dye were administered on 20 cases of oral tongue carcinoma with cN(0) neck and 5 cases with cN(+) neck; routine pathological examination was used to assess the status of SNs. The results of routine pathological examination of cervical specimen were set as golden standard to assess the efficacy of SN biopsy in evaluating the cervical lymph node status. RESULTS: 53 SNs were detected in 24 cases out of the total 25 cases (96%), averaging 2.2 SNs per case. SNs were detected in all 20 cases with cN(0) neck, in which 4 cases with occult cervical metastasis were detected by SN diopsy, without false negative case found in the procedure. In 5 cases with cN(+) neck, SNs were detected in 4 cases. In 4 cases whose SNs were detected, there were 5 cN(+) necks, out of which SNs were detected in 4 cN(+) necks but failed to predicted the cervical lymph node status in 2 necks. However, SNs were detected in 2 out of the other 3 cN(0) necks, both of which were diagnosed as SN(+)pN(+). CONCLUSIONS: Nuclear lymphoscintigraphy and blue dye mapping can be used to trace the SNs in cases with oral tongue carcinoma, with satisfactory detective rate. SN biopsy can accurately evaluate the cervical lymph node status in cases of oral tongue carcinoma with cN(0) neck. Whether it can be used to evaluate the lymph node status of the cN(0) neck in case with a contralateral cN(+) neck is worthy of further research.

[Inducible nitric oxide synthase and basic fibroblast growth factor expression as prognostic factors in supraglottic squamous cell carcinoma].

BACKGROUND & OBJECTIVE: The prognosis of supraglottic squamous cell carcinoma (SGSCC) was poor. To authors' knowledge, the relationship between inducible nitric oxide synthase (iNOS) and basic fibroblast growth factor (bFGF) and the prognosis of SGSCC has not been addressed to date. This study was designed to evaluate the prognostic significance of these two parameters in SGSCC. METHODS: The expression of iNOS and bFGF protein in 64 patients with SGSCC using LSAB method and pathologic imagine analysis system and their association with neck lymph node metastases, recurrence, and prognosis. RESULTS: (1) The expression of iNOS and bFGF was significantly higher in cervical lymph node positive group (33.2+/-8.8 and 36.1+/-7.8) than in negative group (27.3+/-7.4 and 24.5+/-7.5) with statistical significance. The expression of iNOS and bFGF was higher in recurrence group (36.9+/-1.7 and 34.6+/-2.0) than in no-recurrence group (29.1+/-1.3 and 27.2+/-1.4) with statistical significance. (2) Patients with positive neck lymph node had poorer 5-year survival than those with negative neck lymph node (31.0% vs. 57.1%). Patients with positive iNOS expression had poorer 5-year survival than those with the negative iNOS expression (40.0% vs. 77.8%). However, there was no statistical significance between positive bFGF expression group and negative bFGF expression group. (3) Cox model multivariate regression analysis showed that lymph node status, the expression of iNOS and postoperative radiotherapy were independent prognosis factors, whereas the T staging and the expression of bFGF were not. CONCLUSION: The expression of iNOS was one of the independent prognostic factors, but it is necessary to study further for iNOS and bFGF to predict the prognosis of patients with SGSCC using immunohistochemical technique.

[Diagnosis of unknown primary cervical metastatic carcinoma].

Theoretically, primary carcinomas affirmatively exist when a cervical metastasis is diagnosed. However, not all primary carcinoma can be detected under present examination practically. Whether the primaries are found affects the outcomes of long-term survival and quality of life of the patients. With the exploitation of new medical instruments, development of diagnostic techniques, and improvement of diagnostic methods, more and more primaries in the patients who were formerly diagnosed as cervical metastatic carcinoma can be detected. This article aims mainly at review of definition and traditional and new developed diagnostic methods of unknown primary cervical metastatic carcinoma (UPCMC).

[Optimized methods of sentinel node localization in cN0 tongue carcinoma].

BACKGROUND & OBJECTIVE: At present, there is no clinical examination and biochemical marker available to assess the lymph node status of tongue carcinoma with clinically negative neck (cN0) accurately. Therefore, the treatment of the cN0 neck in tongue carcinoma is of blind to some extent. Application of sentinel node(SN) biopsy may possibly bring about the individualized management of the cN0 neck of tongue carcinoma. This study was designed to assess whether lymph node status can be accurately evaluated by SN biopsy and to screen out the optimized sentinel node localization method. METHODS: Preoperative nuclear lymphoscintigraphy and intraoperative methylene blue dye mapping were performed in 24 cases of tongue carcinoma to reveal the efficacy of sentinel node biopsy in evaluating the lymph node status in cN0 tongue carcinoma. Shortcomings and advantages of lymphoscintigraphy, methylene blue dye mapping and combination of both methods were discussed. RESULTS: Sentinel nodes were detected in all cases with both methods. Sentinel nodes were found with metastasis in 4 cases. No non-sentinel node was found with metastasis while sentinel nodes were pathologically negative. The detection rates were 3.5 sentinel nodes per case by lymphoscintigraphy, and 2.7 by methylene blue dye, while only 2.2 sentinel nodes by combined methods. CONCLUSION: Either lymphoscintigraphy or methylene blue dye mapping can be used to assess the cervical lymph node status of cN0 tongue carcinoma accurately. Combination with both methods is the most efficient and practicable method in sentinel node detection.

[Regularity and therapeutic strategy of cervical lymph node metastasis in squamous cell carcinoma of the tongue].

BACKGROUND & OBJECTIVE: At present, whether neck dissection should be employed in squamous cell carcinoma (SCC) of the tongue with clinically node negative neck(cN0) is still controversial. This study was designed to explore the regularity of cervical lymph node metastasis in SCC of the mobile part of the tongue, and to discuss the theories and principles of employment of selective neck dissection in cN0 cases. METHODS: A retrospective research was performed on clinical data of 214 cases of SCC of the tongue treated with surgery from 1991 to 1997. Distribution of cervical lymph node metastasis of cN0 pN(+)= (pathologically node positive) and cN(+) (clinically node positive) pN(+)= cases were analyzed; the survival rates of different groups were compared; the factors that impact the survival of SCC of the tongue were screened out by Cox regression analysis. RESULTS: Cervical lymph node metastases were found in 69 cases. The metastatic rate was 32.2%. Metastases occurred in level I, II, III, IV, V of the ipsilateral neck were 22.3%, 33.5%, 22.3%, 4.6%, 1.0%, in level I,II,III, IV,V of the contralateral neck were 6.6%, 3.6%, 3.0%, 2.0%, 0.5%, respectively. The 5-year survival rates of the pN(+)= group and the pN0 group were 47% and 83%, respectively(P< 0.001). T stage and N stage were independent factors that impact the long-term outcome of SCC of the tongue. CONCLUSION: Level I,II,III of the ipsilateral neck tend to be involved when cervical lymph node metastases occur. Selective neck dissection can be used to treat the cervical metastasis in cN0 cases, as well as to evaluate the cervical lymph node status in order to determine whether comprehensive neck dissection should be employed.