Neck Control Rate Research Articles

Risk and prognostic analysis of cervical lymph node metastasis in cN+ laryngeal squamous cell carcinoma

Objective:To analyze the clinical, pathological features and metastatic regularity of cervical lymph node metastasis in cN+ laryngeal squamous cell carcinoma, and to explore its diagnosis and management. Methods:Among 1030 patients with laryngeal squamous cell carcinoma who underwent surgery in the Department of Otolaryngology, The First Affiliated Hospital of Chongqing Medical University from March 2011 to January 2021, 83 patients with cN+ were included in the retrospective analysis of clinical data and follow-up data. Results:Among the 83 cases of cN+ laryngeal carcinoma, there were pN+65 cases and pN-18 cases. The false positive rate of cN+ was 21.7%. cN+ cervical lymph node metastasis was related to classification and staging, and the difference was statistically significant（P<0.05）.The false positive rate of cN+ in different types of laryngeal carcinoma was 57.7% （16/27） in glottic type and 3.9% （2/55） in supraglottic type. With the increase of T stage, the false positive rate decreased.The false positive rates of different CT imaging features were as follows:①Size:the critical lymph nodes of more than 2 sizes were 27.3% （3/11）, the 1~3 cm of lymph nodes was 29.4% （15/51）, and the lymph nodes > 3 cm were not false positive （0/21）;②The enhancement types of uniform enhancement, non-uniform enhancement and circular enhancement were 34.3% （12/35）, 31.6% （6/19） and 0% （0/29） respectively. ③The proportion of unclear shape and boundary of lymph nodes was 0（0/24）.The neck recurrence rate was 2.4% in the selective neck dissection （SND） and 20.0% in the non-SND. The 3-year neck area control rates of SND and non-SND group were 93.7% and 81.1% respectively, and the difference was statistically significant （P < 0.05）. The 3-year cumulative survival rates of pN+ group and pN- group were 75.5% and 87.5%, respectively, and there was no significant difference between the two groups （P > 0.05）. The 3-year cumulative survival rates of lymph node extranodal extension ENE+ group and ENE- group were 50.6% and 79.3%, respectively, and the difference was statistically significant （P < 0.05）. Conclusion: There is false positive in cN+ laryngeal carcinoma, which is related to tumor classification and staging. Preoperative imaging diagnosis of cN+ should not be over-dependent on size, but should be combined with the specific manifestations of lymph node metastasis such as circular enhancement and unclear boundaries. Proper use of SND in the treatment of cN+ laryngeal carcinoma is safe and effective, and reduces the risk of overtreatment. In patients with pN+ laryngeal carcinoma, postoperative supplementary treatment can improve the neck control rate and survival rate. However, even if postoperative treatment is performed in patients with ENE+, it is still an unfavorable factor affecting the prognosis.

Long-Term Follow-Up Of Primary And Adjuvant Proton Therapy For Sinonasal Cancer

To report long-term disease control, patterns of recurrence, survival, and toxicity after proton therapy (PT) for sinonasal cancer. We reviewed the records of 143 adult, non-metastatic patients treated with primary (18%) or adjuvant (82%) PT for sinonasal cancers (excluding melanoma, sarcoma, and lymphoma). The most common histologies were squamous carcinoma (29%), olfactory neuroblastoma (23%), and adenoid cystic carcinoma (16%). Most patients had advanced stage disease (T3, 24%; T4, 66%), 11% were N+, and 52% were high grade. Surgical management included endoscopic resection alone (50%), with craniotomy (10%), or open procedures (40%). At the time of PT, 31% had gross disease at the primary site. Most patients received hyperfractionation (1.2 GyRBE twice daily, 91%) and chemotherapy (70%, most commonly low-dose weekly cisplatin). Median RT dose was 73.6 GyRBE and 84% received > 70 GyRBE. Kaplan-Meier method was used to estimate disease control and survival endpoints and log-rank and cox-proportion hazard models were used to for univariate and multivariate models were used to assess prognostic factors. Serious, late G3+ toxicities were reported per CTCAE v4. The median follow-up was 4.4 years (range, 0.1 – 12.5) for all patients and 4.9 years (range, 0.9 – 12.5) for living patients. The local control (LC), neck control, disease-free, cause-specific, and overall survival (OS) rates were 80%, 96% 62%, 64%, and 59% at 5 years. Surgery improved local control; however, the benefit of surgery was only apparent after gross total resection. At 5 years, LC was 90% for patients without gross disease at PT, compared with 62.9% after subtotal resection, and 55% after biopsy alone (p < 0.001). Gross residual disease at the time of PT was the only significant prognostic factor for LC on multivariate analysis. High-grade, T4, and local-recurrence after therapy were associated with decreased OS. Serious late toxicity occurred in 22% (G3, 16%; G4, 3%; and G5, 3%). G3+ toxicity occurred in 22% of patients. CNS necrosis and vision loss occurred in 6% and 3.5%, and 2 patients (1%) had radiation-associated 2nd tumors (meningioma). PT after gross-total resection results in excellent long-term local control, which is a strong predictor of long-term survival. About 50-60% of patients will still achieve long-term LC even with gross disease. Balancing the benefits of LC against significant toxicity remains a challenge. High-grade histology was strongly associated with distant dissemination, and surgery should be avoided in such patients when non-morbid gross-total resection is unlikely.

Patterns of failure and clinical outcomes of post-operative buccal mucosa cancers treated with adjuvant ipsilateral radiotherapy.

PurposeAdjuvant radiotherapy (RT) in buccal mucosa cancers is guided by histopathological factors. The decision to treat ipsilateral or bilateral draining lymph node is on physician discretion and guidelines do not have a defined indication regarding this. We aimed to analyze the failure patterns and survival in buccal mucosa cancers treated with adjuvant ipsilateral RT.Materials and MethodsOne hundred sixteen cases of post-operative buccal mucosa cancers—pT3 or more, node positive, close margins (1–5 mm), lymphovascular invasion positive, perineural invasion positive, depth of invasion >4 mm—treated with RT to primary and ipsilateral nodes from May 2013 to May 2019 were retrospectively analyzed. Patients were treated to a dose of 60–66 Gy (44 Gy in the first phase and a coned down boost of 16–22 Gy in the second phase) with three-dimensional conformal radiotherapy on a linear accelerator. Primary end point was to assess control rates and secondary end point was to evaluate the overall survival (OS) and disease-free survival (DFS) outcomes. ResultsMedian age was 46 years with male; female ratio of 110:6. The edition of the American Joint Committee on Cancer stage distributions were I (3.4%), II (34.4%), III (24.1%), and IV (37.9%). At a median follow-up of 22 months, crude rates of local failure, regional failure, and contralateral neck failure were 9.4%, 10.3%, and 3.4%, respectively. The 2-year contralateral neck control rate was 94.9%. Pathological positive node portended poorer OS (86.6% vs. 68.6%; p = 0.015) and DFS (86.5% vs. 74.9%; p = 0.01).ConclusionIncidence of contralateral recurrence with ipsilateral irradiation in buccal mucosa cancers is low with descent survival outcomes, particularly in node negative cases.

The Efficacy of Low Postoperative Radiation Dose in Patients with Advanced Hypopharyngeal Cancer without High-Risk Factors.

ObjectiveTo evaluate the feasibility and efficacy of low postoperative radiotherapy (PORT) dose in patients with advanced hypopharyngeal squamous cell carcinoma (HPSCC) and identify prognostic factors in this group.Patients and MethodsBetween January 2013 and September 2015, 110 consecutive patients with HPSCC with no high-risk factors were treated postoperatively to 50 Gy (n=89), 56 Gy (n=12), and 60 Gy (n=9) in 2 Gy/fraction. Overall survival (OS), 3-year progression-free survival (PFS), 3-year loco-regional recurrence-free survival (LRFS), and treatment-related toxicities were analyzed.ResultsMedian follow-up time was 40 months (range=6–75 months). The 3-year local-regional control (LRC) and 3-year neck control rate were 86.3% and 91.8%, respectively. The 3-year OS, PFS, and LRFS were 69.9%, 65.5%, and 80.5%, respectively. In a univariate analysis, T stage showed a significant correlation with improved OS, PFS, and LRFS (P=0.008, P=0.039, P=0.034). On multivariate analysis, T stage showed a significant correlation with improved OS and PFS. N stage showed a significant correlation with improved PFS. However, interval surgery-radiotherapy, reconstructive methods, and RT dose cannot serve as a significant prognostic factor for survival outcome.ConclusionThis study suggests that treating no high-risk factors for locally advanced HPSCC with a dose of 50 Gy to the whole operative bed and elective lymph node levels cannot compromise disease control and survival.

Selective Neck Dissection and Survival in Pathologically Node-Positive Oral Squamous Cell Carcinoma.

The most important prognostic factor in oral squamous cell carcinoma (OSCC) is neck metastasis, which is treated by neck dissection. Although selective neck dissection (SND) is a useful tool for clinically node-negative OSCC, its efficacy for neck node-positive OSCC has not been established. Sixty-eight OSCC patients with pN1–3 disease who were treated with curative surgery using SND and/or modified-radical/radical neck dissection (MRND/RND) were retrospectively reviewed. The neck control rate was 94% for pN1–3 patients who underwent SND. The five-year overall survival (OS) and disease-specific survival (DSS) in pN1-3 OSCC patients were 62% and 71%, respectively. The multivariate analysis of clinical and pathological variables identified the number of positive nodes as an independent predictor of SND outcome (OS, hazard ratio (HR) = 4.98, 95% confidence interval (CI): 1.48–16.72, p < 0.01; DSS, HR = 6.44, 95% CI: 1.76–23.50, p < 0.01). The results of this retrospective study showed that only SND for neck node-positive OSCC was appropriate for those with up to 2 lymph nodes that had a largest diameter ≤3 cm without extranodal extension (ENE) of the neck and adjuvant radiotherapy. However, the availability of postoperative therapeutic options for high-risk OSCC, including ENE and/or multiple positive lymph nodes, needs to be further investigated.

Suggestions for surveillance and radiation strategy in nasopharyngeal carcinoma treated with IMRT: Based on hazard-rate and patterns of recurrence

ObjectiveThe study was designed to appraise the locoregional recurrence patterns using conventional two-dimensional radiotherapy (2D-RT) and intensity modulated radiation therapy (IMRT) in nasopharyngeal carcinoma (NPC) in order to better establish the scenario of the modern radiotherapy and the duration of surveillance. Materials and MethodsWe reviewed the institutional database to identify patients with pathologically confirmed, non-metastatic NPC who completed radical 2D-RT or IMRT at our center from 2000 to 2011. We collected data on clinicopathologic features, treatments and outcomes. Statistical analyses were performed using SPSS 20.0 or STATASE 14.0. ResultsThe median follow-up was 60.1 months. Of 2315 patients, 1289 (53%) were treated with 2D-RT and 1026 (47%) with IMRT. IMRT group achieved better locoregional control rate, with the 5-year locoregional relapse-free survival (LRRFS) were 84.9% and 87.7% among patients received 2D-RT and IMRT, respectively (P = 0.050). IMRT was superior to 2D technique in terms of local relapse-free survival (LRFS) (88.4% vs 91.1%, P = 0.047) and the advantage was only significant in T3-4 subgroup (81.6% vs 90.2%, P = 0.000). Similar neck control rates were observed using different RT techniques. And the recurrence time appeared to be postponed by IMRT, with peaks accounting for the year 1.5 and year 3–4 compared to which was predominant at the first two years using 2D-RT in nature. ConclusionsIMRT provided an improved LRRFS in overall stage and LRFS in advanced T stage for NPC compared with 2D-RT. Annual hazard of recurrence also changed with RT techniques.

Oncologic safety of cervical nerve preservation in neck dissection for head and neck cancer.

Although the functional merits of preserving cervical nerves in neck dissection for head and neck cancer have been reported, the oncologic safety has not yet been determined. Therefore, the purpose of this study was to evaluate the safety of cervical nerve preservation. A retrospective chart review was performed on patients with head and neck cancer who had been treated by neck dissection between 2009 and 2014 at Kyoto Medical Center. Management of cervical nerves and clinical results were analyzed. A total of 335 sides of neck dissection had been performed in 222 patients. Cervical nerves were preserved in 175 neck sides and resected in 160 sides. The 5-year overall survival (OS) rate calculated by the Kaplan-Meier method was 71%. The 5-year neck control rate was 95% in cervical nerve preserved sides and 89% in cervical nerve resected sides. Preserving cervical nerves in neck dissection is oncologically safe in selected cases.

Analyses of clinicopathologic factors affecting neck control after postoperative radiation as adjuvant treatment for lymph node metastasis in head and neck squamous cell carcinoma

To investigate the clinicopathologic factors associated with neck control and distant metastasis in patients with neck metastases in head and neck squamous cell carcinoma (HNSCC) after postoperative radiation as adjuvant treatment. Clinicopathologic data of 208 pathologic N+ (pN+ ) patients with HNSCC initially treated with neck dissection and postoperative radiation in Bethune International Peace Hospital of China from January 2004 to December 2009 were reviewed. The clinicopathologic factors, includeding age, sex, primary tumor site, pathologic T and N stage, tumor growth pattern, histological grade, tumor resection margin, size and number of positive lymph node, number of levels with positive lymph node, and extracapsular nodal spread (ECS), were evaluated for their association with neck control and distant metastasis in patients with HNSCC after postoperative radiation. Univariate χ(2) test and multiple stepwise logistic regression model were used for the analysis. Overall 5-year neck control rate after postoperative radiotherapy was 72.6% (151/208), with 84.0% (63/75) for SND, 72.9% (78/107) for MRND, and 38.5% (10/26) for RND, respectively. Univariate analysis showed that neck control after postoperative radiation was related with following factors: primary tumor site, pathologic N stage, size of positive node, number of levels with positive node, number of positive node, and ECS. Pathologic N stage and number of levels with positive lymph node were associated with distant metastasis. Multivariate analysis indicated that ECS was the most significant risk factor for neck metastasis after surgery and postoperative radiotherapy and the number of levels with positive node was the most significant risk factor for distant metastasis. ECS is the most important pathologic factor in planning postoperative adjuvant treatment for pN+ patients with HNSCC, therefore ECS should be evaluated routinely after neck dissection. The value of postoperative radiotherapy in controlling the ECS-related recurrence after surgery is limited. Postoperative concurrent chemoradiotherapy and targeted therapy can be considered in HNSCC patients with ECS.

Tailored multimodality therapy guided by a two-step decision making process for head-and-neck cancer of unknown primary.

BackgroundThere is no consensus on the treatment of head-and-neck cancer of unknown primary (HNCUP). The objective of this study is to report our single institution's experience of a tailored multimodality therapy guided by a two-step decision making process.Materials and MethodsFrom January 2007 to November 2013, 92 consecutive patients of HNCUP were treated. 77 patients were treated according the process above, 24 were treated by radiotherapy to the nasopharyngeal site, 7 received neck dissection and radiotherapy to other putative mucosal site, 30 were treated by neck dissection alone, and 16 received neck dissection followed by radiotherapy to the neck. SPSS 20.0 software was used for statistical analysis.ResultsAfter a median follow-up of 34 months, the 3-year overall survival rate was 84.5%. The 3-year mucosal control rate, neck control rate, distant metastasis-free survival rate and disease-free survival rate were 80.9%, 76.2%, and 92.0%, respectively. Of the 24 patients treated as putative nasopharyngeal carcinoma, no primary emerged from any site. Primary tumor emerged in 14 patients, and no primary emerged in the 31 patients treated with putative site radiation (3-year mucosal control rate: 100% vs. 67.9%, p = 0.010). Of the 46 patients treated with neck dissection with/without postoperative radiation, 14 developed neck recurrence, and patients without postoperative radiation suffered more ipsilateral neck recurrence.ConclusionsThe two-step decision-making process seem to be reasonable in treating Chinese HNCUP patients. However, this results need to be prospectively validated.

Technique for reliable sentinel node biopsy in squamous cell carcinomas of the floor of mouth.

Applicability of sentinel node biopsy (SNB) for tumors of the floor of mouth (FOM) is controversial. Prospective evaluation of the accuracy of gamma-probe-guided superselective neck dissection of the preglandular triangle of level I for SNB in FOM squamous cell carcinoma (SCC) after preoperative lymphoscintigraphy and single photon emission CT (SPECT)/CT. In total, 22 sentinel lymph nodes were harvested in level I. Eight of 22 (36%) were seen on lymphoscintigraphy and 11 (50%) on SPECT/CT. Eleven sentinel lymph nodes (50%) were only detected intraoperatively. In unilateral tumors, 20% were contralateral, and, in midline tumors, 93% showed bilateral level I sentinel lymph nodes. The false-negative rate was 8.3%, the negative predictive value was 96.4%, and the false-omission rate was 3.6%. The ultimate neck control rate, including salvage treatment, was 100%. SNB in FOM can be reliably performed using the presented surgical technique. Level I exploration, bilaterally in midline tumors, is mandatory irrespective of the visualization of sentinel lymph nodes in other levels. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1367-1372, 2016.

Selective Versus Comprehensive Neck Dissection in Patients With T1 and T2 Oral Squamous Cell Carcinoma and cN0pN+ Neck

There is still no consensus on the oncologic safety of selective neck dissection (SND) in the management of pathologically positive neck in patients with oral squamous cell carcinoma (OSCC). This study compared the clinical outcome between SND and comprehensive neck dissection (CND) for patients with T1 and T2 OSCC and a clinically negative but pathologically positive neck. Retrospective study of medical records of patients with T1 and T2 OSCC and clinical N0 but pathologic N(+) disease from March 2000 through March 2011 was performed. Thirty-seven patients underwent SND or CND. Median follow-up was 51months. Regional control and disease-specific survival rates were statistically analyzed. No significant differences in 3-year ipsilateral neck control rate (81.8 vs 91.7%; P= .590 by log-rank test) and overall regional control rate (72.7 vs 86.8%; P= .424 by log-rank test) were found between the SND and CND groups. Three-year disease-specific survival rates of the SND and CND groups were 72.7 and 82.1%, respectively. No significant difference was found between these 2 groups by log-rank test (P= .428). The results indicate that SND in conjunction with postoperative radiotherapy is effective in the management of patients with T1 and T2 OSCC and cN0pN(+) neck.

Facial lymph node involvement as a prognostic factor for patient survival in oral cavity squamous cell carcinoma.

To investigate the incidence of metastasis to facial lymph nodes (FLNs) and to determine its impact on the prognosis and survival of patients at onset of oral cavity squamous cell carcinoma (OSCC). A retrospective review of 641 patients with OSCC treated with curative surgery (CS) alone or CS + postoperative radiotherapy (PORT) was performed. Based on FLN status, an analysis of clinicopathologic parameters, prognosis, and survival was conducted. By classifying patients according to FLN status, a reasonable treatment modality was identified in the low-risk group, which was defined as those who had N0-1 disease, negative margin, and no extracapsular nodal spread (ENS). FLN involvement was identified in 103 patients (16%), which showed statistically significant associations with several established risk factors and negatively affected local controls (P < 0.001), neck controls (P < 0.001), and disease-specific survival (P < 0.001). Compared to CS alone, CS + PORT increased the 5-year neck control rate (76.8 vs. 30.7%, P = 0.006) and disease-specific survival rate (67.8 vs. 30.7%, P = 0.037) of the OSCC patients with FLN metastasis in the low-risk group. Metastasis to FLNs is strongly associated with poor disease control and lower survival rate of OSCC patients. PORT minimized the residual risk of involved FLN in the low-risk group.

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

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

Clinical utility of multimodality imaging with dynamic contrast-enhanced MRI, diffusion-weighted MRI, and 18F-FDG PET/CT for the prediction of neck control in oropharyngeal or hypopharyngeal squamous cell carcinoma treated with chemoradiation.

The clinical usefulness of pretreatment imaging techniques for predicting neck control in patients with oropharyngeal or hypopharyngeal squamous cell carcinoma (OHSCC) treated with chemoradiation remains unclear. In this prospective study, we investigated the role of pretreatment dynamic contrast-enhanced perfusion MR imaging (DCE-PWI), diffusion-weighted MR imaging (DWI), and [18F]fluorodeoxyglucose-positron emission tomography (18F-FDG PET)/CT derived imaging markers for the prediction of neck control in OHSCC patients treated with chemoradiation. Patients with untreated OHSCC scheduled for chemoradiation between August, 2010 and July, 2012 were eligible for the study. Clinical variables and the following imaging parameters of metastatic neck lymph nodes were examined in relation to neck control: transfer constant, volume of blood plasma, and volume of extracellular extravascular space (Ve) on DCE-PWI; apparent diffusion coefficient (ADC) on DWI; maximum standardized uptake value, metabolic tumor volume, and total lesion glycolysis on 18F-FDG PET/CT. There were 69 patients (37 with oropharynx SCC and 32 with hypopharynx SCC) with successful pretreatment DCE-PWI and DWI available for analysis. After a median follow-up of 31 months, 25 (36.2%) participants had neck failure. Multivariate analysis identified hemoglobin level <14.3 g/dL (P = 0.019), Ve <0.23 (P = 0.040), and ADC >1.14×10−3 mm2/s (P = 0.003) as independent prognostic factors for 3-year neck control. A prognostic scoring system was formulated by summing up the three significant predictors of neck control. Patients with scores of 2–3 had significantly poorer neck control and overall survival rates than patients with scores of 0–1. We conclude that hemoglobin levels, Ve, and ADC are independent pretreatment prognostic factors for neck control in OHSCC treated with chemoradiation. Their combination may identify a subgroup of patients at high risk of developing neck failure.

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

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

Supraomohyoid neck dissection and modified radical neck dissection for clinically node-negative oral squamous cell carcinoma: A prospective study of prognosis, complications and quality of life

BackgroundTo assess the prognosis and morbidity between supraomohyoid neck dissection (SOND) and modified radical neck dissection (MRND) for oral squamous cell carcinoma (OSCC) in patients with a clinically node-negative neck (cN0). Patients and methodsThis prospective randomized study began in June 1999, and patient accrual concluded in May 2010. The cN0 neck was confirmed on clinical palpation by senior doctors. Ultimately, there were 322 patients recruited into the study. ResultsPatient demographics were well balanced between the two groups. There were 10 patients in the SOND group and 21 patients in the MRND group who developed nodal recurrence without associated local recurrence or distant metastasis. The 3-year neck control rate (NCR) rate was 92.6% for the SOND group and 87.5% for the MRND group (in favor of SOND, P = 0.108). There was no significant difference between the SOND group and the MRND group in the 3-year disease-specific survival (DSS) rate (79.0% vs. 76.9%, P = 0.659). Importantly, there were significantly fewer complications in the SOND group compared with the MRND group (13.0% vs. 21.9%, P = 0.040). The disease-free survivors in the SOND group also reported better pain relief (P = 0.013) and shoulder function (P < 0.001) than those in the MRND group one year after treatment. ConclusionsWe recommend SOND as a priority treatment for cN0 OSCC patients.

Neck observation is appropriate in T1–2, cN0 oral squamous cell carcinoma without perineural invasion or lymphovascular invasion

Management of cN0 neck, elective neck dissection (END) or observation, remains controversial for T1-2 oral squamous cell carcinoma (OSCC). To allow for the safe observation of cN0 neck, it is mandatory to define predictors with high negative predictive value (NPV) for cervical lymph node (LN) status. Pathologic re-evaluation was performed in tumors of 253 consecutive patients with T1-2, cN0 OSCC. The predictive roles of pathologic parameters for cervical LN status in guiding neck management were investigated. Cervical LN metastasis (LN+) occurred at a similar rate between observation and END groups (20.8% vs. 22.2%, p=0.807), indicating poor discriminatory value for cervical LN status by clinical judgment. Compared with T classification, tumor thickness and differentiation, PNI/LVI (perineural invasion/lymphovascular invasion) demonstrated the highest NPV (85.5%). Hypothetically using PNI/LVI status to guide neck management, a dramatic reduction in overtreatment rate could be achieved (54.2% to 20.2%), with a minimal increase in undertreatment rate (6.3% to 9.9%). In patients without PNI or LVI (PNI/LVI-), the ultimate neck control rate (96.9% vs. 96.3%, p=1.000) and 5-year disease-specific survival rate (91.1% vs. 92.8%, p=0.863) were equivalent between observation and END. However, a significantly higher incidence of neck recurrence was found with observation (16.9% vs. 6.5%, p=0.031), with 93.8% occurring within one year and 73.3% being successfully salvaged. Observation under close follow-up for the first year is appropriate in T1-2, cN0 OSCC without PNI or LVI, for the achievement of equivalent ultimate neck control and 5-year disease-specific survival rates compared with END.

Selective versus comprehensive neck dissection in the treatment of patients with a pathologically node-positive neck with or without microscopic extracapsular spread in oral squamous cell carcinoma

The objective of this study was to compare the prognosis and complications between selective neck dissection (SND) and comprehensive neck dissection (CND) for patients with a pathologically node-positive neck in squamous cell carcinoma of the tongue and the floor of the mouth. This was a retrospective cohort study. There was no significant difference between the SND group and the CND group in 3-year neck control rate (86.2% vs. 85.9%, P=0.797) or disease-specific survival (DSS) rate (64.6% vs. 61.9%, P=0.646). Further analyses of the respective 3-year DSS rates in the SND and CND subgroups were as follows: pN1 without extracapsular spread (ECS), 67.7% vs. 72.2%, P=0.851; pN2b without ECS, 64.7% vs. 68.8%, P=0.797; and pN+ with ECS, 57.1% vs. 60.0%, P=0.939. Of note, there were significantly fewer complications in the SND group compared with the CND group (7.3% vs. 20.0%, P=0.032). Multivariate analysis showed that the modality of neck treatment, pN+ status, and microscopic ECS did not serve as independent prognostic factors. SND plus adjuvant radiotherapy is a management strategy of high efficiency and minor morbidity for selected oral cancer patients with a pN+ neck with or without microscopic ECS.

Modified radical neck dissection for residual neck disease after radiotherapy of nasopharyngeal carcinoma.

Although radical neck dissection is proposed as a standard salvage procedure for the management of radiotherapy-resistant nasopharyngeal carcinoma of the neck, modified radical neck dissection may be appropriate for select patients. This study was designed to evaluate the efficacy of individualized neck dissections based on preoperative imaging studies and intraoperative exploration for the management of radiotherapy-resistant nasopharyngeal carcinoma of the neck. The study included 42 consecutive patients who failed radiotherapy or chemo-radiotherapy for nasopharyngeal carcinoma of the neck and underwent a total of 46 radical neck dissections or modified radical neck dissections. Selection of the proper type of neck dissection was based on preoperative imaging studies and intraoperative exploration. The patients' clinical features, pathologic characteristics, complications, and treatment outcome were estimated and analyzed. Radical neck dissection and modified radical neck dissection were performed on 19 and 27 necks, respectively. Thirty-three necks (71.7%) had multiple node metastases. Nineteen necks (41.3%) had node metastases at two or more levels. The overall morbidity rate was 11.9%. The 5-year neck control rate (NCR) was 79.1% for 46 necks. The 5-year overall survival and disease free survival for 42 patients were 58.0% and 44.0%, respectively. No statistically significant differences were found in comparing OS, DFS, NCR between the MRND and RND groups. Individualized neck dissection based on preoperative imaging studies and intraoperative exploration is appropriate for the management of radiotherapy-resistant nasopharyngeal carcinoma of the neck.

Individualized IMRT treatment approach for cervical lymph node metastases of unknown primary

The goal of the present study was to evaluate the outcome of risk-adapted planning treatment volumes (PTVs) in patients with cervical lymph node metastases of unknown primary cancer (UPC) treated with intensity-modulated radiotherapy (IMRT). Between January 2006 and November 2012, 28 patients with cervical lymph node metastases of UPC were treated in our institution with IMRT either postoperatively (n = 20) or as definitive treatment (n = 8). Nodal involvement distributed as follows: N1 (n = 2), N2a (8), N2b (10), N2c (4), and N3 (4). Systemic therapy with cisplatin or cetuximab was added concomitantly in 20 of 28patients (71 %). Radiotherapy using simultaneously integrated boost (SIB-IMRT) was carried out with 2.0 or 2.11Gy single doses up to 66/70Gy. Mean/median follow-up was 31.6/30.5months (range 3-78months). In all, 15 of 28patients were treated with unilateral SIB-IMRT (54 %). An elective PTV to the contralateral oropharynx and contralateral levelII-III lymph nodes was carried out in 8patients with PET-CT suspected but not histologically proven involvement, recurrences or former tumor of the oropharynx. More extended treatment fields were reserved for patients with N2c or bilaterally N3 status (n = 5). The 3-year overall survival, mucosal control, neck control and distant metastasis-free survival rates were 76, 100, 93, and 88 %, respectively. No patient suffered from a locoregional recurrence. Two patients treated with radiotherapy alone had persistent nodal disease. No gradeII or higher late sequel has been observed. Our single center approach to treat patients with cervical lymph node metastases of UPC with individualized, risk-adapted SIB-IMRT resulted in high locoregional tumor control and was well tolerated.