Need For Elective Neck Dissection Research Articles

Is elective neck dissection necessary for patients with cT3-4N0 parotid gland cancer?

ObjectiveManagement of the cervical lymph nodes in patients with cT3-4N0 parotid gland cancer (PGC) has been controversial. This study investigated the need for elective neck dissection (END) in patients with cT3-4N0 PGC. MethodsWe retrospectively examined cervical lymph node metastasis, overall survival (OS), and disease-free survival (DFS) rates in 40 patients with cT3-4N0 PGC according to whether or not END was performed. ResultsCervical lymph node metastasis occurred in 27.5% of patients and level II was the most common area. Recurrence could be treated by salvage neck dissection. There was no significant difference in OS (P=0.581) or DFS (P=0.728) between the group that underwent END and the group that did not. ConclusionEND at level II is worth performing because of the occult lymph node metastasis rate. The area of neck dissection should be limited because there is no evidence that END improves the prognosis of cT3-4N0 PGC.

Accuracy of the preoperative diagnostic workup in patients with head and neck cancers undergoing neck dissection in terms of nodal metastases

PurposeThe presence of cervical lymph node metastases is one of the most influential prognostic factors in head and neck squamous cell carcinomas. The management of clinically N0 neck in patients with head and neck cancer remains controversial: elective neck dissection has relatively high morbidity, adversely affecting the quality of life, however, abandoning elective neck dissection is known to compromise overall survival in numerous primaries. The purpose of this study was to evaluate the accuracy of the conventional imaging modalities (CT, MRI, US) and fine-needle aspiration cytology (FNAC) in the detection of lymph node metastases in the neck.MethodsSixty two patients were included in the study, who underwent primary tumor resection and neck dissection. Preoperative nodal status was compared with postoperative histopathology nodal status. In our retrospective study, we reviewed the patient documentation. Statistical analysis of the data—with descriptive statistics and correlation analysis—was performed with Chi-square test.ResultsThe sensitivity of conventional imaging modalities and FNAC were 82.8% and 81.8%, respectively, while specificity were 73.9% and 100%, respectively. Positive predictive value calculated for imaging modalities and FNAC were 82.8%, 100%, respectively, while negative predictive values were 73.9% and 66.6%, respectively.ConclusionNeither the sensitivity of imaging modalities (CT, MRI, US) nor FNAC reached 100%, none of these methods can definitively exclude the presence of regional tumor metastasis. According to these data, no permissive alteration should be allowed from the current guidelines (e.g. NCCN) based on imaging/FNAC examinations regarding the need for elective neck dissection.

Radiological approach for the newly incorporated T staging factor, depth of invasion(DOI), of the oral tongue cancer in the 8th edition of American Joint Committee on Cancer (AJCC) staging manual: assessment of the necessity for elective neck dissection.

The 8th edition of American Joint Committee on Cancer's (AJCC) Cancer Staging Manual was modified by incorporating depth of invasion (DOI) in the T categorization of oral cavity cancer. This is because DOI is strongly associated with cervical lymph node metastasis, which is the most important negative prognostic factor of oral cavity cancer. This major change in the AJCC Cancer Staging Manual caused re-staging of T category in several cases. Although, the DOI on MRI and CT (radiological DOI; r-DOI) strongly correlated with pathological DOI (p-DOI), it is often 2-3mm larger than p-DOI. Due to this variance, estimation of p-DOI based on r-DOI may not be accurate. However, when a lesion is undetectable on MRI, p-DOI was often smaller than 4mm. On the other hand, when MRI depicts lesions with styloglossus and hyoglossus muscle invasion, p-DOI was always larger than 4mm. These correlations between MRI findings and p-DOI are important when assessing the need for elective neck dissection, as the National Comprehensive Cancer Network (NCCN) recommends elective neck dissection in cases with DOI greater than 4mm.

Elective Neck Dissection in T1T2 Oral Squamous Cell Carcinoma with Proven N0 Neck: Essential or Not? A Meta-analysis Study

Abstract Background Oral squamous cell carcinoma (SCC) is characterized by a high risk of metastases to lymph nodes in the neck. The incidence of occult cervical metastases is relatively high. Surgical resection is the treatment of choice. Our study included patients with early oral cancer (T1/T2) Squamous cell carcinoma with proven N0 Neck. Objective The aim of the present study was to evaluate the need for elective neck dissection (END) in T1/T2 oral squamous cell carcinoma with proven N0 Neck. Patients and Methods a meta-analysis for the evaluation of recurrence rate after neck dissection in early oral cancers was conducted. This study included published English medical articles in the last 30 years, concerning early oral SCC with proven N0 Neck. (24) articles were included with a total number of 2192 of patients and 1619 controls. Results There was a significant heterogeneity among the included studies. Regarding the regional recurrence rate, neck dissection (ND) was associated with significantly lower risk of recurrence when being compared with observation. Regarding the 5-year survival rate, (10) studies were included with a total number of 1211 of patients and 948 controls. There was no significant heterogeneity among the included. There was a statistically significant difference between ND and Control. Conclusion Elective neck dissection is better than observation in early oral cancers T1/T2 N0 neck.

The updated AJCC/TNM staging system (8 th edition) for oral tongue cancer

An increasing amount of literature shows solid evidence that the depth of invasion (DOI) of oral cavity squamous cell carcinoma is an independent predictor for occult metastasis, recurrence, and survival (1-3). Furthermore, the DOI of the primary tumor has been a major criterion when deciding to perform elective neck dissection on oral cavity squamous cell carcinoma patients since as early as the mid-1990s (4). A cut-off value of 4 mm has conventionally been used when determining the need for elective neck dissection, based on a study by Kligerman et al . (4). Thereafter, several reports have proposed a range of cut-off points for improving survival, detection of occult nodal metastases, and decreasing risk of locoregional recurrence (5,6).

Management of the neck in malignant parotid neoplasm

<p class="abstract">Parotid gland cancer (PGC) are rare and accounts for 3% of all head and neck malignancies.The classification of parotid tumour is complex and comprises both benign and malignant neoplasms of epithelial and non-epithelial origin.There is marked variation in the histological features of these tumours,therefore treatment options of parotid cancer is widely varied.Lymph node metastasis to the neck is one of the most important factors in therapy and prognosis for patients with parotid malignancy. This article reviews the literature regarding neck management of parotid cancer in cases of both clinically positive (cN+) and clinically negative (cN-) neck nodes. The literature search was performed using Google search engine, PUB Med to identify relevant articles on recommendations for neck management in patients with parotid cancer in cases of both clinically positive (cN+) and negative (cN-) neck nodes. Due to the rarity of parotid cancer and the wide histopathological varieties, the literature was hard to interpret. There is a consensus about managing clinically positive neck with therapeutic neck dissection. Most studies agree on elective neck dissection in certain indications which are high T stage, high grade histology, facial paralysis, age, extraglandular extension, peri-lymphatic invasion. Level II to IV appears to be at higher risk and can be done through the same parotidectomy incision. The role of irradiation in cN- necks is not clear but some studies recommend its usage for curative intent and argue that it adds less morbidity than the elective neck dissection. Although the management of the neck in cN+ patients is widely agreed, controversy still exists about the need for elective neck dissection in cN- patients and the levels which should be dissected.</p>

The negative predictive value (NPV) of FDG-PET/CT in the Head and Neck Squamous Cell Carcinoma (HNSCC) N0 patient, the first report of the ACRIN 6685 trial.

6041 Background: This study evaluated the negative predictive value for node negativity in HNSCC. Methods: Patients were enrolled from 8/10 until 12/16 from 38 centers in the US and 1 center in China. This was a prospective, non-randomized trial. The study was designed to recruit 292 patients; however, 287 were enrolled by study closure. Inclusion criteria were newly diagnosed cT2-T4 SCC patients from the head and neck with one side cN0 who were willing to undergo an elective neck dissection. CN0 was determined by a negative neck CT or MR scan. Exclusions included non-SCC, non-surgical candidates, skin, nasopharynx or sinus primaries. PET/CT imaging reading performed centrally and pathology were analyzed at the neck level (left or right). To estimate confidence intervals, we used a nonparametric bootstrap to account for the correlation of data between sides of neck of the same patient. Correlative data and other image analyses will be reported separately. Results: PET/CT scans and pathology were available for 211 (table) N0 sides of neck for review at last interim analysis. NPV estimate with 95% CI for bilateral necks: 0.896 (0.831, 0.950) and specific to the N0 sides: 0.922 (0.862, 0.973). Conclusions: FDG PET/CT has high NPV for node negativity in HNSCC. This may obviate the need for elective neck dissection in N0 HNSCC patients. This trial was open about three times longer than planned, and a major obstacle to accrual was the generalized assumption among the oncology community that PET/CT had a high NPV. Therefore, patients sent to study centers for further diagnosis and treatment often had their PET/CT scans performed on non-ACRIN certified equipment. This required investigators to forgo offering the trial or the PET/CT was repeated. Our results may suggest application for pre-operative PET/CT nodal imaging of other primaries/lymphatic basins staged cN0. Funding from the National Cancer Institute through the grants U01 CA079778, U01 CA080098, CA180820, CA180794. Clinical trial information: NCT00983697. [Table: see text]

Depth of invasion and GLUT-1 as risk predictors in oral squamous cell carcinoma

Object:Predictor of the risk of subclinical nodal metastasis in early oral cancer would be of significant benefit in determining the need for elective neck dissection or adjuvant therapy. Depth of invasion (DOI) and glucose transporter (GLUT-1) expression have been assigned an independent prognostic significance in predicting the risk of nodal metastasis. The present study has been undertaken to evaluate the mechanisms linking GLUT-1 expression to DOI in progressive grades of oral squamous cell carcinoma (OSCC).Method:The GLUT-1 expression was analysed by immunohistochemistry, and its association with the DOI was assessed in 90 patients in progressive histological grades of OSCC.Result:We hypothesized that OSCC characterized by high frequency of lymph node metastasis, distant metastasis, or local recurrences showed highly significant statistical correlation of DOI with the GLUT-1 over expression at the invasion front in progressive histological grades of OSCC, thereby revealing their potential role in pre...

Retrospective observational study of occult cervical lymph-node metastasis in T1N0 tongue cancer.

Delayed neck metastasis is the most significant prognostic factor for early tongue cancer. The main strategies for controlling cervical lymph nodes in Japan are elective neck dissection or watchful waiting. Elective neck dissection offers significantly better survival, but adversely impacts patient quality of life; consequently, here we investigated how to identify high-risk patients warranting elective neck dissection. We retrospectively evaluated 67 patients with T1N0 oral tongue squamous cell carcinoma who underwent primary treatment in our department from April 2001 to March 2015. All the patients underwent watchful waiting alone for neck management. We investigated the rates of occult neck metastasis, prognosis and circumstances of recurrence, and associations with pathological tumor thickness, depth and muscle invasion by the primary tumor. Correlation between the thickness in pathological specimens and that at magnetic resonance imaging was additionally investigated. Neck recurrence was evident in 20 patients, of which 19 developed within 1 year. Therefore, the rate of occult neck metastasis was 29.9%. Patients with muscle invasion, tumor thickness ≥2 mm or tumor depth ≥2 mm on surgical specimens were significantly more likely to develop delayed neck metastasis. Prognosis was significantly worse for patients with muscle invasion or tumor thickness ≥2 mm. Thickness using magnetic resonance imaging was well correlated with pathological thickness. Patients with tumors ≥2 mm in thickness or muscle invasion developed neck metastasis, suggesting that elective neck dissection may be warranted for patients with these findings. For preoperative assessment of the need for elective neck dissection, magnetic resonance imaging would be a potential modality for T1N0 tongue cancer.

Is there a role for elective neck dissection with salvage laryngectomy? A decision‐analysis model

Elective neck dissection for the clinically negative neck is often a matter of debate. A decision-analysis model that was published in 1994 established the widely accepted principle that neck dissection is warranted when the risk for occult metastases is higher than 20%. The aim of the present study was to build a specific and up-to-date decision-analysis model to determine the need for elective neck dissection during salvage laryngectomy after chemoradiation failure and to identify the variables that effect the decision. Decision-analysis model. A decision-analysis model was performed to compare the outcome of patients after salvage total laryngectomy with and without an elective neck dissection. Probabilities and expected utilities were derived from available literature to construct the model. Monte Carlo simulation and sensitivity analysis were used to calculate our models' outcomes and to identify the variables that influence the model most, respectively. When calculating our model results with published data, we found that elective neck dissection is not warranted during salvage total laryngectomy. Optimal decision was found to be sensitive by two variables: 1) the probability for cure with neck dissection, and 2) the probability for regional-only recurrence after salvage laryngectomy without neck dissection. In multiway sensitivity analysis, only when cure rate with neck dissection exceeded 82%, adding neck dissection was the preferred decision. In practice, cure rates for patients after salvage total laryngectomy are around 50% to 65%. Based on our decision-analysis model, we do not recommend routine elective neck dissection during salvage total laryngectomy after failure of chemoradiation.

Secretory Leukocyte Protease Inhibitor (SLPI) Expression and Tumor Invasion in Oral Squamous Cell Carcinoma

Differential expression of secretory leukocyte protease inhibitor (SLPI) impacts on tumor progression. SLPI directly inhibits elastase and other serine proteases, and regulates matrix metalloproteinases, plasminogen activation, and plasmin downstream targets to influence invasion. We examined tissues from human oral squamous cell carcinoma (OSCC) for SLPI expression in parallel with proteases associated with tumor progression and evaluated their relationships using tumor cell lines. Significantly decreased SLPI was detected in OSCC compared to normal oral epithelium. Furthermore, an inverse correlation between SLPI and histological parameters associated with tumor progression, including stage of invasion, pattern of invasion, invasive cell grade, and composite histological tumor score was evident. Conversely, elevated plasmin and elastase were positively correlated with histological parameters of tumor invasion. In addition to its known inhibition of elastase, we identify SLPI as a novel inhibitor of plasminogen activation through its interaction with annexin A2 with concomitant reduced plasmin generation by macrophages and OSCC cell lines. In an in vitro assay measuring invasive activity, SLPI blocked protease-dependent tumor cell migration. Our data suggest that SLPI may possess antitumorigenic activity by virtue of its ability to interfere with multiple requisite proteolytic steps underlying tumor cell invasion and may provide insight into potential stratification of oral cancer according to risk of occult metastasis, guiding treatment strategies.

耳下腺癌における予防的頸部郭清と術後放射線治療について

Regional lymph node metastases significantly influence the prognosis of patients with parotid cancer. To assess our indications of elective neck dissection and postoperative radiotherapy for parotid cancer, a retrospective chart review was performed. Between 2001 and 2009, 35 patients with parotid cancer were initially treated at our department. The median follow-up was 30 months (range, 10-90 months). Out of all patients, 31 (89%) patients were preoperatively diagnosed as malignant, while 4 (11%) patients were initially diagnosed as benign. Mucoepidermoid carcinoma was the most common histological type (10 patients). Twenty-two tumors (63%) were pathologically diagnosed as high-grade. The numbers of patients with Stages I, II, III, and IVA were 3, 10, 7, and 15, respectively. Ipsilateral neck dissection (Level II-V) was performed in seven patients with clinically positive neck metastasis (cN+), and in ten patients without lymph node metastasis who had T4 disease, high-grade malignancy, or positive neck (Level II) metastasis during intraoperative evaluation. Postoperative radiotherapy was performed in 24 patients with pathological T4, high-grade malignancy, positive surgical margin, multiple neck metastasis and/or extranodal extension (ENI). Seven of 28 (25%) patients with clinically N0 had pathologically positive neck metastasis (pN+). Regional recurrence developed in one patient with high-grade malignancy and ENI (T4N2b). Disease-specific survival rates for Stages I, II, III, and IVA at 3 years were 100%, 73%, 100%, and 37%, respectively. Loco-regional control rates for pN0 (21 patients) and pN+ (14 patients) at 3 years were 90% and 95%, respectively. Our present favorable loco-regional control supported our current indications of elective neck dissection and postoperative radiotherapy. We also recommend intraoperative biopsy of level IIB nodes to study the need for elective neck dissection. (author)

Abstract 4555: Remote sensing image dtection; a new tool for evaluation the tumor thickness in tongue SCC

Abstract A preoperative predictor of the risk of subclinical nodal metastasis would be useful. Studies have shown a strong correlation between histological tumor depth and the risk of nodal metastasis. To assess if preoperatively measured tumor depth predicts an increased risk of subclinical metastatic neck disease and thus the need for elective neck dissection. To further pin-point the boundary between normal to infective tissues, biopsy is generally performed. However, the similarity and the general nature of tissue substances between normal and cancer cells are sometimes hard to distinguish by human eyes. This is also true for experienced radiologist. Therefore, computer aided cancer cell classification is highly beneficial for such diagnoses. In this presentation, we implemented methods that are found highly successfully in satellite remote sensing image detection and classification. These methods can be grouped into two major categories, supervised and unsupervised classification. The supervised methods, Least Squares Orthogonal Subspace Projection (LSOSP), Non-negative Constraint Least Squares (NCLS) and Fully Constraint Least Squares (FCLS), require a detail library of every possible tissue signatures consist in the MR image. But, the classification results can be generally more accurate. On the other hand, the unsupervised methods, Automatic Target Detection (ATGP), Unsupervised Non-negative Constraint Least Squares (UNCLS), and Unsupervised Fully Constraint Least Squares (UFCLS), can automatically generate tissue classification results. However, parameters for these techniques such as the number of tissues need to be predefined. Also, the cancer cell classification still needs human intervention to justify the location of infectious region. Based on our experiments, both category of methods are show promising results. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4555.

Is preoperative ultrasonography accurate in measuring tumor thickness and predicting the incidence of cervical metastasis in oral cancer?

The need for elective neck dissection in patients with early stage oral cancer is controversial. A preoperative predictor of the risk of subclinical nodal metastasis would be useful. Studies have shown a strong correlation between histological tumor depth and the risk of nodal metastasis. To determine if preoperative ultrasonography is an accurate measure of tumor depth in oral carcinoma. To assess if preoperatively measured tumor depth predicts an increased risk of subclinical metastatic neck disease and thus the need for elective neck dissection. Twenty one consecutive patients with biopsy proven squamous cell carcinoma of the tongue/floor of mouth were analyzed prospectively. Each patient received a preoperative ultrasonography to assess tumor depth which was compared to histological measures. Univariate analysis was used to correlate tumor thickness and T stage with neck metastasis. There was a significant correlation between the preoperative ultrasonography and histological measures of tumor depth (correlation coefficient 0.981, P<0.001). The overall rate of lymph node metastasis was 52%. The rate of metastasis was 33% in N0 necks. In the group with tumors<5mm in depth, the neck metastatic rate was 0%, as compared with 65% in the group 5mm. Using univariate analysis tumor depth and T stage were significant predictors of cervical metastasis (P=0.0351 and P=0.0300, respectively). Preoperative ultrasonography is an accurate measure of tumor depth in oral carcinoma. Tumor thickness is a significant predictor of nodal metastasis and elective neck dissection should be considered when this thickness is 5mm.

Squamous cell carcinoma of the maxillary gingiva, alveolus, and hard palate: is there a need for elective neck dissection?

We retrospectively studied 17 patients with squamous cell carcinoma (SCC) of the maxillary gingiva, alveolus, and hard palate who were treated over a 7-year period (2000–2007) to investigate whether selective neck dissection is justified at an early stage. Four patients presented with metastases in the neck, and all developed early recurrence in the neck, with poor prognosis. Of the 13 patients who initially had no sign of metastases, two developed regional metastases within the first 18 months of initial treatment. Squamous cancers of the maxillary gingiva, alveolus, and hard palate should be treated aggressively, and elective neck dissection should be considered because of the high risk of occult metastases. Prospective studies are difficult because of the rarity of the tumour.

Magnetic resonance imaging versus clinical palpation in evaluating cervical metastasis from head and neck cancer

We prospectively compared the value of MRI and clinical palpation for detecting cervical metastases in patients with primary cancer of the head and neck. Sixty patients with squamous cell carcinoma of the upper aerodigestive tract were evaluated with MRI and clinical palpation before undergoing a total of 81 neck dissections. The results of preoperative clinical palpation and MRI were compared with the histopathologic outcome. The sensitivity and specificity were 75.6% and 97.5%, respectively, for clinical palpation and 73.2% and 95%, respectively, for MRI. The rate of occult cervical metastasis was 24% with clinical palpation and 26.8% with MRI. The use of MRI did not improve the rate of early detection of occult metastasis, nor did it improve the detection of extracapsular spread. Our findings show that we could not depend on palpation or MRI alone to determine the need for elective neck dissection. However, MRI can be used to improve the preoperative grading of cervical lymph nodes. In selected cases, this may direct surgeons to convert the treatment plan to choose a more conservative neck dissection or, after sentinel node sampling and frozen-section control, to convert the treatment to a more radical dissection. (Otolaryngol Head Neck Surg 2000;123:324–7.)

Supraglottic carcinoma: a retrospective study of 114 patients

We retrospectively evaluated the management of supraglottic carcinoma at our centre during the last 35 years to determine the preferred mode of treatment. A review of the medical records yielded 114 patients with supraglottic T1 and T2 carcinoma who were diagnosed and treated in the Departments of Otolaryngology, Head and Neck Surgery, and Oncology between 1959 and 1993. Of these, 47 (41.2%) had T1 carcinoma (stage I) and 67 (58.8%) T2 (stage II). Treatment varied among radiotherapy, surgery, or combined radiotherapy and surgery. Twelve patients underwent elective neck dissection, one of whom (8.3%) was found to have occult metastases. Local failures were noted in 22 patients (11 T1: 11 T2), three of whom also had neck metastases. All except one T2 patient received radiotherapy. Radiotherapy yielded the best survival rates for T1 disease as combined therapy did for T2. Five-year recurrence rates for T1 patients were 35% for those treated by radiotherapy and 42% for those treated with combined therapy; corresponding figures for T2 patients were 39% and 28%. We suggest that patients with T1 supraglottic carcinoma be managed with radiotherapy and patients with T2 with combined therapy. We believe there is no need for elective neck dissection, especially in T1.

Lymph node staging in patients with clinically negative neck examinations by ultrasound and ultrasound-guided aspiration cytology

To assess the usefulness of ultrasound and ultrasound-guided fine-needle aspiration cytology in detecting occult cervical lymph node metastases, 107 patients with squamous cell carcinoma of the head and neck, who underwent 132 elective neck dissections, had preoperative ultrasound examination. During the assessment of the last 54 patients, who underwent 70 elective neck dissections, ultrasound-guided aspiration cytology was available. Although ultrasound was able to detect lymph node metastases in the majority of patients, the accuracy of this technique never exceeded 70% (93 of 132 procedures). With ultrasound-guided aspiration cytology, accuracy was 89% (62 of 70 procedures). This latter technique seems to be the modality of choice for the assessment of the clinically negative neck. Its use obviates the need for elective neck dissection, done because of the high risk of occult metastasis.