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Oral and Maxillofacial Surgery

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01-06-2012 | Review Article

Surgical management of the N0 neck in early stage T1–2 oral cancer; a personal perspective of early and late impalpable disease

Author: R. A. Ord

Published in: Oral and Maxillofacial Surgery | Issue 2/2012

Abstract

Introduction

The management of the N0 neck in early stage oral cancer remains controversial. The evidence in the literature for elective neck dissection, which is reviewed in this paper, is conflicting. My personal view is that most papers mistakenly assume that the N0 equates to an “early stage” neck whereas a neck with palpable nodes represents disease at a “late” stage.

Discussion

I believe that this is the same mindset that prevented us from realizing that depth rather than size was the important prognostic determinant for the primary tumor; because the T stage was based on tumor size. The N stage is also based on size and number of nodes and by these criteria N0 would be the earliest stage. However, although an N0 neck with impalpable intra-nodal disease may be regarded as early impalpable disease an N0 neck with microscopic extra-capsular spread (ECS) would be “late/advanced” impalpable disease. Likewise, a clinically positive neck with intra-nodal disease still represents early disease compared to a clinically positive neck with ECS.

Conclusion

The lack of trials and studies stratifying NO and N +ve necks into early and late disease and comparing outcomes between these cohorts may explain the lack of clear-cut evidence regarding the role for elective neck dissection.

Vandenbrouk C, Sancho-garnier H, Chassagne D, Saravane D, Cachin Y, Micheau C (1980) Elective versus therapeutic neck dissection in epidermoid carcinoma of the oral cavity: results of a randomized clinical trial. Cancer 46(2):386–390CrossRef

Fakih AR, Rao RS, Borges AM, Patel AR (1989) Elective versus therapeutic neck dissection in early carcinoma of the oral tongue. Am J Surg 153(4):309–313CrossRef

Kligerman J, Lima RA, Soares JR, Prado L, Dias FL, Freitas EQ, Olivatto LO (1994) Supraomohyoid neck dissection in the treatment of T1/T2 squamous cell carcinoma of oral cavity. Am J Surg 168(5):391–394PubMedCrossRef

Anderson PE, Cambronero E, Shaha AR, Shah JP (1996) The extent of neck disease after regional failure during observation of the neck. Am J Surg 172(6):689–691CrossRef

Hosal AS, Carrau RL, Johnson JT, Myers EN (2000) Selective neck dissection in the management of the clinically node-negative neck. Laryngoscope 110(12):2037–2040PubMedCrossRef

Alvi A, Johnson JT (1996) Extracapsular spread in the clinically negative neck (N0): implications and outcome. Otolaryngol Head Neck Surg 114(1):65–70PubMedCrossRef

Woolgar JA, Rogers SN, Lowe D, Brown JS, Vaughn ED (2003) Cervical lymph node metastasis in oral cancer: the importance of even microscopic extracapsular spread. Oral Oncol 39920:130–137CrossRef

Yeun APW, Wei WI, Wong YM, Tang KC (1997) Elective neck dissection versus observation in the surgical treatment of early oral tongue carcinoma. Head Neck 19:583–588CrossRef

Yeun APW, Ho CM, Chow TL, Tang LC et al (2009) Prospective randomized study of selective neck dissection versus observation for N0 neck of early tongue carcinoma. Head Neck 31(6):765–772CrossRef

10.

Lubek J, El-Hakim M, Salama AR, Liu X, Ord RA (2011) Gingival carcinoma: retrospective study of 72 patients and indications for elective neck dissection. Brit J Oral Maxfac Surg 49(3):182–185CrossRef

11.

Montes DM, Carlson ER, Fernandes R, Ghali GE, Lubek J, Ord R, Bell B, Dierks E, Schmidt BL (2011) Oral maxillary squamous carcinoma: an indication for neck dissection in the clinically negative neck. Head Neck 33(11):1581–1585PubMedCrossRef

12.

Morris LG, Patel SG, Shah JP, GanlyI (2011) High rates of regional failure in squamous cell carcinoma of the hard palate and maxillary alveolus. Head Neck 33(6):824–830PubMedCrossRef

13.

Shah JP, Candela FC, Poddar AK (1990) The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity. Cancer 66(1):109–113PubMedCrossRef

14.

Shah JP, Andersen PE (1994) The impact of nodal metastasis on modifications of neck dissection. Ann Surg Oncol 1(6):521–532PubMedCrossRef

15.

Li XM, Wei WI, Guo XF, Lam LK (1996) Cervical lymph node metastatic patterns of squamous carcinomas in the upper aerodigestive tract. J Laryngol Otol 110(10):937–941PubMedCrossRef

16.

Spiro JD, Spiro RH, Shah JP, Sessions RB, Strong EW (1998) Critical assessment of supraomohyoid neck dissection. Am J Surg 156(4):286–289CrossRef

17.

Byers RM, Weber RS, Andrews T, Mc Gill, Kare R, Wolf P (1997) Frequency and therapeutic implications of “skip metastases” in the neck from squamous carcinoma of the oral tongue. Head Neck 19(1):14–19PubMedCrossRef

18.

Khafif A, Lopez-Garza JR, Medina JE (2001) Is dissection of level IV necessary in patients with T1–3 N0 tongue cancer? Laryngoscope 111(6):1088–1090PubMedCrossRef

19.

Kraus DH, Rosenberg DB, Davidson BJ, Shaha AR, Spiro RH, Strong EW, Schantz SP, Shah JP (1996) Supraspinal accessory nerve lymph node metastases in supraomohyoid neck dissection. Am J Surg 172(6):646–649PubMedCrossRef

20.

Talmi YP, Hoffman HT, Horowitz Z, McCullough TM, Funk GF, Graham SM, Peleg M, Yahalom R, Teicher S, Kroneberg J (1998) Patterns of metastases to the upper jugular lymph nodes (the “submuscular recess”). Head Neck 20(8):682–686PubMedCrossRef

21.

Lim YC, Song MH, Kim SC, Kim KM, Choi EC (2004) Preserving level IIb lymph nodes in elective supraomohyoid neck dissection for oral cavity squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 130(9):1088–1091PubMedCrossRef

22.

Rassekh CH, Johnson JT, Myers EN (1995) Accuracy of intraoperative staging of the N0 neck in squamous cell carcinoma. Laryngoscope 105(12):1334–1336PubMedCrossRef

23.

Finn S, Toner M, Timon C (2002) The node negative neck: accuracy of clinical intraoperative lymph node assessment in head and neck cancer. Laryngoscope 112(4):630–633PubMedCrossRef

24.

Ozeki S, Tashiro H, Okamato M, Matsushima T (1985) Metastasis to the lingual lymph node in carcinoma of the tongue. J Maxillofacial Surg 13(6):277–281CrossRef

25.

Zhang T, Ord RA, Wei WI, Zhao J (2011) Sublingual lymph node metastases of early tongue cancer: report of two cases and review of the literature. Int J Oral Maxillofac Surg 40(6):597–600PubMedCrossRef

26.

Woolgar JA (1999) Histological distribution of cervical lymph node metastases from intraoral/oropharyngeal squamous cell carcinomas. Br J Oral Maxillofac surg 37(3):175–180PubMedCrossRef

27.

Leemans CR, Tiwari R, Naula JJ, Snow GB (1991) Discontinuity vs in-continuity neck dissection in carcinoma of the oral cavity. Arch Otolaryngol Head Neck Surg 117(9):1003–1006PubMedCrossRef

28.

Tesseroli MA, Calabrese L, Carvalho AL, Kowalski LP, Chiesa F (2006) Discontinuos vs in-continuity dissection in carcinoma of the oral cavity. Experience of two oncologic hospitals. Arch Otorhinolaryngol Ttal 26(6):350–355

29.

Weiss Mh, Harrison LB, Isaacs RS (1994) Use of decision analysis in planning a management strategy for the stage N0 neck. Arch Otolaryngol Head Neck Surg 120(7):699–702PubMedCrossRef

30.

Okura M, Aikawa T, Sawai NY, Lida S, Kogo M (2009) Decision analysis and treatment threshold in a management for the N0 neck of the oral cavity. Oral Oncol 45(100):908–911PubMedCrossRef

31.

Byers RM, El-Naggar AK, Lee YY, Rao B, Fornage B, Terry NH, Sample D, Hankins P, Smith TL, Wolf PJ (1998) Can we detect or predict the presence of occult nodal metastases in patients with squamous cell carcinoma of the tongue? Head Neck 20(20):138–144PubMedCrossRef

32.

Lin MJ, Guiney A, Iseli CE, Buchanan M, Iseli TA (2011) Prophylactic neck dissection in early oral tongue squamous cell carcinoma 2.1–4 mm depth. Otolaryngol Head Neck Surg 144(4):542–548PubMedCrossRef

33.

Salama A, McClure S, Ord RA. Clinical predictions of metastasis in T1/T2 tongue cancer. Scientific abstract presented at 11th ICOOC meeting in Grado Italy

34.

Russolo M, Giacomarra V, Papanikolla L, Tirelli G (2002) Prognostic indicators of occult metastases in oral cancer. Laryngoscope 112(7):1320–1323PubMedCrossRef

35.

Saka SM, McDonald DG (1989) Sampling of jugulo-digastric lymph nodes in oral cancer. J Oral Pathol Med 18(2):123–124PubMedCrossRef

36.

Brennan JA, Mao L, Hruban RH, Boyle JO, Eby Y, Koch WM, Goodman SN, Sidransky D (1995) New Eng J Med 332(7):429–435PubMedCrossRef

37.

Ambrosch P, Brinck U (1996) Detection of nodal metastases in head and neck cancer by serial sectioning and immunostaining. Oncology 10(8):1221–1226PubMed

38.

Hamakawa H, Fukuzumi M, Bao Y, Sumida T, Kayahara H, Onishi A, Sogawa K (2000) Keratin mRNA for detecting micrometastasis in cervical lymph nodes of oral cancer. Cancer Lett 160(1):115–123PubMedCrossRef

39.

Ferlito A, Devaney KO, Rinaldo A, Devaney SL, Carbone A (1999) Micrometastases do they have an impact on prognosis. Ann Otol Rhinol Laryngol 108(12):185–189

40.

Woolgar JA (1999) Micro-metastasis in oral/oro-pharyngeal squamous cell carcinoma; incidence, histopathological features and clinical implications. Br J Oral Maxillofac Surg 37(3):181–186PubMedCrossRef

41.

Rhee D, Wenig BM, Smith RV (2002) The significance of immunohistochemically demonstrated nodal micrometastases in patients with squamous cell carcinoma of the head and neck. Laryngoscope 112(11):1970–1974PubMedCrossRef

42.

Nieuwenhuis EJ, Leemans CR, Kimmer JA, Denkers F, Snow GB, Brakenhokk RH (2003) Assessment and clinical significance of micrometastases in lymph nodes of head and neck cancer patients detected by E48(Ly-6D) quantitative reverse transcription–polymerase chain reaction. Lab Invest 83(8):1233–1240PubMedCrossRef

43.

Spiro JD, Spiro RH, Shah JP, Sessions RB, Strong EW (1988) Critical assessment of supraomohyoid neck dissection. Am J Surg 156(4):286–289PubMedCrossRef

44.

Byers RM, Clayman GL, McGill D, Andrews T, Kare RP, Roberts DB, Goepfert H (1999) Selective neck dissections for squamous cell carcinoma of the upper aerodigestive tract: patterns of regional failure. Head Neck 21(6):499–505PubMedCrossRef

45.

Yeun AP, Lam KY, Chan AC, Wei WI, Lam LK, Ho WK, Ho CM (1999) Clinicopathological analysis of elective neck dissection for N0 neck of early oral tongue carcinoma. Am J Surg 177(1):90–92CrossRef

46.

Ambrosch P, Kron M, Pradier O, Steiner W (2001) Efficacy of selective neck dissection: a review of 503 cases of elective and therapeutic treatment of the neck in squamous cell carcinoma of the upper digestive tract. Otolaryngol Head Neck Surg 124(2):180–187PubMedCrossRef

47.

Cooper JS, Palak TS, Forasttiere AA, RTOG 9501/Intergroup et al (2004) Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Eng J Med 350(19):1937–1944CrossRef

48.

Bernier J, Domenge C, Ozsahin M, EORTC trial 22931 et al (2004) Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Eng J Med 350(19):1945–1952CrossRef

49.

Bernier J, Pfister DG, Cooper JS (2005) Adjuvant chemo- and radiotherapy for poor prognosis head and neck squamous cell carcinoma. Crit Rev Oncol Hematol 56(3):353–364PubMedCrossRef

50.

Bernier J, Cooper JS, Palak TF et al (2005) Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORCT (#22931) and RTOG (#9501) head. Neck 27(10):843–850CrossRef

51.

Bernier J, Vermorken JB, Koch WM (2006) Adjuvant therapy in patients with resected poor-risk head and neck cancer. J Clin Oncol 24(17):2629–2635PubMedCrossRef

52.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Head and Neck cancers. NCCN.org

53.

Oliver RJ, Clarkson JE, Conway DI et al (2011) Interventions for the treatment of oral and oro-pharyngeal cancers: surgical treatment. Cochrane Database Syst Rev 9:CD006205PubMed

Title: Surgical management of the N0 neck in early stage T1–2 oral cancer; a personal perspective of early and late impalpable disease
Author: R. A. Ord
Publication date: 01-06-2012
Publisher: Springer-Verlag
Published in: Oral and Maxillofacial Surgery / Issue 2/2012
Print ISSN: 1865-1550
Electronic ISSN: 1865-1569
DOI: https://doi.org/10.1007/s10006-012-0325-x

At a glance: The STEP trials

Springer Medicine

Surgical management of the N0 neck in early stage T1–2 oral cancer; a personal perspective of early and late impalpable disease

Abstract

Introduction

Discussion

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Discussion

Conclusion

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