Dr. Serena WongDr. Serena Wong

Queen Elizabeth HospitalQueen Elizabeth Hospital

IntroductionIntroductionBackgroundCurrent debates in neck management◦Why is neck treatment so

controversial?◦What are the options for neck

treatment?◦What is the evidence on neck

treatment?

BackgroundBackground

BackgroundBackgroundIncidence: 1.7 per 100000 108 new cases in 20110.7% of all new cancer cases 6th leading cancer worldwide32-40% of all head and neck

cancers

HK Cancer registry

How early is early?How early is early?

N0 N1 N2 N3

T1 I

T2 II

T3 III

T4a IVa

T4b IVb

IVC: M1

AJCC Cancer Staging Manual. 7th ed, 2010

T stagingT staging

Head and Neck Cancer Guide

N stagingN staging

Head and Neck Cancer Guide

N stagingN staging

Merritt et al. Arch Otolaryngol Head Neck Surg 1997; 123: 149-152

Giancarlo et al. Anticancer Res 1998; 18: 2805-9

Akoglu et al. J Otolaryngol 2005; 34: 384-94

Fan et al. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2014;49(1):39-43

Sensitivity

Specificity

Ultrasound 72-80% 59-96%

CT 78-83% 80-96%

MRI 50% 75%

PET-CT 67% 85%

N stagingN staging

Increased risk of occult metastasisIncreased risk of occult metastasis◦Tumor thickness / depth of invasion (> 3 or

4mm)◦Higher T stage◦Perineural and angiolymphatic invasion◦Poor tumor differentiation

Yuen et al. Am J Surg. 2000; 180: 139-143Sparano et al. Otolarngol Head Neck Surg 2004; 131: 472-6

N stagingN staging• Incidence of occult neck

metastasis–T1: 16-38%–T2: 21-57%–T3: 77%Kaya et al. Am J Otolaryngol 2011;22:59-64

• Presence of LN mets: most important prognostic factor– Woolgar JA: Oral Oncol 26. 42(3): 229-239

Current Debates in Current Debates in Neck ManagementNeck Management

Debates in neck Debates in neck managementmanagement

Probability of Probability of neck neck

metastasismetastasis

Prognostic Prognostic implicationsimplications

ComplicatioComplications of neck ns of neck dissectiondissection

Options for neck Options for neck managementmanagement1. Elective Neck Dissection (END)

2. Watchful waiting3. Other options:

◦Neck irradiation◦Sentinel LN biopsy

Which level?Which level?

•95% metastatic nodes are in ipsilateral levels I-III

•Skip metastasis: 16%

Liu et al. Oral Oncol 47 (2011) 136-141

Byers et al. Head Neck, 19 (1997) 14–19

Elective neck dissectionElective neck dissection

1. Supraomohyoid neck dissection (I-III)

2. Modified radical neck dissection (I-V)

Brazilian Head and Neck Cancer Study Group. Am J Surg. 1998 Nov;176(5):422-7

http://emedicine.medscape.com/article/1894829-overview

Elective neck dissectionElective neck dissection

Options for neck Options for neck managementmanagement1. Prophylactic Elective Neck Dissection (END)

2. Watchful waiting2. Watchful waiting3. Other options:

◦Neck irradiation◦Sentinel LN biopsy

ObservationObservationCompliance is crucialMRND for salvage of regional

recurrencesMany neck recurrences will be of

advanced stage with poor prognostic factors such as extracapsular spread◦ Andersen et al. Am J Surg 1996; 172:689-

691

END vs ObservationEND vs Observation

Authors Duration

Country Study population

T stage

Tumor location

Survival Benefit

Vandenbrouck et al (1980)

1966-1973

France 75 T1-3 Oral cavity

No

Fakih et al (1989)

1985-1988

India 70 T1-2 Tongue No

Kligerman et al (1994)

1987-1992

Brazil 67 T1-2 Oral cavity

Yes

Yuen et al (2009)

1996-2004

Hong Kong

71 T1-2 Tongue No

Vandenbrouck C et al. Cancer; 1980: 46: 386-90Fakih AR et al. Am J Surg 1989; 158: 309-313Kligerman J et al. Am J Surg 1994; 168: 391-4

Yuen AP et al. Head Neck 2009; 31: 765-72

Prospective randomized study of selective neck Prospective randomized study of selective neck dissection versus observation for N0 neck of early dissection versus observation for N0 neck of early

tongue carcinomatongue carcinomaYuen PW, Ho CM, Chow TL, Tang LC, Wei W et alYuen PW, Ho CM, Chow TL, Tang LC, Wei W et al

Outcomes: Outcomes: -Node related mortality: 0%-Salvage rate: 100% -5 year Disease specific survival:

- END: 89%- Observation: 87% (Not statistically

significant)

A meta-analysis of the RCTs on elective neck A meta-analysis of the RCTs on elective neck dissection versus therapeutic neck dissection in dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative oral cavity cancers with clinically node-negative

neckneckFasunla AJ, Greene BH, Timmesfeld N et al. Fasunla AJ, Greene BH, Timmesfeld N et al.

Do we have the answer Do we have the answer yet?yet?

Elective Neck Dissection

Observation

Pros • Less nodal recurrence

• Less surgical morbidity than radical or MRND

• Accurate N staging

• Avoid unnecessary neck dissection in truly N0 patients

Cons • Shoulder morbidities • Strict compliance to FU• Poor prognostic factors

on recurrence

Options for neck Options for neck managementmanagement1. Prophylactic Elective Neck Dissection (END)

2. Watchful waiting3. Other options: 3. Other options:

◦Neck irradiation◦Sentinel LN biopsy

IrradiationIrradiationElective irradiation of the N0 neck

produces results equivalent to that of neck dissection◦ G.H. Fletcher. Cancer, 29 (1972), pp. 1450–1454◦ Bataini et al. Eur Arch Otorhinolaryngol, 250

(1993), 442–445

Disadvantages: ◦No histopathological staging◦complications of radiation◦Secondary neoplasms

Sentinel LN biopsySentinel LN biopsy

Atula T et al. Eur Arch Otorhinolaryngol. 2008;265 Suppl 1:S19-23 Tschopp et al. Otolaryngol Head Neck Surg, 132 (2005), 99–102

Paleri et al. Head Neck, 27 (2005), 739–747Kovacs AF. Surg Oncol Clin N Am 16 (2007), 81-100

s

Sensitivity: 93%

Negative predictive value: 94%

Upstaging rate: 13-60%

ConclusionConclusionManagement of the N0 neck in

stage I and II tongue cancer is controversial◦Main options for management: Elective

neck dissection vs observationStringent follow up is crucial in

detection of early nodal metastasis for successful salvage surgery

Further developments: Sentinel LN biopsy

The EndThe End

ReferencesReferences http://www.intechopen.com/books/melanoma-from-early-detection-to-treatment/sentinel-lymph-node-biopsy-

for-melanoma-and-surgical-approach-to-lymph-node-metastasi (figure on slide 25) Keski-Santti et al. Sentinel lymph node biopsy or elective neck dissection for patients with oral squamous cell

carcinoma. Eur Arch Otorhinolaryngol 2008: 265 (suppl): S13-S17 Govers et al. Sentinel lymph node biopsy for SCC of the oral cavity: A diagnostic meta-analysis. Oral Oncol

2013: 49; 726-732 Fasunla AJ et al. A meta-analysis of the RCTs on elective neck dissection versus therapeutic neck dissection

in oral cavity cancers with clinically node negative neck. Oral Oncol 2011: 47: 320-324 Kovacs AF. Head and neck squamous cell carcinoma: Sentinel node or selective neck dissection. Surg Oncol

Clin N Am 2007; 16: 81-100 Fan SF et al. Sentinel lymph node biopsy versus elective neck dissection in patients with cT1-2N0 oral tongue

SCC. Oral Pathol Oral Radiol 2014; 117: 186-190 Melkane AE, et al. Sentinel Node biopsy in early oral squamous cell carcinomas: A 10 year experience.

Laryngoscope 2012; 122: 1782-1788 Amaral TMP et al. Predictive factors of occult metastasis and prognosis of clinical stages I and II squamous

cell carcinoma of the tongue and floor of mouth. Oral Oncol 2004; 40: 780-786 Yuen APW et al. A comparison of the prognostic significance of tumor diameter, length, width, thickness,

area, volume and clinicopathological features of oral tongue carcinoma. Am J Surg 2000; 180: 139-143 Sparano A et al. Multivariate predictors of occult neck metastasis in early oral tongue cancers. Otolaryngol

Head Neck Surg 2004; 131: 472-6 Yuen APW et al. Prospective randomized study of selective neck dissection versus observation for N0 neck of

early tongue carcinoma. Head Neck 2009; 31: 765-772 Kligerman et al. Supraomohyoid neck dissection in the treatment of T1/2 squamous cell carcinoma of oral

cavity. Am J Surg 1994; 168: : 391-4

Prognostic implications◦Regional recurrence is the most

common cause of treatment failure Yuen et al. Head Neck 1997; 19:583-588

◦Recurrence rate: 23.7-42% Brugere et al 1996; Khahf et al. 1991;

Okamoto et al 2002

◦Poor salvage surgery outcomes◦Accurate N staging (diagnostic

limitation)

Elective neck dissectionElective neck dissectionOccult metastasis rate > 20%

◦Weiss et al. Arch Otolaryncol Head Neck Surg 1994, 120(7): 699-702

PrognosisPrognosis

5 year survival relative rateT1: 71%T2: 59%T3: 47%T4: 37%

American Cancer Society

Elective Neck Elective Neck DissectionDissectionWhich side?Which side?Contralateral LN metastasis: 4%

◦ Lim et al. Laryngoscope 2006; 116: 461-465

Higher risk of contralateral neck involvement:

positive ipsilateral nodesadvanced stage primary tumors tumors crossing midlineKoo et al. Head Neck. 2006 Oct;28(0):896-901