Characteristics of Patients with Upstaging by Sentinel Lymph Node Biopsy of the N0 Neck in Head and Neck Cancer

Introduction: To investigate the possible role of sentinel lymph node biopsy (SLNB) to upstage the N0 neck in patients with oral and oropharyngeal squamous cell carcinoma. Methods: Patients with T1-T2 oral and oropharyngeal squamous cell carcinoma accessible to injection and staged N0 into the neck by palaption and CTscan were enrolled in the study. All patients underwent regular follow-up to identify possible recurrence. Results: A sentine lymph node biopsy was performed by 21 consecutive patients. 4 of the 21 patients were upstaged by SNLB. There was a mean follow-up of 31 months. Two patients developed subsequent disease after having been staging by SLNB, respectively negative in one case and positive in the other case. Tumor site, the staging of the primary tumor, presence of ulceration, tumor thickness were the same in the upstaged initially N0 patients. Conclusions: Sentinel lymph node biopsy can be used to upstage the N0 neck patients in perhaps well defined patients.

Is Routine Bilateral Neck Dissection Absolutely Necessary in the Management of N0 CT Negative Neck in Patients with T4 Laryngeal Head and Neck Carcinoma?

Objectives: Elective neck treatment of clinically N0 patients in patients with head and neck carcinomas is widely accepted as a standard approach. However, the issue whether elective neck treatment should routinely be directed on both sides of the neck is still controversial. The present study is aimed at determining whether T4 staged head and neck carcinomas required bilateral neck dissection in the management clinically No necks especially CT negative cervical nodes. Methods: We performed a retrospective analysis of patients with advanced head and neck disease who received bilateral neck dissection. All the patients had curative surgery as their initial treatment for the primary tumor and the neck. Results: All the 28 consecutive patients had T4 staged primary laryngeal cancer. Patients with clinically and radiologically N+ disease had invaded lymph node metastases in all cases. Patients staged clinically and radiologically N0 had no invaded cervical lymph nodes found by pathologic examination. Patients staged clinically N0 and radiologically N+ had invaded cervical lymph nodes in 8/12 cases and in 50% (4/8) of the cases bilaterally. Conclusion: This study showed the importance on adequate clinical and radiological staging. By patients with advanced disease clinically and radiologically N0, bilateral neck dissection should not be necessary. But in patients radiologically N+, routine bilateral neck dissection is beneficial.

Upper mediastinal and paratracheal node dissection in total (pharyngo) laryngectomy, it is really indicated?

Introduction: Advanced laryngeal and hypopharyn- geal cancers are aggressive tumors with a poor prog- nosis. Multiple lymph node metastases often occur in the neck as well as in the upper mediastinum and thus upper mediastinal dissection is crucial to im- proving the cure rate. However, excessive mediastinal dissection can increase postoperative morbidity and mortality making it important to employ the proper technique and appropriate extent of dissection. In the present study, we aimed to determine the need and the prognostic importance of mediastinal dissection in patients with advanced carcinoma of the upper aerodigestive tract. Methods: A retrospective review of the records of 30 patients who underwent (phar- ynxgo) laryngectomy for advanced squamous cell carcinomas was done. 17 patients had laryngeal car- cinomas, 13 had hypopharyngeal carcinomas. The mediastinal dissection was designed to remove mainly the paratracheal and retrooesophageal lymph nodes. Results: 60 neck dissections and 30 mediastinal dis- section were performed in 30 patients and yielded positive nodes were found in 20/30 patients. Neck nodes were positive in 9/17 of the patients with la-ryngeal cancer and 11/13 of the patients with hypo- pharyngeal cancers respectively. Positive nodes were detected in the neck regardless of T stage. The medi- astinal nodes were positive in 0% of the patients with laryngeal cancer. Upper mediastinal metastases were detected positive in 6/13 of the hypopharyngeal pa-tients. In these patients, mediastinal metastases were associated with tumors greater than 35 mm. The ma- jority of positive paratracheal nodes were less than 1 cm in diameter and appeared negative preoperatively. 0% of the patients had positive paratracheal nodes alone in a histologically negative cervical neck dissec-tion Regarding the appropriate extent of dissection, no major complications were observed. Conclusions: There is little controversy about neck dissection in advanced tumors of the (pharyngo) larynx. Laryn- geal carcinomas showed no positive mediastinal no- des in this series. The study highlighted the propen- sity of advanced hypopharyngeal cancers to involve the paratracheal nodes.

Salvage surgery after failure of non surgical therapy for advanced head and neck cancer

Introduction: for organ and function preservation, chemoradiotherapy is gaining popularity for primary treatment of advanced head and neck cancer, re- serveing surgery for salvage. Methods: Retrospective outcome analysis to determine the results of salvage surgery after failure of primary treatment of advan- ced head and neck cancer by chemoradiotherapy. 104 patients with advanced head and cancer were initially treated by chemoradiotherapy. Follow-up was evalu- ated in 27 patients undergoing salvage surgery for re- current tumor (larynx n = 13;oral cavity n = 9;hypo- pharynx n = 5). The initial tumor is stage T3 in 11 cases and T4 in 16 cases. 10 patients had primary tumors stage III and 17 patients had tumors stage IV. Results: One postoperative death occured following surgery. The overall incidence of complications was 9/ 27 (%). Recurrent disease developed at the primary initially treated in 25 cases and in the neck in 2 cases after a mean follow-up of 11 months (3 - 136 months). After salvage surgery, loco-regional recurrence and/ or distant disease developed in 10/27 patients after a mean follow-up of 4 months. 6/10 (60%) patients died after re-recurrence despite salvage chemotherapy. Conclusion: Salvage surgery after failure of initial chemoradiotherapy is burdened with high morbi- dity and bad oncological outcome. We demonstrated that it is difficult to salvage locally recurrent head and neck cancer especially at more advanced T-stages or when tumor recur. The limited effect of surgical salvage for recurrent tumor need to be addressed when choosing the initial treatment plan.