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Management of the clinically N0
neck in early-stage oral squamous
cell carcinoma
Dr jameel kifayatullah
Management of the clinically N0 neck
in early-stage oral squamous
cell carcinoma
• The management of the neck in early, low
volume disease (clinically T1/T2 oral cavity
tumours) has long been debated. The risk of
occult nodal involvement in cT1/T2 OSCC is
estimated around 20 to 30%.
• In early oral cancer the rate of occult
metastasis is estimated between 20 and 40%.
main policies
The main policies that have been considered in
managing the neck in early oral cancer are the
following:
1. Upfront elective neck dissection (END)
2. Watch and wait policy, and more recently
3. Sentinel node biopsy (SNB)
patterns of spread
• Lateralised tumours,such as buccal, gingival,
retromolar and maxillary OSCC metastasise
first into ipsilateral levels I and IIa .
• The more anterior the tumour is located the
higher the likelihood of Level IA involvement
and the more posterior the higher the chance
of level IIa involvement.
• In buccal OSCC, the facial lymph node is at
risk
patterns of spread
• Tongue OSCC predominantly spreads to levels I
and II with a small fraction (6 -12%) of tumours
metastasizing contralaterally or bilaterally
depending on the tumour's proximity to the
midline and its histopathological aggressiveness
• The more posterior the tongue tumour, the
higher the chance of level IIB and contralateral
nodal metastasis, due to higher lymphatic
interconnections posteriorly towards the base of
tongue
patterns of spread
• Tumours arising close to the midline such as the floor
of mouth(FOM) or the palate spread to levels I and IIA
with approximately 25% probability of bilateral or
contralateral nodal involvement
• In the majority of OSCC patients, level IV is only
involved when other neck levels are positive for
metastasis.
• Byers reported that clinically N0 OSCC metastasised to
level IV in 15.8% of the cases,where 5.5% accounted
for true skip metastasis.
Patterns of spread
• True skip metastases to level IV account for 2%
or less of the cases, predominantly from
tongue OSCC.
• Level V in cN0 oral cancer is rarely involved
(less than 1%)
Extent of elective neck dissection
• There is consensus that the extent of the END
should be in the form of a selective I-IV neck
dissection, as this is equally effective than
more extensive, but morbid, types of ND
(MRND, RD) (Huang et al., 2008), as long as
there is a minimum yield of 18 lymph nodes
Sentinal Node Biopsy
• This approach essentially involves
preoperative injection of a radiotracer
(nanocolloid labelled with Technetium 99
m,99m Tc) atthe tumour site (submucosal
tumour periphery), followed by
planar lymphoscintigraphy in conjunction with
SPECT/CT (single photon emission computed
tomography combined with low-dose
CT) to localise the draining lymph nodes
When to do neck dissection In SNB
• The protocol of SNB dictates that if a node is
found positive for metastasis then a formal
neck dissection should be carried out
SNB in identifying echelon nodes
• The ability to accurately identify the echelon node appears to be
site-specific, with FOM tumours displaying higher false negative
rates (usually due to “shine-through” artefact) in the range of 25%
(Civantos et al., 2010; Milenovic et al., 2014; Alvarez et al., 2014)
• There is very little evidence to date about the usefulness of SNB in
maxillary cancer (Boeve et al., 2017) and the current stance favours
elective neck dissection as recurrences (all T-stage maxillary
tumours) affect the contralateral neck in high ratio (45.5%) (Joosten
et al., 2017).
Lymphoscintigraphy in SNB
• Lymphoscintigraphy can be useful in
identifying the sentinel node in cases of
bilateral or contralateral drainage (12-20%)
depending on proximity to
midline(approximately 2% of occult metastasis
to contralateral site)
SNB
• Sentinel node positivity or ‘upgrade’ of the neck status rate
varies from 8.7% (N =103) (Kovacs et al., 2009) to 38% (N =111) in
SNB studies (Broglie et al., 2013), further necessitating formal neck
dissection. The latter reveals additional positive lymph nodes
(upstaging the disease to pN2 or pN3) in approximately 20% of the
otherwise clinically staged as N0 cases (Broglie et al., 2013; Den
Toom et al., 2015; Pedersen et al., 2016; Moya-Plana et al., 2018;
Loree et al., 2019; Milenovic et al., 2014; Rigual et al., 2013). All SNB
studies demonstrate lower survival outcomes in the SNB positive
patients (OS range 38%-71% in SNB positive patients).
SNB
• Therefore, despite the evidence that SNB
benefits true Pn0 early-stage OSCC patients by
sparing them from the potential morbidity of
ND, the technique might prove
disadvantageous for N(+) patients as it is not
therapeutic for this group and exposes
those patients to two operative procedures,
potentially delaying the delivery of adjuvant
treatment
SNB
It becomes prudent to attempt to predict the
SNB result and therefore reserve this
approach for patients who are not at high risk
of occult nodal disease .
Vertical dimension of tumours growth
• The vertical dimension of a tumour's growth
can be measured by its Thickness or its depth
of invasion
Tumour thickness
Tumour thickness represents the vertical
dimension of the tumour measured from the
deepest point of invasion to its mucosal
surface.
Depth of invasion (DOI)
• Depth of invasion (DOI) is measured from the
deepest point of invasion to the basement
membrane of the most normal adjacent
mucosa
FOM
• The tumour thickness threshold for FOM
tumours beyond which the incidence of nodal
metastasis rises over 20%, therefore indicating
benefit from prophylactic/staging neck
dissection is 1.5 mm
Tongue scc
• The threshold for tongue OSCC is set at 4-5
mm.
Depth of invasion
• Further research on the field has clarified that
it is the tumour's depth of invasion (DOI) that
reflects more accurately its penetrative and
infiltrative potential as opposed to its
thickness.
Correlation between DOI and nodal
metastasis
• There is a positive correlation between DOI
and nodal metastasis.
• The DOI is a better predictive parameter in
comparison to thickness and the accepted DOI
threshold beyond which the risk of nodal
metastasis increases is 1.5 mm for FOM
tumours and 4 mm for the rest of oral cavity.
NCCN GUIDELINES
• The NCCN strongly suggests END for
tumour DOI 4 mm or above and reserves SNB
only for thin OSCC of a DOI up to 2 mm
ASCO Guidelines
• The ASCO (American society of clinical
oncology)Guidelines favour upfront elective
neck dissection and also recommend a low
threshold for elective surgical treatment of
the contralateral neck in tumours proximal to
the midline
Recommended policy
• Based on the current best available evidence
we propose that elective neck dissection
should comprise the default mainstay
treatment of the cN0 neck.
Advantages of END
Elective surgical management of the neck has the following
advantages:
1) Accurate staging: Selective neck dissection allows analysis of all
the nodal basins in the draining region of the primary tumour
and provides the most reliable means of staging.
2) Locoregional Control :END pre-empts the best opportunity
for locoregional control of the disease (prophylactic and thera
peutic management).
3)Adjuvant treatment planning: Pathological assessment of the
regional lymph nodes allowing timely planning and delivery of
appropriate adjuvant therapy (RT or CRT)
Depth of invasion
• The primary tumour depth of invasion (DOI)
constitutes indisputably a key parameter in
the evaluation of the risk for nodal occult
metastasis and the overall prognosis of the
disease and it should be taken under
consideration in the treatment planning
(primary and adjuvant).
SNB
• SNB risks de-escalating the therapeutic approach in
high risk cancers and should be reserved for carefully
selected cases, when nodal metastasis is unlikely to
occur
• SNB has a role in clinically thin (less than 2 mm DOI)
tongue, buccal and alveolar SCC while it can also be
considered in histologically favourable SCCs of 2-4 mm
DOI.
• SNB should not be employed in FOM tumours due to
the inherent site-specific inaccuracies of the technique
and its high false negative ratio in this anatomical
subsite
Floor of mouth tumours
• FOM tumours should be considered high risk
for regional failure and should be approached
differently, due to the early preponderance of
tumours to spread (DOI 1.5 mm).
• In FOM OSCC strong consideration for bilateral
selective neck dissection must be given
Selective Neck Dissections
• Supraomohyoid neck
dissection. Level IIb
removed when
necessary
Supraomohyoid dissection
• This entails resecting the following groups:
submental, submandibular (group I, excising the
submaxillary gland), high jugular (group II), and
mid jugular (group III). The deep limit of resection
consists of the branches of the cervical plexus
and the posterior limit is the lateral border of the
SCM. Since nodes are present medially and
laterally to the accessory spinal nerve, node
group II is divided into IIa (anterior and inferior to
the nerve) and IIb (posterosuperior to the nerve).
Lateral dissection
• It involves the excision
of levels II, III, and IV
(upper, middle, and
lower jugular lymph
nodes).
Posterolateral dissection
• Mostly employed in skin
diseases of the occipital
region, it entails
removing the
suboccipital and
retroauricular nodes
together with node
levels II, III, IV, and V.
Anterior dissection
• Mostly employed in the
management of thyroid
cancer, it involves the
prelaryngeal (Delphian
node), pretracheal and
paratracheal chains
(recurrent laryngeal
nodes), and
perithyroidal nodes in
general.

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clinically N0 neck in oral cancer

  • 1. Management of the clinically N0 neck in early-stage oral squamous cell carcinoma Dr jameel kifayatullah
  • 2. Management of the clinically N0 neck in early-stage oral squamous cell carcinoma • The management of the neck in early, low volume disease (clinically T1/T2 oral cavity tumours) has long been debated. The risk of occult nodal involvement in cT1/T2 OSCC is estimated around 20 to 30%. • In early oral cancer the rate of occult metastasis is estimated between 20 and 40%.
  • 3. main policies The main policies that have been considered in managing the neck in early oral cancer are the following: 1. Upfront elective neck dissection (END) 2. Watch and wait policy, and more recently 3. Sentinel node biopsy (SNB)
  • 4. patterns of spread • Lateralised tumours,such as buccal, gingival, retromolar and maxillary OSCC metastasise first into ipsilateral levels I and IIa . • The more anterior the tumour is located the higher the likelihood of Level IA involvement and the more posterior the higher the chance of level IIa involvement. • In buccal OSCC, the facial lymph node is at risk
  • 5. patterns of spread • Tongue OSCC predominantly spreads to levels I and II with a small fraction (6 -12%) of tumours metastasizing contralaterally or bilaterally depending on the tumour's proximity to the midline and its histopathological aggressiveness • The more posterior the tongue tumour, the higher the chance of level IIB and contralateral nodal metastasis, due to higher lymphatic interconnections posteriorly towards the base of tongue
  • 6. patterns of spread • Tumours arising close to the midline such as the floor of mouth(FOM) or the palate spread to levels I and IIA with approximately 25% probability of bilateral or contralateral nodal involvement • In the majority of OSCC patients, level IV is only involved when other neck levels are positive for metastasis. • Byers reported that clinically N0 OSCC metastasised to level IV in 15.8% of the cases,where 5.5% accounted for true skip metastasis.
  • 7. Patterns of spread • True skip metastases to level IV account for 2% or less of the cases, predominantly from tongue OSCC. • Level V in cN0 oral cancer is rarely involved (less than 1%)
  • 8. Extent of elective neck dissection • There is consensus that the extent of the END should be in the form of a selective I-IV neck dissection, as this is equally effective than more extensive, but morbid, types of ND (MRND, RD) (Huang et al., 2008), as long as there is a minimum yield of 18 lymph nodes
  • 9. Sentinal Node Biopsy • This approach essentially involves preoperative injection of a radiotracer (nanocolloid labelled with Technetium 99 m,99m Tc) atthe tumour site (submucosal tumour periphery), followed by planar lymphoscintigraphy in conjunction with SPECT/CT (single photon emission computed tomography combined with low-dose CT) to localise the draining lymph nodes
  • 10.
  • 11. When to do neck dissection In SNB • The protocol of SNB dictates that if a node is found positive for metastasis then a formal neck dissection should be carried out
  • 12. SNB in identifying echelon nodes • The ability to accurately identify the echelon node appears to be site-specific, with FOM tumours displaying higher false negative rates (usually due to “shine-through” artefact) in the range of 25% (Civantos et al., 2010; Milenovic et al., 2014; Alvarez et al., 2014) • There is very little evidence to date about the usefulness of SNB in maxillary cancer (Boeve et al., 2017) and the current stance favours elective neck dissection as recurrences (all T-stage maxillary tumours) affect the contralateral neck in high ratio (45.5%) (Joosten et al., 2017).
  • 13. Lymphoscintigraphy in SNB • Lymphoscintigraphy can be useful in identifying the sentinel node in cases of bilateral or contralateral drainage (12-20%) depending on proximity to midline(approximately 2% of occult metastasis to contralateral site)
  • 14. SNB • Sentinel node positivity or ‘upgrade’ of the neck status rate varies from 8.7% (N =103) (Kovacs et al., 2009) to 38% (N =111) in SNB studies (Broglie et al., 2013), further necessitating formal neck dissection. The latter reveals additional positive lymph nodes (upstaging the disease to pN2 or pN3) in approximately 20% of the otherwise clinically staged as N0 cases (Broglie et al., 2013; Den Toom et al., 2015; Pedersen et al., 2016; Moya-Plana et al., 2018; Loree et al., 2019; Milenovic et al., 2014; Rigual et al., 2013). All SNB studies demonstrate lower survival outcomes in the SNB positive patients (OS range 38%-71% in SNB positive patients).
  • 15. SNB • Therefore, despite the evidence that SNB benefits true Pn0 early-stage OSCC patients by sparing them from the potential morbidity of ND, the technique might prove disadvantageous for N(+) patients as it is not therapeutic for this group and exposes those patients to two operative procedures, potentially delaying the delivery of adjuvant treatment
  • 16. SNB It becomes prudent to attempt to predict the SNB result and therefore reserve this approach for patients who are not at high risk of occult nodal disease .
  • 17. Vertical dimension of tumours growth • The vertical dimension of a tumour's growth can be measured by its Thickness or its depth of invasion
  • 18. Tumour thickness Tumour thickness represents the vertical dimension of the tumour measured from the deepest point of invasion to its mucosal surface.
  • 19. Depth of invasion (DOI) • Depth of invasion (DOI) is measured from the deepest point of invasion to the basement membrane of the most normal adjacent mucosa
  • 20. FOM • The tumour thickness threshold for FOM tumours beyond which the incidence of nodal metastasis rises over 20%, therefore indicating benefit from prophylactic/staging neck dissection is 1.5 mm
  • 21. Tongue scc • The threshold for tongue OSCC is set at 4-5 mm.
  • 22. Depth of invasion • Further research on the field has clarified that it is the tumour's depth of invasion (DOI) that reflects more accurately its penetrative and infiltrative potential as opposed to its thickness.
  • 23.
  • 24. Correlation between DOI and nodal metastasis • There is a positive correlation between DOI and nodal metastasis. • The DOI is a better predictive parameter in comparison to thickness and the accepted DOI threshold beyond which the risk of nodal metastasis increases is 1.5 mm for FOM tumours and 4 mm for the rest of oral cavity.
  • 25. NCCN GUIDELINES • The NCCN strongly suggests END for tumour DOI 4 mm or above and reserves SNB only for thin OSCC of a DOI up to 2 mm
  • 26. ASCO Guidelines • The ASCO (American society of clinical oncology)Guidelines favour upfront elective neck dissection and also recommend a low threshold for elective surgical treatment of the contralateral neck in tumours proximal to the midline
  • 27. Recommended policy • Based on the current best available evidence we propose that elective neck dissection should comprise the default mainstay treatment of the cN0 neck.
  • 28. Advantages of END Elective surgical management of the neck has the following advantages: 1) Accurate staging: Selective neck dissection allows analysis of all the nodal basins in the draining region of the primary tumour and provides the most reliable means of staging. 2) Locoregional Control :END pre-empts the best opportunity for locoregional control of the disease (prophylactic and thera peutic management). 3)Adjuvant treatment planning: Pathological assessment of the regional lymph nodes allowing timely planning and delivery of appropriate adjuvant therapy (RT or CRT)
  • 29. Depth of invasion • The primary tumour depth of invasion (DOI) constitutes indisputably a key parameter in the evaluation of the risk for nodal occult metastasis and the overall prognosis of the disease and it should be taken under consideration in the treatment planning (primary and adjuvant).
  • 30. SNB • SNB risks de-escalating the therapeutic approach in high risk cancers and should be reserved for carefully selected cases, when nodal metastasis is unlikely to occur • SNB has a role in clinically thin (less than 2 mm DOI) tongue, buccal and alveolar SCC while it can also be considered in histologically favourable SCCs of 2-4 mm DOI. • SNB should not be employed in FOM tumours due to the inherent site-specific inaccuracies of the technique and its high false negative ratio in this anatomical subsite
  • 31. Floor of mouth tumours • FOM tumours should be considered high risk for regional failure and should be approached differently, due to the early preponderance of tumours to spread (DOI 1.5 mm). • In FOM OSCC strong consideration for bilateral selective neck dissection must be given
  • 32. Selective Neck Dissections • Supraomohyoid neck dissection. Level IIb removed when necessary
  • 33. Supraomohyoid dissection • This entails resecting the following groups: submental, submandibular (group I, excising the submaxillary gland), high jugular (group II), and mid jugular (group III). The deep limit of resection consists of the branches of the cervical plexus and the posterior limit is the lateral border of the SCM. Since nodes are present medially and laterally to the accessory spinal nerve, node group II is divided into IIa (anterior and inferior to the nerve) and IIb (posterosuperior to the nerve).
  • 34. Lateral dissection • It involves the excision of levels II, III, and IV (upper, middle, and lower jugular lymph nodes).
  • 35. Posterolateral dissection • Mostly employed in skin diseases of the occipital region, it entails removing the suboccipital and retroauricular nodes together with node levels II, III, IV, and V.
  • 36. Anterior dissection • Mostly employed in the management of thyroid cancer, it involves the prelaryngeal (Delphian node), pretracheal and paratracheal chains (recurrent laryngeal nodes), and perithyroidal nodes in general.