Early Tongue Cancer Controversies in management of the neck

1
Early Tongue CancerControversies in management
of the neck

• Dr. Serena Wong
• Queen Elizabeth Hospital

2
Introduction

• Background
• Current debates in neck management
• Why is neck treatment so controversial?
• What are the options for neck treatment?
• What is the evidence on neck treatment?

3
Background
4
Background

• Incidence 1.7 per 100000
• 108 new cases in 2011
• 0.7 of all new cancer cases
• 6th leading cancer worldwide
• 32-40 of all head and neck cancers

HK Cancer registry
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How early is early?
N0 N1 N2 N3
T1 I
T2 II
T3 III III
T4a IVa IVa IVa
T4b IVb IVb IVb IVb
IVC M1 IVC M1 IVC M1 IVC M1
AJCC Cancer Staging Manual. 7th ed, 2010
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T staging
Head and Neck Cancer Guide
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N staging
Head and Neck Cancer Guide
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N staging
Sensitivity Specificity
Ultrasound 72-80 59-96
CT 78-83 80-96
MRI 50 75
PET-CT 67 85

• 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. 201449(1)39-43

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N staging

• Increased risk of occult metastasis
• Tumor thickness / depth of invasion (gt 3 or 4mm)
• Higher T stage
• Perineural and angiolymphatic invasion
• Poor tumor differentiation
• Yuen et al. Am J Surg. 2000 180 139-143
• Sparano et al. Otolarngol Head Neck Surg 2004
  131 472-6

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N staging

• Incidence of occult neck metastasis
• T1 16-38
• T2 21-57
• T3 77
• Kaya et al. Am J Otolaryngol 20112259-64
• Presence of LN mets most important prognostic
  factor
• Woolgar JA Oral Oncol 26. 42(3) 229-239

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Current Debates in Neck Management
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Debates in neck management
Probability of neck metastasis
Complications of neck dissection
Prognostic implications
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Options for neck management

• 1. Elective Neck Dissection (END)
• 2. Watchful waiting
• 3. Other options
• Neck irradiation
• Sentinel LN biopsy

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Elective neck dissection

• 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) 1419
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Elective neck dissection

• Supraomohyoid neck dissection (I-III)
• Modified radical neck dissection (I-V)

No difference in survival and recurrence
Brazilian Head and Neck Cancer Study Group. Am J
Surg. 1998 Nov176(5)422-7 http//emedicine.medsc
ape.com/article/1894829-overview
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Options for neck management

• 1. Prophylactic Elective Neck Dissection (END)
• 2. Watchful waiting
• 3. Other options
• Neck irradiation
• Sentinel LN biopsy

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Observation

• Compliance is crucial
• MRND for salvage of regional recurrences
• Many neck recurrences will be of advanced stage
  with poor prognostic factors such as
  extracapsular spread
• Andersen et al. Am J Surg 1996 172689-691

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END 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
386-90 Fakih AR et al. Am J Surg 1989 158
309-313 Kligerman J et al. Am J Surg 1994 168
391-4 Yuen AP et al. Head Neck 2009 31 765-72
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Prospective randomized study of selective neck
dissection versus observation for N0 neck of
early tongue carcinomaYuen PW, Ho CM, Chow TL,
Tang LC, Wei W et al

• Outcomes
• Node related mortality 0
• Salvage rate 100
• 5 year Disease specific survival
• END 89
• Observation 87
• (Not statistically significant)

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A meta-analysis of the RCTs on elective neck
dissection versus therapeutic neck dissection in
oral cavity cancers with clinically node-negative
neckFasunla AJ, Greene BH, Timmesfeld N et al.
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Do we have the answer 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
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Options for neck management

• 1. Prophylactic Elective Neck Dissection (END)
• 2. Watchful waiting
• 3. Other options
• Neck irradiation
• Sentinel LN biopsy

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Irradiation

• Elective irradiation of the N0 neck produces
  results equivalent to that of neck dissection
• G.H. Fletcher. Cancer, 29 (1972), pp. 14501454
• Bataini et al. Eur Arch Otorhinolaryngol, 250
  (1993), 442445
• Disadvantages
• No histopathological staging
• complications of radiation
• Secondary neoplasms

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Sentinel LN biopsy

• Sensitivity 93
• Negative predictive value 94
• Upstaging rate 13-60

• Atula T et al. Eur Arch Otorhinolaryngol.
  2008265 Suppl 1S19-23
• Tschopp et al. Otolaryngol Head Neck Surg, 132
  (2005), 99102
• Paleri et al. Head Neck, 27 (2005), 739747
• Kovacs AF. Surg Oncol Clin N Am 16 (2007), 81-100
• s

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Conclusion

• Management of the N0 neck in stage I and II
  tongue cancer is controversial
• Main options for management Elective neck
  dissection vs observation
• Stringent follow up is crucial in detection of
  early nodal metastasis for successful salvage
  surgery
• Further developments Sentinel LN biopsy

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The End
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References

• http//www.intechopen.com/books/melanoma-from-earl
  y-detection-to-treatment/sentinel-lymph-node-biops
  y-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

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• Prognostic implications
• Regional recurrence is the most common cause of
  treatment failure
• Yuen et al. Head Neck 1997 19583-588
• 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)

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Elective neck dissection

• Occult metastasis rate gt 20
• Weiss et al. Arch Otolaryncol Head Neck Surg
  1994, 120(7) 699-702

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Prognosis

• 5 year survival relative rate
• T1 71
• T2 59
• T3 47
• T4 37

American Cancer Society
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Elective Neck Dissection

• Which side?
• Contralateral LN metastasis 4
• Lim et al. Laryngoscope 2006 116 461-465
• Higher risk of contralateral neck involvement
• positive ipsilateral nodes
• advanced stage primary tumors
• tumors crossing midline
• Koo et al. Head Neck. 2006 Oct28(0)896-901