Accuracy of intraoperative staging of the N0 neck in squamous cell carcinoma

Abstract

Management of the neck in squamous cell carcinoma of the upper aerodigestive tract continues to be a topic of great debate. One major problem is that incorrect clinical staging is expected in approximately 20% of necks. This is true of both clinical stage N0 and N+ necks, even when imaging studies are used. This prospective study of 108 necks in 79 patients examined the role of intraoperative palpation and inspection in improving the surgeon's ability to predict nodal stage. Of 62 patients with N0 necks clinically on both sides, 26 were staged N+ by intraoperative node examination. Nineteen of the 26 were histologically negative (73% false‐positive). Of the 36 patients staged intraoperatively as N0, 10 were histologically positive (28% false‐negative). Of 108 necks judged clinically to be N0, 25 (23%) had occult metastases and 11 (10%) had extracapsular spread. Forty‐one of 108 clinical N0 necks were believed to have positive nodes at the time of neck dissection. Of these 41 necks, 30 (73%) were found to be histologically N0 (false‐positive). Of the 67 clinical N0 necks that were also believed to be N0 intraoperatively, occult metastases were found in 14 (21% false‐negative). Therefore, intraoperative staging did not significantly improve the false‐negative rate. Frozen‐section biopsy obtained in the operating room was reliable in 24 (92.3%) of 26 patients. Although frozen‐section biopsy was not performed in all patients, these data suggest that upstaging the neck without frozen‐section biopsy is much less reliable. This study supports the use of frozen‐section biopsy before converting the selective dissection to a radical or modified neck dissection in most instances.

Molecular Staging of Cervical Lymph Nodes in Squamous Cell Carcinoma of the Head and Neck

“…Consequently, many patients have to undergo a second surgical procedure to complete lymph node dissection after definitive pathologic assessment identifies microscopic metastatic disease not evident on intraoperative analysis. Our own work, and that reported by others, suggests that low sensitivity may also be an issue for intraoperative SLN analysis in SCCHN (18,21). Performing a second surgery on the neck is an undesirable scenario because this would likely increase complications and morbidity and could delay the use of adjuvant therapy.…”

“…This technique has the potential to define those cN0 patients in whom neck dissection is most appropriate (i.e., those who are pathologically node positive), thereby obviating END and its associated morbidities in nodenegative patients. Numerous single-institution studies have suggested that SLN mapping in SCCHN accurately predicts the status of the neck (5,(17)(18)(19)(20)(21), and this finding is currently being evaluated in a large multicenter validation trial sponsored by the American College of Surgeons Oncology Group (ACOSOG Z0360 trial). When combined with intraoperative analysis of the SLN(s), this approach could allow for definitive staging and surgical treatment in a single procedure.…”

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

“…less than 4mm in primary tumor of the tongue), and favorable histologic differentiation [41,135]. They proposed a reliance on the radiological evaluation of the neck to take decision on the extent of treatment [55] and emphasized on the importance of frozen section as a guide on whether or not to proceed to neck dissection [122].…”

Cervical node metastasis in T1 squamous cell carcinoma of oral tongue- pattern and the predictive factors

“…Use of radiological means like ultrsonography and CT scan has not contributed much to improvement in the staging [24,25]. Even the intra operative assessment has been found to be [26,27]. New imaging methods like PET-CT scan is not sensitive enough to modify the indication of elective neck dissection [28].…”