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O.E. Nieweg et al.
42. Van der Ploeg IMC, Nieweg OE, Van Rijk MC, Valdés
Olmos RA, Kroon BBR. Axillary recurrence after a
tumour-negative sentinel node biopsy in breast cancer
patients: a systematic review and meta-analysis of the
literature. Eur J Surg Oncol. 2008;34:1277–84.
43. Karim RZ, Scolyer RA, Li W, Yee VSK, McKinnon
JG, Li LXL, et al. False negative sentinel lymph node
biopsies in melanoma may result from defi ciencies in
nuclear medicine, surgery, or pathology. Ann Surg.
2008;247:1003–10.
44. Rosenberg SA. Why perform sentinel-lymph-node
biopsy in patients with melanoma? Nat Clin Pract
Oncol. 2008;5:1.
45. Thomas JM. Prognostic false-positivity of the sentinel
node in melanoma. Nat Clin Pract Oncol. 2008;5:
18–23.
46. Morton DL, Cochran AJ, Thompson JF. The rationale
for sentinel-node biopsy in primary melanoma. Nat
Clin Pract Oncol. 2008;5:510–1.
47. Garreau JR, Faries MB, Ye X, Morton DL. Mood state
and melanoma outcome in the Multicenter Selective
Lymphadenectomy Trial. J Clin Oncol. 2009;27:15S,
abstract 9603.
48. Faries MB, Thompson JF, Cochran A, Elashoff R,
Glass EC, Mozzillo N, et al. The impact on morbidity
and length of stay of early versus delayed complete
lymphadenectomy in melanoma: results of the
Multicenter Selective Lymphadenectomy Trial (I).
Ann Surg Oncol. 2010;17:3324–9.
49. Gershenwald JE, Berman RS, Porter G, Mansfi eld PF,
Lee JE, Ross MI. Regional nodal basin control is not
compromised by previous sentinel lymph node biopsy
in patients with melanoma. Ann Surg Oncol.
2000;7:226–31.
50. Chao C, Wong SL, Ross MI, Reintgen DS, Noyes RD,
Cerrito PB, et al. Patterns of early recurrence after
sentinel lymph node biopsy for melanoma. Am
J Surg. 2002;184:520–4.
51. Lee RJ, Gibbs JF, Proulx GM, Kollmorgen DR, Jia C,
Kraybill WG. Nodal basin recurrence following
lymph node dissection for melanoma: implications
for adjuvant radiotherapy. Int J Radiat Oncol Biol
Phys. 2000;46:467–74.
52. Gershenwald JE, Ross MI. Sentinel-lymph-node
biopsy for cutaneous melanoma. N Engl J Med.
2011;364:1738–45.
53. Morton DL, Cochran AJ, Thompson JF. Authors’
response to a letter to the editor re: sentinel node biopsy
for early-stage melanoma. Ann Surg. 2007;245:828–9.
54. Morton DL, Elashoff R. Sentinel node biopsy: facts to
clear the alleged clouds. Arch Dermatol. 2008;
144:685–6.
55. Sanki A, Uren RF, Moncrieff M, Tran KL, Scolyer
RA, Lin HY, et al. Targeted high-resolution ultrasound is not an effective substitute for sentinel lymph
node biopsy in patients with primary cutaneous melanoma. J Clin Oncol. 2009;27:5614–9.
56. Thompson JF, Cochran AJ, Faries MB. Sentinel-node
biopsy in melanoma. N Engl J Med. 2014;370:2149–50.
57. Estourgie SH, Nieweg OE, Valdés Olmos RA,
Hoefnagel CA, Kroon BBR. Review and evaluation of
sentinel node procedures in 250 melanoma patients
with a median follow-up of 6 years. Ann Surg Oncol.
2003;10:681–8.
58. Wong SL, Morton DL, Thompson JF, Gershenwald
JE, Leong SP, Reintgen DS, et al. Melanoma patients
with positive sentinel nodes who did not undergo
completion lymphadenectomy: a multi-institutional
study. Ann Surg Oncol. 2006;13:809–16.
59. Scheri RP, Essner R, Turner RR, Ye X, Wanek L,
Morton DL. Do isolated tumor cells in the sentinel
node in melanoma affect long-term prognosis? Ann
Surg Oncol. 2007;14 Suppl:11.
60. Veenstra HJ, Brouwer OR, van der Ploeg IM, Kroon
BBR, Nieweg OE. Five-year follow-up of 16 melanoma patients with a Starz I-involved sentinel node in
whom completion lymph node dissection was omitted. Melanoma Res. 2012;22:436–9.
61. Vera DR, Wallace AM, Hoh CK. [(99m)Tc]MAG(3)mannosyl-dextran: a receptor-binding radiopharmaceutical for sentinel node detection. Nucl Med Biol.
2001;28:493–8.
62. Buckle T, van Leeuwen AC, Chin PT, Janssen H,
Muller SH, Jonkers J, et al. A self-assembled multimodal complex for combined pre- and intraoperative
imaging of the sentinel lymph node. Nanotechnology.
2010;21:355101.
63. Brouwer OR, Buckle T, Vermeeren L, Klop WM,
Balm AJ, van der Poel HG, et al. Comparing the
hybrid fl uorescent-radioactive tracer indocyanine
green-99mTc-nanocolloid with 99mTc-nanocolloid
for sentinel node identifi cation: a validation study
using lymphoscintigraphy and SPECT/CT. J Nucl
Med. 2012;53:1034–40.
64. Van den Berg NS, Brouwer OR, Schaafsma BE,
Matheron HM, Klop WM, Balm AJ, et al. Multimodal
surgical guidance during sentinel node biopsy for melanoma: combined gamma tracing and fl uorescence
imaging of the sentinel node through use of the
hybrid tracer indocyanine green-(99m)Tc-Nanocolloid.
Radiology. 2015;275:521–9.
65. Brouwer OR, Klop WM, Buckle T, Vermeeren L, van
den Brekel MW, Balm AJ, et al. Feasibility of sentinel
node biopsy in head and neck melanoma using a
hybrid radioactive and fl uorescent tracer. Ann Surg
Oncol. 2012;19:1988–94.
66. Vermeeren L, Valdés Olmos RA, Klop WM, van der
Ploeg IM, Nieweg OE, Balm AJ, et al. SPECT/CT for
sentinel lymph node mapping in head and neck melanoma. Head Neck. 2011;33:1–6.
67. Wendler T, Herrmann K, Schnelzer A, Lasser T, Traub
J, Kutter O, et al. First demonstration of 3-D lymphatic mapping in breast cancer using freehand
SPECT. Eur J Nucl Med Mol Imaging. 2010;
37:1452–61.
68. Mihaljevic AL, Rieger A, Belloni B, Hein R, Okur A,
Scheidhauer K, et al. Transferring innovative freehand SPECT to the operating room: fi rst experiences
10 Radioguided Sentinel Lymph Node Mapping and Biopsy in Cutaneous Melanoma
https://t.me/med1917
163
with sentinel lymph node biopsy in malignant melanoma. Eur J Surg Oncol. 2014;40:42–8.
69. Nieweg OE. Current status of sentinel lymph node
biopsy in patients with melanoma. Rozhl Chir
Mesicnik Cesk Chir Spol. 2014;93:485–90.
70. Eggermont AMM, Chiarion-Sileni V, Grob JJ,
Dummer R, Wolchok JD, Schmidt H. Ipilimumab ver-
sus placebo after complete resection of stage III melanoma: initial effi cacy and safety results from the
EORTC 18071 phase III trial. J Clin Oncol.
2014;32:LBA9008.
71. Scolyer RA, Murali R, Satzger I, Thompson JF. The
detection and signifi cance of melanoma micrometastases in sentinel nodes. Surg Oncol. 2008;17:165–74.
Part V
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Clinical Application: Head and Neck
Radioguided Sentinel Lymph
https://t.me/med1917
Node Mapping and Biopsy
in Oral Cancer
Remco de Bree and Christina Bluemel
1 1
Contents
11.1 Introduction 167
11.2 Sentinel Lymph Node Procedure 168
11.3 Diagnostic Value of Sentinel Lymph
Node Procedure 171
11.4 Advantages of Sentinel Lymph
Node Biopsy 172
11.5 Limitations of Current Sentinel
Lymph Node Procedure 173
11.6 Improvements in Sentinel Lymph
Node Procedure 174
11.7 Conclusion and Outlook 176
References 177
Abstract
Oral cancer is one of the most common head
and neck malignancies. As lymph node metastases are one of the most important prognostic
factors, an elective neck dissection (END) has
been widely performed for accurate staging of
the cervical lymph nodes. However, up to
75 % of patients are overtreated and may suffer from side effects of END. In 2001, the fi rst
results and advantages of sentinel lymph node
biopsy (SLNB) as an alternative for neck staging in clinically node negative patients with
oral cancer were fi rstly discussed in an international conference. The high detection rate,
sensitivity, and low false-negative rate of
SLNB was demonstrated in multicenter studies. However, due to the complex lymphatic
drainage and close vicinity of the injection
site, SLNB in head and neck is challenging.
The development of new tracers and technologies might facilitate the intraoperative detection of SLNs and improve results of SLNB.
R. de Bree , MD, PhD ()
Department of Head and Neck Surgical Oncology ,
UMC Utrecht Cancer Center, UMCU Utrecht ,
Heidelberglaan 1000 , Utrecht 3584 CX,
The Netherlands
r.debree@umcutrecht.nl
e-mail:
C. Bluemel , MD
Department of Nuclear Medicine , University Hospital
of Würzburg , Würzburg , Germany
© Springer International Publishing Switzerland 2016
K. Herrmann et al. (eds.), Radioguided Surgery: Current Applications and Innovative
Directions in Clinical Practice, DOI 10.1007/978-3-319-26051-8_11
11.1 Introduction
Oral cancer is one of the most common head and
neck cancers. A total of 30,260 new cases of oral
cancer are estimated in the United States in 2015,
and the incidence is rising [ 1 , 2 ]. Squamous cell
carcinoma is the most frequent tumor type in the
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R. de Bree and C. Bluemel
oral cavity and has a high propensity to metastasize through lymphatics to regional lymph nodes
rather than to spread hematogenously. Moreover,
regional metastasis at time of diagnosis is one of
the most important prognostic factors. The presence of cervical lymph node metastasis roughly
reduces survival by half [ 3 ]. Patients with multi-
ple contralateral or bilateral metastases in the
neck have even a more markedly reduced survival. It is generally accepted that the neck has to
be treated by surgery (i.e., neck dissection) and/
or radiotherapy with or without chemotherapy
when lymph node metastases are present.
Unfortunately, there is no single noninvasive
imaging technique, which could detect occult
(clinically undetectable) lymph node metastasis
reliably enough [
4 , 5 ]. Recently a meta-analysis
comparing computed tomography (CT), magnetic
resonance imaging (MRI), positron emission
tomography (PET), and ultrasound (US) for the
detection of cervical lymph node metastasis in
head and neck cancer patients with a clinically
negative (cN0) neck was performed by Liao et al.
[ 6 ]. The pooled estimates for sensitivity on a per-
neck basis were 52 % (95 % confi dence interval
(CI): 39–65), 65 % (CI: 34–87), 66 % (CI: 47–80),
and 66 % (CI: 45–77) for CT, MRI, PET, and US,
respectively. The pooled estimates for specifi city
were 93 % (CI: 87–97), 81 % (CI: 64–91), 87 %
(CI: 77–93), and 78 % (CI: 71–83) for CT, MRI,
PET, and US, respectively. In this study, US-guided
fi ne-needle aspiration cytology (USgFNAC) was
not included, because of several methodological
reasons [
6 ]. The reported sensitivity of USgFNAC
in cN0 neck was between 42 and 73 % [ 5 , 7 ].
Consequently, the management of the cN0 neck is
still a controversial issue. There is general agreement
that elective treatment of the neck is indicated when
there is a high likelihood of occult, i.e., clinically and
radiologically undetectable, lymph node metastases.
A neck dissection is generally performed when the
neck needs to be entered to resect the primary tumor
or to reconstruct the surgical defect. When the feasibility of regular follow-up is questionable, the neck
will be generally treated [ 4 , 5 ]. The dilemma to treat
the cN0 neck applies to most early-stage (T1-T2cN0)
oral squamous cell carcinomas (OSCC).
The rationale for elective (prophylactic) treatment is based on the following assumptions. First,
occult metastases will inevitably develop into clinically manifest disease. Second, even with watchful waiting, some patients will develop extensive
or even inoperable disease in the neck with a waitand-see policy. Third, if left untreated, disease in
the neck may be associated with a higher incidence
of distant metastases developing while the undetected lymph node metastasis is growing to a clinically detectable size. The arguments against
elective treatment of the neck are as follows. First
a large proportion of patients are subjected to the
morbidity (e.g., shoulder dysfunction [ 8 ]) and
costs of unnecessary treatment. Second, such
treatment may remove or destroy a barrier to cancer spread and a route of cancer spread in case of
local recurrence or second primary tumor.
11.2 Sentinel Lymph Node
Procedure
The standard sentinel lymph node (SLN) procedure in OSCC consists of lymphoscintigraphy,
biopsy, and histopathological examination of the
SLN. In a 2-day protocol 40–100 MBq and in a
same-day protocol 25–40 MBq of technetium- 99m
99m
(
Tc)-labelled colloidal albumin divided over 4
aliquots of 0.1–0.2 mL each is generally peritumorally submucosally injected (Fig. 11.1 ). In gen-
eral, directly after injections, dynamic and static
a
Fig. 11.1 Case of a patient with a paramedian cT1N0 fl oor
of mouth carcinoma on the left side. ( a ) Peritumoral injection
99m
Tc-labelled nanocolloid. ( b ) Dynamic scintigrams. ( c )
of
Planar late scintigrams. ( d ) Peritumoral injection of patent
blue . ( e ) Gamma-probe-guided sentinel lymph node biopsy.
( f ) Blue coloration of sentinel lymph node. ( g ) Confi rmation
of hot sentinel lymph node by activity counting
11 Radioguided Sentinel Lymph Node Mapping and Biopsy in Oral Cancer
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b
c
169
Fig. 11.1 (continued)
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R. de Bree and C. Bluemel
d
f
e
g
Fig. 11.1 (continued)
planar lymphoscintigraphy followed by singlephoton emission tomography/computed tomography (SPECT-CT) imaging is performed [
imaging (2–4 h after injections) is generally only
needed in patients with midline tumors and tumors
in the oral cavity other than mobile tongue or lateral fl our of mouth [ 10 ], or if no clear, SLN could
be visualized in early imaging [
preoperative lymphoscintigraphy results, the position of the SLN is marked on the skin [
The main radiopharmaceutical used in Europe
99m
is
Tc-labelled nanocolloidal albumin with a
mean particle size of 8–30 nm, whereas in the
United States, this tracer is not approved, and
9 ]. Late
9 ]. Based on the
9 ].
99m
Tc-rhenium sulfi de colloid (mean particle size
23–25 nm) and
99m
Tc-sulfi de colloid (particle size
<100–200 nm) are used. Since these radiopharmaceuticals are registered for breast cancer and melanoma, all these tracers have to be used off-label.
99m
Tc-labelled- tilmanocept (
99m
Tc-diethylenetriamine pentaacetic acid- mannosyl-dextran) [ 11 –
13 ], a novel receptor-targeted radiopharmaceutical,
recently received approval from the Food and Drug
Administration (FDA) and positive statement of
the European Medicines Agency (EMA) for use in
SLNB for melanoma, breast cancer, and head and
neck cancer. It is nonparticulate radiotracer that
contains multiple mannose moieties with high
11 Radioguided Sentinel Lymph Node Mapping and Biopsy in Oral Cancer
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171
affi nity for the CD206 receptor found on macrophages and dendritic cells, enhancing targeting to
these cells within the sentinel lymph node. In breast
cancer and melanoma, it may have improved clearance from the injection site and enhanced retention
within the SLN [ 11 , 12 , 14 ]. This tracer has only
recently been tested in early oral squamous cell
cancer (OSCC) [ 15 ] and head and neck cancers
[ 13 ]. There have yet to be any head-to-head studies
comparing
99m
Tc- labelled- tilmanocept to
99m
Tc-
labelled colloids [ 9 ].
Sentinel lymph node biopsy (SLNB) is performed under general anesthesia, and intraoperative detection of the SLN is possible by a
combination of peritumorally injected blue dye
(coloration) and a portable, handheld gamma
probe (radionuclide detection). One or more blue
and/or radioactive (‘hot’) SLNs are identifi ed and
excised. Since the use of blue dye appeared to be
of limited additional values, some surgeons do
not use this dye anymore in head and neck cancers [
16 ]. This was recently confi rmed by a sen-
sitivity of only 40 % found in 15 patients who
received only intraoperative peritumorally injections of 1 % isosulfan dye [ 17 ].
After surgical removal, the SLN is investigated by meticulous histopathological examination using stepped serial sectioning and
immunohistochemistry. Current best practice
guidelines for the provision of SNB in early
OSCC patients have been outlined, which provide a framework for the currently evolving recommendations for its use [
9 ].
11.3 Diagnostic Value of Sentinel
Lymph Node Procedure
The feasibility of the SLN concept in OSCC was
fi rst reported by Alex and Krag in 1996 [ 18 ] and
has been validated in several studies in which all
patients underwent an elective neck dissection
(END) after SLNB [ 19 ]. The histopathological
examination of the neck dissection specimen was
used as reference (gold) standard. Although several studies have validated the SLNB concept in
OSCC, the American College of Surgeons
Oncology Group (ACOSOG) performed a vali-
dation study (Z0360) with 140 patients in 25
institutions and found a sensitivity of 90 % and a
negative predictive value of 96 %, and these fi gures were even better for experienced surgeons
20 ]. A recent meta-analysis of these validation
[
studies with 631 OSCC patients showed a pooled
sensitivity and negative predictive value of 94 %
and 96 %, respectively [ 21 ]. A more recent meta-
analysis of 35 studies in which all 1211 patients
underwent a neck dissection revealed pooled sensitivity and negative predictive value of 93 % and
97 %, respectively [ 22 ]. Because routine histo-
pathological examination (and not step-serial
sectioning and immunohistochemistry) of the
neck dissection specimen was used as the reference standard, occult micrometastases might
have been missed [
23 ], potentially contributing
to higher fi gures for sensitivity and negative
predicting value. Therefore, to investigate the
accuracy and utility of SLNB only (without subsequent neck dissection in all patients), follow-up
should be used as reference standard [ 24 ].
However, when new tracers or instruments are
tested, the validation concept using END as reference standard should be considered.
After initial studies to validate the SLN concept in early OSCC patients, several prospective
observational studies have been reported. In these
studies, a neck dissection was performed only
when the SLN contained a metastasis, while a
watchful waiting strategy was followed when the
SLN did not contain metastasis. In a European
multicenter study of 134 cT1/2N0 OSCC patients,
55 patients underwent SLNB followed by END,
while 79 patients underwent SLNB as the sole
staging tool [
25 ]. In 125 (93 %) patients, the SLN
was successfully harvested. For the two groups
together, using a reference standard of 5 years
follow-up after SLNB staging, a sensitivity of
91 % and a negative predictive value of 95 % were
found. In a large single center study ( n = 103
patients), no false-negative ipsilateral fi ndings
were found. Lymphoscintigraphy revealed a hot
spot in 98 %, the detection rate was 96 %, and a
mean of 2.65 SLNs were harvested per patient
[ 26 ]. In another single center study of 79 cT1/2N0
patients with oral and oropharyngeal SCC, lymphoscintigraphy showed a hot spot in 95 %, the
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R. de Bree and C. Bluemel
perioperative detection rate was 99 %, and a mean
of 2.7 SLNs were harvested for a sensitivity of
91 % and a negative predictive value of 90 % [ 27 ].
A recent meta-analysis including 847 patients
from 21 studies showed a pooled sensitivity of
93 % (CI: 90–95 %) in oral cancer patients [ 28 ].
With neck dissection as reference standard, the
sensitivity was 94 % (CI: 90–97 %), while when
follow-up was the reference standard, a sensitivity
of 91 % (CI: 84–95 %) was found. The vast majority of the studies included were performed in
patients with early OSCC. The negative predictive
values ranged from 88 to 100 % [ 28 ]. More
recently, a retrospective study of 90 previously
untreated early OSCC patients with a clinically
N0 neck who underwent SLNB (only neck dissection after positive SLNB) was reported: a lymphoscintigraphic identifi cation rate of 98 %,
surgical detection rate of 99 %, and upstaging rate
of 30 % were found. Using a median follow-up of
10 months, the sensitivity was 93 % and the negative predictive value was 97 % [ 29 ].
In a meta-analysis, Liao et al. [ 30 ] reported that
the best negative predictive rate was the combination of CT or MRI followed by SLNB, when compared to CT or MRI in combination with US,
USgFNAC, or PET. Unfortunately, the combination of USgFNAC and SLNB (only when
USgFNAC is negative) was not investigated,
although USgFNAC was the second best diagnostic technique after SLNB in this meta- analysis.
Since SLNB is a more complex and invasive procedure, it can be anticipated that the combination of
USgFNAC and SLNB is the most sensitive combination for the detection of occult lymph node
metastases with less burden to the patients compared to SLNB only. This combination may be
valuable also because gross lymphatic involvement
potentially blocks and may alter the lymphatic
drainage and reduce the accuracy of SLNB [
31 ].
11.4 Advantages of Sentinel
Lymph Node Biopsy
Occult metastases can be missed by routine histopathological techniques in up to 15.2 % [ 21 ]. In
SLNB, the lymph node with the highest risk is
examined by step-serial sectioning and immunohistochemistry. Since the neck contains up to
about 100–150 lymph nodes per side, it is practically impossible in daily clinical practice to
examine all lymph nodes from a neck dissection
specimen so rigorously. Therefore, it can be
expected that SLNB or SLNB assisted neck dissection stage the neck more reliable than neck
dissection without SLNB [
The levels dissected during END depend on
the expected drainage pattern of the primary
tumor site. However, Civantos et al. [ 20 ] found in
14 of the 103 (13.6 %) oral cavity carcinomas
and head and neck cutaneous malignancies
lymph node drainage patterns outside the
expected lymph node basins. These unexpected
SLN localizations include not only level IV and
V and the contralateral neck but also in 4 of the
43 oral cancer patients facial SLNs. Kovacs et al.
[ 26 ] reported on the SLN distribution pattern in
103 patients with T1/2N0 oral and oropharyngeal
cancer. Besides SLNs in level IV (18/273) and
level V (5/273), also SLNs in level VI (5/273)
were found. In the ACOSOG Z0360 study, 40 of
the 136 patients had drainage to lymph nodes in
level IV and V, of whom 5 had drainage to level
IV without level I–III. Twenty-seven patients had
bilateral drainage on lymphoscintigraphy [ 33 ].
Flach et al. [ 34 ] found in pretreated necks unex-
pected lymphatic drainage in 67 %. These fi ndings underline the strength of SLNB in assessing
individual drainage patterns.
Recently, a report of a European multicenter
study on 109 oral squamous cell carcinoma
patients with positive SLNB showed additional
(non-SLN) metastases in 34.4 % of the neck dissection specimens. The risk of non-SLN metastases outside the adjacent basins of the positive
SLN was low (7.1 %), suggesting that in the vast
majority of the patients with a positive SNB, a
(super)selective neck dissection may be suffi cient [
35 ]. It can be anticipated that using infor-
mation obtained from the SLNB procedure, neck
dissections can be tailored to the individual
patient.
SLNB is less invasive than an END. Murer
et al. [ 36 ] compared shoulder morbidity and post-
operative complications between 33 SLNB only
32 ].
11 Radioguided Sentinel Lymph Node Mapping and Biopsy in Oral Cancer
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173
and 29 END OSCC patients using questionnaires
and objective measures of active shoulder function. SLNB was associated with a shorter incision, signifi cant less (no) complications, and
signifi cant better (almost normal) shoulder
function. Although all the complications were
minor, they all occurred in patients after END
[ 36 ]. Schiefke et al. [ 37 ] also found a signifi cant
minor disturbance of shoulder function in 24
HNSCC patients receiving SNB only compared
to 25 head and neck SCC (HNSCC) patients who
underwent elective neck dissection assessed by
patient symptom scores and objective measurements. SNB was also associated with signifi cant
less cervical skin numbness and less disturbance
of protopathic (pain) sensitivity compared to
END [ 37 ]. Hernando et al. [ 38 ] compared shoul-
der function, length of the surgical scar, degree of
cervical lymphedema, neck hematoma and the
presence of orocutaneous fi stula in 32 SLNB
patients and 41 elective selective (levels I-III)
patients with early oral cancer and found statistically signifi cant differences in shoulder function
and average scar length. Neck hematomas and
oro- cervical communications occurred only in
the END group [ 38 ]. From these studies, it can be
concluded that SNB presents less postoperative
morbidity than END.
Apart from reducing neck dissection numbers, SLNB may reduce treatment costs. Using a
treatment model derived from the European
Sentinel Node Trial (SENT) information,
O’Conner et al. [
tive treatment costs between patients managed
through a traditional END or SLNB pathway and
found that the SLNB approach is cheaper relative to the traditional surgical approach in the
centers from Spain, the United Kingdom, and
the Netherlands. Kosuda et al. [ 40 ] showed that
SLNB was also cost-effective (compared to
END) using costs referred to billed costs based
on the Japanese national insurance reimbursement system. A recent cost-effectiveness study
in which fi ve different strategies for management of the clinically N0 neck (defi ned as N0
after imaging and ultrasound- guided fi ne-needle
aspiration cytology) in OSCC patients were
compared predicted that the SLNB followed by
39 ] produced estimates for rela-
neck dissection (if positive) or watchful waiting
(if negative) is more cost-effective than END,
watchful waiting, and gene expression proofi ng
(GEP) followed by neck dissection (if high risk)
and GEP and SN (in case of high risk GEP)
followed by neck dissection (if SNB positive) or
watchful waiting [ 41 ].
11.5 Limitations of Current
Sentinel Lymph Node
Procedure
From these data, it can be concluded that the introduction of SLNB in early oral cancer has been successful. This was recognized by the National
Comprehensive Cancer Network (NCCN) and
resulted in incorporation in the NCCN Clinical
Practice Guidelines in Oncology of Head and
Neck Cancers (version 2.2014): “Sentinel lymph
node biopsy is an alternative to elective neck dissection for the identifi cation of occult cervical
metastasis in patients with early (T1 or T2) oral
cavity carcinoma in centers where experience for
this procedure is available. Its advantages include
decreased morbidity and improved cosmetic outcome.” [ 42 ] However, in some subsites of the oral
cavity, e.g., fl oor of mouth (FOM), these results
are signifi cantly worse. With respect to FOM
tumors, detection of the SLN appeared to be more
diffi cult: SLN successfully harvested in 88 % vs.
96 % and a signifi cantly lower sensitivity for FOM
tumors compared to other sites (80 % vs. 97 %)
[
25 ]. This is probably due to the close spatial rela-
tion between the primary tumor and the fi rst draining lymph nodes (SLNs). The injection site
(around the primary tumor) produces a large
hotspot on lymphoscintigraphy possibly hiding
SLN(s) in the close proximity of the primary
tumor (“shine through”). It is therefore of utmost
importance and challenging to improve SLNB in
patients with early OSCC at these subsites.
Technical improvements are needed to bring SNB
for carcinoma of all subsites in the oral cavity to
the same high level. More precise information on
the localization of the SLN may reduce operating
time and the risk of damaging vulnerable structures such as nerves and vessels in the neck
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