Outcome of patients with early stage oral cancer managed by an observation strategy towards the N0 neck using ultrasound guided fine needle aspiration cytology: No survival difference as compared to elective neck dissection
Introduction
The single most important tumor-related prognostic factor in patients with head and neck squamous cell cancer is the status of the cervical lymph nodes.1 Patients with lymph node metastases require treatment of the neck. When the neck needs to be entered for excision of the primary tumor or reconstruction of the surgical defect, a neck dissection needs to be performed. Currently, management of the clinically negative (cN0) neck in patients whose tumor can be resected transorally remains controversial. In general an elective neck dissection (END) is justified if the estimated risk of occult lymph node metastases exceeds 15–20%.2 However, this policy inevitably results in overtreatment in some patients, since the incidence of occult lymph node metastases in patients treated with elective neck dissections is only 10–36%.[3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]
Observation of the neck may be considered when a reliable diagnostic technique is available to reduce the risk of undetected lymph node metastases. Previous studies in patients with a cN0 neck have shown that ultrasound guided fine needle aspiration cytology (USgFNAC) is the most reliable diagnostic technique with a sensitivity of 48–73% and a specificity approaching 100%.[15], [16], [17], [18] In 1992, we adapted our management of the cN0 neck in patients with T1–T2 oral carcinomas that can be excised transorally. USgFNAC is from then on routinely used as initial staging of the neck. In case of negative USgFNAC findings, these patients are treated by transoral excision with careful observation of the neck as an alternative to END if strict adherence to a surveillance protocol can be followed. After primary treatment the patients are subsequently regularly followed by clinical examination and USgFNAC of the neck, a so called ‘wait and scan’ policy.19 While diminishing morbidity in the majority of patients, as a prerequisite this strategy should not negatively influence the patient in terms of disease control. This wait and scan policy has been evaluated in 2002 by Nieuwenhuis et al.20 who analyzed 161 patients with T1–T2 oral and oropharyngeal cancer and cN0 neck by pre-treatment USgFNAC (1993–2000) focusing on regional control. These patients were treated by transoral excision and followed by USgFNAC of the neck at regular intervals during the first 2 years. This policy included strict follow-up of the neck with physical examination every 6 weeks and USgFNAC examinations every 3–4 months. During follow-up 21% of the patients developed lymph node metastases and 79% could be salvaged (88% regional control).20
As a follow-up on this study, we report on the outcome of the wait and scan policy in patients with T1–T2 oral cancer in terms of survival. Survival is an outcome parameter for treatment, and is a method to measure successful treatment. If the wait and scan policy is considered as an alternative for elective neck dissection, this policy should not harm the patient and survival should not be worse than elective neck management.
Section snippets
Patients and methods
We studied a consecutive series of previously untreated patients who were treated by transoral excision for a T1–T2 carcinoma of the mobile tongue or floor of mouth during a 15 year period (1990–2004). All patients were classified clinically N0 by USgFNAC. Exclusion criteria were prior or simultaneous second primary tumor and adjuvant radiotherapy. A total of 285 patients were included. The patients were divided into two groups based on type of treatment of the neck: 234 patients were followed
Patient and tumor characteristics of W&S and END patients
Patient and tumor characteristics are shown in Table 1. Patients in the W&S group were significantly older and had significantly more pT1 tumors as compared to patients treated by END. Tumor site and tumor differentiation were also statistically significantly different. Other variables did not show a significant difference between the groups (Table 1).
Of the 234 W&S patients, 169 (72.2%) remained free of lymph node metastases (N0) and 65 patients (27.8%) developed delayed lymph node metastases.
Discussion
This study presents a survival analysis of a large series of patients with T1–T2 cancer of the mobile tongue or floor of mouth with a wait and scan follow-up policy of the neck with regular USgFNAC. The 5-year DSS and OS of W&S patients were 94.2% and 81.6%, respectively, and these rates were comparable to those of END patients. The most important finding is that in W&S patients with delayed metastases the 5-year DSS and OS were similar to END patients with proven metastases in the neck
Conclusion
Survival rates of patients with T1–T2 oral cancer who were classified cN0 by USgFNAC followed by a wait and scan policy are comparable to patients with elective neck dissection. In W&S patients with delayed lymph node metastases survival rates remained similar to patients with positive elective neck dissection. Patients with delayed metastases had more often extracapsular spread but the number of metastases in the neck dissection specimen did not significantly differ from positive elective neck
Conflict of interest statement
None declared.
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2020, Journal of Dental SciencesCitation Excerpt :Importantly, wide excision with elective neck dissection provides good tumor control and survival benefits.9,10 However, it is still controversial whether elective neck dissection in early stage oral cancer should be performed to improve survival.3,11 Multiple surgical morbidities are also taken into account for neck dissection, including wound, nerve, and vascular complications.