Sentinel node biopsy or elective neck dissection in early oral cancer: a point of contention

Abstract

We appreciate the efforts made by de Bree et al., in going through our article on the prognostic impact of micrometastasis (MM) and isolated tumor cells (ITC) in early oral squamous cell carcinoma and raising some debatable questions [1, 2]. We read with interest the retrospective study by de Toom et al. exploring the impact of size of metastasis in the sentinel lymph node (SLN) biopsy using serial step sectioning and keratin staining. Metastasis in SLN’s were identified in 22% of the cases [3]. However, serial step sectioning and staining in a freshly extracted SLN is not a feasible option when it is subjected to frozen-section analysis. As a result, it is not uncommon to miss a MM or an ITC in an unfixed hematoxylin and eosin-stained specimen. Further, in the study by Kinjal et al., who prospectively looked at incidence of MM and ITC in clinically and radiologically node negative neck reported a true incidence of approximately 9% in early-stage oral cavity squamous cell carcinoma [4]. Recently non-inferiority randomized controlled trials by French [5] and Japanese group [6] have shown equivalent survival and long-term functional outcome in SLN biopsy and elective neck dissection (END) group. Studies have shown similar functional outcomes in SLN biopsy group and END group in the long term [5]. Though SLN biopsy assisted END seems to be a useful proposition, one must consider the current logistical and technological limitations across healthcare systems [7]. In the coming years, SLN biopsy may become the standard of care treatment for oral cancer, however, till then all procedures less than an END should be considered only in trial settings.