Clare Schilling

Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer

PURPOSE Optimum management of the N0 neck is unresolved in oral cancer. Sentinel node biopsy (SNB) can reliably detect microscopic lymph node metastasis. The object of this study was to establish whether the technique was both reliable in staging the N0 neck and a safe oncological procedure in patients with early-stage oral squamous cell carcinoma. METHODS An European Organisation for Research and Treatment of Cancer-approved prospective, observational study commenced in 2005. Fourteen European centres recruited 415 patients with radiologically staged T1-T2N0 squamous cell carcinoma. SNB was undertaken with an average of 3.2 nodes removed per patient. Patients were excluded if the sentinel node (SN) could not be identified. A positive SN led to a neck dissection within 3 weeks. Analysis was performed at 3-year follow-up. RESULTS An SN was found in 99.5% of cases. Positive SNs were found in 23% (94 in 415). A false-negative result occurred in 14% (15 in 109) of patients, of whom eight were subsequently rescued by salvage therapy. Recurrence after a positive SNB and subsequent neck dissection occurred in 22 patients, of which 16 (73%) were in the neck and just six patients were rescued. Only minor complications (3%) were reported following SNB. Disease-specific survival was 94%. The sensitivity of SNB was 86% and the negative predictive value 95%. CONCLUSION These data show that SNB is a reliable and safe oncological technique for staging the clinically N0 neck in patients with T1 and T2 oral cancer. EORTC Protocol 24021: Sentinel Node Biopsy in the Management of Oral and Oropharyngeal Squamous Cell Carcinoma.

Sentinel Lymph Node Biopsy for T1/T2 Oral Cavity Squamous Cell Carcinoma—A Prospective Case Series

BackgroundSentinel lymph node biopsy (SLNB) is an established technique in breast and melanoma surgery and is gaining acceptance in the management of oral cavity squamous cell carcinoma. We report a single institution’s experience of SLNB between 2006 and 2010.MethodsProspective consecutive cohort study of 59 patients recruited between 2006 and 2010. All patients underwent SLNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with step-serial sectioning and immunohistochemistry. Endpoints included: overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS).ResultsA total of 59 patients (36 male and 23 female) were operated on. Of these, 42 patients (71%) were pT1 and 17 patients (29%) were pT2. In two patients the sentinel node was not identified and proceeded to elective neck dissection. A total of 150 nodes were harvested from the remaining 57 patients of which 21 nodes were positive in 17 patients; three patients had positive contralateral nodes. The 2-year OS, DSS, LRFS, and RRFS for the SLNB negative patients were 97.5, 100, 95.8, and 95.8% and for the SLNB positive patients 68.2, 81.8, 83.9, and 100% respectively. Only OS and DSS approached statistical significance with P values of 0.07 and 0.06.ConclusionsSLNB is a safe and accurate diagnostic technique for staging the neck with a negative predictive value in our series of 97.5%. Furthermore, in our series three patients (5%) had positive contralateral neck drainage that would have been missed by conventional ipsilateral neck dissection.Sentinel lymph node biopsy (SLNB) is an established technique in breast and melanoma surgery and is gaining acceptance in the management of oral cavity squamous cell carcinoma. We report a single institution’s experience of SLNB between 2006 and 2010. Prospective consecutive cohort study of 59 patients recruited between 2006 and 2010. All patients underwent SLNB with preoperative lymphoscintigraphy, intraoperative blue dye, and handheld gamma probe. Sentinel nodes were evaluated with step-serial sectioning and immunohistochemistry. Endpoints included: overall survival (OS), disease-specific survival (DSS), local recurrence-free survival (LRFS), and regional recurrence-free survival (RRFS). A total of 59 patients (36 male and 23 female) were operated on. Of these, 42 patients (71%) were pT1 and 17 patients (29%) were pT2. In two patients the sentinel node was not identified and proceeded to elective neck dissection. A total of 150 nodes were harvested from the remaining 57 patients of which 21 nodes were positive in 17 patients; three patients had positive contralateral nodes. The 2-year OS, DSS, LRFS, and RRFS for the SLNB negative patients were 97.5, 100, 95.8, and 95.8% and for the SLNB positive patients 68.2, 81.8, 83.9, and 100% respectively. Only OS and DSS approached statistical significance with P values of 0.07 and 0.06. SLNB is a safe and accurate diagnostic technique for staging the neck with a negative predictive value in our series of 97.5%. Furthermore, in our series three patients (5%) had positive contralateral neck drainage that would have been missed by conventional ipsilateral neck dissection.

The relative cost of sentinel lymph node biopsy in early oral cancer.

INTRODUCTION The European Sentinel Node (SENT) trial addressed the question of the clinically lymph node negative (cN0) neck in early oral squamous cell carcinoma (OSCC). Apart from reducing neck dissection numbers, sentinel lymph node biopsy (SLNB) may reduce treatment cost. Using a treatment model derived from SENT trial information, estimates were produced of relative treatment costs between patients managed through a traditional surgical or SLNB pathway. METHODS The model created two management approaches, the traditional surgical pathway and SLNB pathway. Using SENT trial data regarding the proportion of patients with positive, negative and false negative SLNBs a relative cost ratio (RCR) for 100 hypothetical patients passing down each pathway was generated. RESULTS From a cohort of 481 patients, 25% had a positive SLNB, 75% a negative result and 2.5% a false negative result. Treatment of 100 hypothetical patients using the SLNB pathway is 0.35-0.60 the cost of treating the same cohort using traditional surgery techniques. Even if 100% of SLNBs are positive the SLNB approach is 0.91 of the cost of the traditional surgical approach. CONCLUSION The SLNB approach appears to be cheaper relative to the traditional surgical approach, especially when extrapolated to 100 hypothetical patients.

Implications of a positive sentinel node in oral squamous cell carcinoma.

The role of sentinel node biopsy in head and neck cancer is currently being explored. Patients with positive sentinel nodes were investigated to establish if additional metastases were present in the neck, their distribution, and their impact on outcome.

Sentinel node in oral cancer: the nuclear medicine aspects. A survey from the sentinel european node trial

Purpose Nuclear imaging plays a crucial role in lymphatic mapping of oral cancer. This evaluation represents a subanalysis of the original multicenter SENT trial data set, involving 434 patients with T1-T2, N0, and M0 oral squamous cell carcinoma. The impact of acquisition techniques, tracer injection timing relative to surgery, and causes of false-negative rate were assessed. Methods Three to 24 hours before surgery, all patients received a dose of 99mTc-nanocolloid (10–175 MBq), followed by lymphoscintigraphy. According to institutional protocols, all patients underwent preoperative dynamic/static scan and/or SPECT/CT. Results Lymphoscintigraphy identified 723 lymphatic basins. 1398 sentinel lymph nodes (SNs) were biopsied (3.2 SN per patient; range, 1–10). Dynamic scan allowed the differentiation of sentinel nodes from second tier lymph nodes. SPECT/CT allowed more accurate anatomical localization and estimated SN depth more efficiently. After pathological examination, 9.9% of the SN excised (138 of 1398 SNs) showed metastases. The first neck level (NL) containing SN+ was NL I in 28.6%, NL IIa in 44.8%, NL IIb in 2.8%, NL III in 17.1%, and NL IV in 6.7% of positive patients. Approximately 96% of positive SNs were localized in the first and second lymphatic basin visualized using lymphoscintigraphy. After neck dissection, the SN+ was the only lymph node containing metastasis in approximately 80% of patients. Conclusions Best results were observed using a dynamic scan in combination with SPECT/CT. A shorter interval between tracer injection, imaging, and surgery resulted in a lower false-negative rate. At least 2 NLs have to be harvested, as this may increase the detection of lymphatic metastases.

Role of intraoperative sentinel node imaging in head and neck cancer

At the present time, there is a dilemma concerning the best management of the neck in patients presenting with early head and neck squamous cell carcinoma (HNSCC). Occult cervical metastasis is found in up to a quarter of HNSCC patients with radiologically N0 necks, and for this reason, conventional treatment includes elective neck dissection (END) alongside tumour excision. Sentinel node biopsy (SNB) offers an alternative accurate and minimally invasive method of staging the neck, which has been safely applied to oral cancer. SNB is a patient-specific procedure which has an enhanced recovery compared to END but is currently not widely offered to patients. There are exciting developments in the technology supporting SNB, improving the accuracy and ease of the procedure and opening up the technique to new tumour types. We describe our experiences in using a novel intraoperative navigation device for sentinel node retrieval and review other advances in SNB practice which have the potential to change the standard management for patients with early HNSCC.

Oxford Handbook of Oral and Maxillofacial Surgery

Concise and bulleted, this handbook is broken down into easy-to-read chunks based on daily duties. Sections such as In Theatre and In Clinic cover all the common complaints you will see there, and give vital information for surviving any situation. The handbook also contains sections covering emergencies, presenting syndromes and commonly-used drugs and dental materials. With OMFS now part of the Core Training programme for surgical trainees, this handbook will ensure you have a solid grasp of the basics and fundamentals, and have the confidence to deal with all oral and maxillofacial presentations, practices, and procedures. All junior doctors, specialist nurses, and medical students will find this rapid-reference handbook easy to use, and a vital companion for both study and practice.

Intraoperative sentinel node imaging versus SPECT/CT in oral cancer – a blinded comparison

INTRODUCTION Sentinel node biopsy (SNB) is gaining popularity as a staging tool in oral cancer. Protocol mandates radiotracer injection and pre-operative imaging (LSG ± SPECT/CT) in the nuclear medicine department. This approach limits application to accessible tumours and to centres with nuclear medicine. New technology, freehand single photon emission computed tomography (fhSPECT), has proved a useful adjunct in intraoperative imaging and localisation of sentinel nodes. This study investigates fhSPECT as an alternative to traditional imaging, an approach that would widen the remit of SNB. METHODS Fifty consecutive cT1-T2 N0 oral cancer patients received radiotracer followed by lymphoscintigraphy and SPECT/CT. Surgery was undertaken using fhSPECT by a surgeon blinded to pre-operative imaging. Prior to biopsy completion, results of pre-operative imaging were reviewed and any additional nodes removed. The accuracy of LSG, SPECT/CT and fhSPECT were compared. RESULTS Nineteen patients had positive sentinel nodes. Disease free survival for sentinel node positive versus negative was significant (p < 0.005). All modalities missed positive nodes in at least one patient. The false negative rate for lymphoscintigraphy, SPECT/CT and fhSPECT was 26.3%, 15.8% and 5.3% respectively. DISCUSSION These data show a surgeon naïve to the results of traditional pre-operative sentinel node imaging can use fhSPECT in the operating theatre to accurately locate sentinel nodes in oral cancer. Freehand SPECT showed excellent sensitivity and a low false negative rate offering the possibility of a streamlined intraoperative sentinel node protocol.

Biopsy of the sentinel lymph node in oral squamous cell carcinoma: analysis of error in 100 consecutive cases

UK national guidelines in 2016 recommended that sentinel lymph node biopsy should be offered to patients with early oral cancer (T1-T2 N0) in which the primary site can be reconstructed directly. This study describes the pitfalls that can be avoided in the technique of biopsy to improve outcomes. We retrospectively analysed the data from 100 consecutive patients and recorded any adverse events. Lymphatic drainage of tracer failed in two patients as a result of procedural errors. Two patients with invaded nodes developed recurrence after total neck dissection, one after micrometastases had been diagnosed, and the other as a result of extranodal spread that had led to understaging and therefore undertreatment. Two results would not have been mistakenly classified as clear if all the harvested nodes had been analysed histologically according to the protocol. The disease-specific (96%) and disease-free (92%) survival were better than expected for a group of whom a third had stage 3 disease. If all harvested nodes had been analysed by the correct protocol then two of the three nodes wrongly designated clear would have been detected, two deaths potentially avoided, and the false-negative rate would have fallen from 8.3% to 2.7%. We conclude that minor deviations from protocol can result in a detrimental outcome for the patient.