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Background: Treatment of clinical N0 neck tumours is controversial in early-stage oral squamous cell carcinoma (OSCC), possibly because T1N0M0 and T2N0M0 merge together at early stages. The purposes of this study were to compare survival outcomes only for T2N0M0 cases based upon treatment elective neck dissection versus neck observation., Methods: T2N0M0 OSCC cases were identified in the Surveillance, Epidemiology, and End Results database of the United States National Cancer Institute between 2004 and 2015. Survival curves for different variable values were generated using Kaplan-Meier estimates and compared using the log-rank test. Variables that achieved significance at P < 0.05 were entered into multivariable analyses via the Cox proportional hazards multivariate regression., Results: A total of 2857 patients were selected, and 2313 cases were available for disease specific survival (DSS). The 5-year and 10-year overall survival (OS) were 66.7 and 46% for patients receiving elective neck dissection (END), respectively, and 56.4 and 37.2% for patients with neck observation (P < 0.0001). The 5-year and 10-year DSS were 73.6 and 64% for the END group, respectively, versus 64.5 and 54.5% for the neck observation group (P < 0.0001). More importantly, performing END was independently associated with favourable DSS and OS for patients with T2N0M0 OSCC [hazard ratio (HR) = 0.769, P = 0.0069 for DSS; HR = 0.829, P = 0.0031 for OS, neck observation group as reference] according to multivariate survival analysis., Conclusion: END is recommended for T2N0M0 OSCC cases and it is associated with improved DSS and OS., (© 2021. The Author(s).)

Objective: The objective of this study was to evaluate the clinical outcomes in a cohort of patients with early-stage oral tongue squamous cell carcinoma (OTSCC)., Materials and Methods: We conducted a retrospective analysis of patients with pT1-T2N0 (American Joint Committee on Cancer [AJCC] seventh edition) OTSCC treated from 2000 to 2018. Two-year actuarial rates of local regional control, cancer-specific survival, and overall survival were calculated for the entire cohort and patients with/without adjuvant radiation., Results: Ninety-six patients met the criteria with a median follow-up of 4 years; 14 had adjuvant radiation, while 82 had surgery alone. Two-year local regional control was 82.7% (75.4% to 90.8%) for the entire cohort, 84.9% (77.8% to 93.2%) for surgery only, and 70.7% (50.2% to 99.6%) for patients with adjuvant radiation. Two-year progression-free survival was 82.7% (75.3% to 90.8%). Of the 20 patients with recurrence, 11 (55%) were successfully salvaged., Conclusion: Local regional recurrence remains modest in early-stage OTSCC, but salvage is possible with high survival rates., Level of Evidence: Level III-retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objective: Nodal metastasis is one of the strongest predictors of outcomes in oral cavity squamous cell carcinomas (OSCC). The aim was to analyze the interplay of nodal characteristics in OSCC prognosis., Methods: In this retrospective cohort study we included OSCC patients treated with primary surgery including neck dissection between 2005 and 2015 (n = 619). Disease-specific survival (DSS) was the primary endpoint. Optimal cutoffs were identified using recursive-partitioning analysis (RPA). A novel characteristic-metastatic focus-to-lymph node size ratio (MLR)-was introduced. We compared the American Joint Committee on Cancer, Eighth Edition (AJCC8) pN categories to a new categorization., Results: Patients with higher neutrophil-to-lymphocyte ratio had more adverse nodal characteristics. All nodal characteristics were significant predictors of DSS in univariable analysis. In multivariable analysis, only number of positive nodes and MLR remained significant. An RPA including all nodal covariates confirmed the results. Compared with AJCC8, our RPA categorization had better hazard discrimination (0.681 vs. 0.598), but poorer balance value (0.783 vs. 0.708)., Conclusion: Patients with higher neutrophil-to-lymphocyte ratio had more adverse nodal characteristics. Total number of metastatic lymph nodes is the strongest predictor of outcomes in OSCC. MLR is a more powerful predictor than metastatic lymph node size or metastatic focus size alone., (© 2020 Wiley Periodicals LLC.)

Objective: Survival outcomes for human papillomavirus-associated oropharynx squamous cell carcinoma (HPV + OPSCC) treated with surgery alone are unclear. To increase understanding, we assessed overall survival (OS) outcomes using the national cancer database (NCDB)., Methods: We conducted a retrospective analysis of OS of 736 NCDB HPV + OPSCC patients who underwent surgery alone from 2010 to 2014 using univariate and multivariate analyses and the Kaplan-Meir method., Results: Multivariable analysis found the following independent risk factors for death: American Joint Commission on Cancer (AJCC) 8th edition pathologic stage(p)N2 versus pN0 disease (hazard ratio [HR], 5.5; P = 0.000006), macroscopic extranodal extension (ENE) versus non-ENE (HR, 4.9; P < 0.02), a positive lymph nodes (LN) percentage of ≥10% (HR, 4.2; P = 0.0002), and five or more positive LNs (HR, 4.9; P = 0.00004). Three-year OS was significantly worse for AJCC 8th edition pN2 versus pN0 but not for 7th edition pN2 versus pN0 disease. Five-year OS was significantly worse for positive versus negative surgical margins, AJCC 8th edition stage II versus I, and either microscopic or macroscopic ENE versus non-ENE positive LNs. For 523 (71%) AJCC 8th edition stage I patients and for 283 (38%) patients who were pT1-T2, with negative margins, pN0-N1, with ≤4 pathologic LNs, without ENE, and with >20 LNs removed during neck dissection, the 3-year OS rates were 93% and 95%, respectively, and the 5-year OS rates were 91% and 95%, respectively., Conclusion: In the context of the lack of detail and possible inaccuracies found in the NCDB, surgery alone for AJCC 8th edition stage I HPV + OPSCC, particularly pT1-T2, pN0-N1 with ≤4 pathologic LNs, without ENE, and with negative surgical margins has a high OS., Level of Evidence: 4 Laryngoscope, 130:E423-E435, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Our goal was to clarify the comparison between elective neck dissection (END) and the wait-and-see policy in neck management for cT1N0 buccal squamous cell carcinoma (SCC)., Methods: This was a retrospective comparison of 175 prospectively enrolled patients with cT1N0 buccal SCC. The patients were divided into two groups based on the nonrandomized management of the neck: 125 patients received END, and 50 patients were exposed to the wait-and-see policy. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS). Patients were asked to complete the shoulder domain in the University of Washington quality of life questionnaire, version 4, 1 year postoperatively., Results: Ten of the patients undergoing END developed recurrence, and the 5-year LRC rate was 92%. Five patients undergoing the wait-and-see policy developed recurrence, and the 5-year LRC rate was 90%. The difference was not significant (p = 0.668). There were 6 deaths in patients undergoing END, and the 5-year DSS rate was 94%. There were 3 deaths in patients undergoing the wait-and-see policy, and the 5-year DSS rate was 94%; the difference was not significant (p = 0.777). The mean shoulder scores of patients undergoing END and the wait-and-see policy were 93.9 and 100, respectively, and the difference was not significant (p = 0.284)., Conclusion: Elective neck dissection does not carry a survival benefit compared to the wait-and-see policy, and it is not suggested for patients with cT1N0 buccal SCC.

It is known that lymph node metastasis lowers the survival rates in laryngeal carcinoma. This study aimed to investigate the effect of extranodal extension in lymph node metastasis on survival. The demographic characteristics and histopathologic results of 81 patients who underwent total laryngectomy and neck dissection due to advanced larynx squamous cell carcinoma between 2011 and 2018 were reviewed retrospectively. The patients were divided into 3 groups by lymph node metastasis status as reactive lymph node (group 1), lymph node metastasis without detected extranodal extension (group 2), and lymph node metastasis with detected extranodal extension (group 3). Survival analysis was performed between these 3 groups. In the patient population with a mean age of 61.56 years consisting of 6 females and 75 males, demographic characteristics between groups were comparable. Overall survival (OS) rates were detected to be 81% in group 1, 69.2% in group 2, and 61.5% in group 3. Two-year OS rates were detected to be 66.7% in group 1, 46.2% in group 2, and 38.5% in group 3. Statistical difference was detected between group 1 and group 3 both for OS and 2-year OS ( P = .014, P = .008, respectively). No statistical difference was detected between group 2 and group 1, and between group 2 and group 3. In this study, we found a negative effect of detecting neck lymphadenopathy metastasis and extranodal extension on survival in patients who underwent total laryngectomy and neck dissection due to advanced laryngeal carcinoma.

Background and Objectives: The reported risk of nodal metastasis in hard palate and upper gingival squamous cell carcinoma (SCC) has been inconsistent with inadequate consensus regarding the utility of neck dissection in the clinically negative (cN0) neck., Materials and Methods: Using the National Cancer Database, cN0 patients diagnosed with SCC of the head and neck with the subsites of the hard palate and upper gingiva were identified from 2004 to 2014., Results: A total of 1830 patients were identified, and END was performed on 422 patients with cN0 tumors. Pathologically positive nodes occurred in 14% (59/422) of patients in this cohort. Higher tumor stage, academic hospital type, and large hospital volume (>28 cancer-specific cases/year) were associated with a higher likelihood of END both in univariate and multivariate analyses (P < .05). Patients >80 years of age were less likely to receive END on multivariate analysis (OR 0.52, 0.32-0.84). No variables, including advanced T stage, predicted occult metastases. Cox proportional hazards regression analysis showed that patients who underwent END demonstrated improved OS over an 11-year period (hazard ratio 0.75, P = .002). On subgroup analysis, this improvement was significant in patients with both stage T1 and T4 tumors., Conclusions: Tumor stage, hospital type, and hospital volume were associated with higher rates of END for patients with cN0 hard palate SCC and after controlling for clinical factors, END was associated with improved overall survival., (© 2019 Wiley Periodicals, Inc.)

Background: This multicenter retrospective study aimed to determine whether elective neck dissection (END) can be performed for T1-2N0M0 tongue cancer., Methods: Patients with T1-2N0M0 tongue squamous cell carcinoma who received treatment between January 2000 and December 2012 were enrolled at 14 multicenter study sites. The 5-year overall survival (OS) and 5-year disease-specific survival (DSS) were compared between the propensity score-matched END and observation (OBS) groups., Results: The results showed that the OS rates among the 1234 enrolled patients were 85.5% in the END group and 90.2% in the OBS group (P = 0.182). The DSS rates were 87.0% in the END group and 94.3% in the OBS group (P = 0.003). Among the matched patients, the OS rates were 87.1% in the END group and 76.2% in the OBS group (P = 0.0051), and the respective DSS rates were 89.2% and 82.2% (P = 0.0335)., Conclusion: This study showed that END is beneficial for T1-2N0M0 tongue cancer. However, END should be performed for patients with a tumor depth of 4-5 mm or more, which is the depth associated with a high rate of lymph node metastasis. The use of END should be carefully considered for both elderly and young patients.

Background: The purpose of this study was to determine prognostic factors influencing outcomes of surgical treatment in patients with T4a hypopharyngeal cancer., Methods: The present study enrolled 93 patients diagnosed with T4a hypopharyngeal cancer who underwent primary surgery between January 2005 and December 2015 at six medical centers in Korea. Primary tumor sites included pyriform sinus in 71 patients, posterior pharyngeal wall in 14 patients, and postcricoid region in 8 patients. Seventy-two patients received postoperative radio(chemo)therapy., Results: Five-year disease-free survival (DFS) and disease-specific survival (DSS) rates were 38% and 45%, respectively. In univariate analysis, 5-year DFS was found to have significant and positive correlations with margin involvement (p < 0.001) and extracapsular spread (p = 0.025). Multivariate analysis confirmed that margin involvement (hazard ratio (HR): 2.81; 95% confidence interval (CI): 1.49-5.30; p = 0.001) and extracapsular spread (HR: 2.08; 95% CI: 1.08-3.99; p = 0.028) were significant factors associated with 5-year DFS. In univariate analysis, cervical lymph node metastasis (p = 0.048), lymphovascular invasion (p = 0.041), extracapsular spread (p = 0.015), and esophageal invasion (p = 0.033) were significant factors associated with 5-year DSS. In multivariate analysis, extracapsular spread (HR: 2.98; 95% CI: 1.39-6.42; p = 0.005) and esophageal invasion (HR: 2.87; 95% CI: 1.38-5.98; p = 0.005) remained significant factors associated with 5-year DSS., Conclusion: Margin involvement and extracapsular spread are factors influencing recurrence while extracapsular spread and esophageal invasion are factors affecting survival in patients with T4a hypopharyngeal cancer treated by primary surgery.

Objectives/hypothesis: To evaluate outcomes for patients with pathological N3 (pN3) neck disease from human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) and determine variables predictive of survival., Study Design: Retrospective case series with chart review., Methods: This study was conducted between 1998 and 2013 and included patients with HPV-related OPSCC treated with surgery with or without adjuvant therapy and who had pN3 nodal disease. The primary outcome was disease-specific survival (DSS). Secondary outcomes included overall survival (OS), disease-free survival (DFS), adverse events, and gastrostomy tube rates., Results: Thirty-nine patients were included, of whom 36 (90%) underwent adjuvant therapy. Median follow-up was 39 months (range, 2-147 months). Mean age was 56 years, and 87% were male. Seventeen patients (44%) underwent selective neck dissection, whereas six (15%) underwent radical (n = 2) or extended radical (n = 4) neck dissection. Ninety-two percent had extracapsular extension. Five-year Kaplan-Meier estimated DSS, OS, and DFS were 89% (95% confidence interval [CI]: 79%-99%), 87% (95% CI: 75%-99%), and 84% (95% CI: 72%-96%), respectively. The disease recurrence rate was 10% (5% regional, 5% distant metastasis). Patients with less than 5 pathologically positive lymph nodes (P = .041) had improved DFS., Conclusions: Patients with HPV-related OPSCC and pN3 nodal disease treated with surgery and adjuvant therapy have very favorable long-term survival and regional control. Patients with five or more pathologically positive lymph nodes may be at higher risk for recurrence., Level of Evidence: 4. Laryngoscope, 127:2033-2037, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To examine outcomes of selective neck dissection (SND) in patients with human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) who present with clinical neck disease., Study Design: Multi-institutional retrospective review., Methods: Two institutional databases of patients with HPV-related OPSCC were reviewed to identify patients with clinical (c) N1-N3 neck disease who underwent SND ± adjuvant therapy., Results: Three hundred and twenty-four patients were identified with a median follow-up of 49 months (range 3-199 months). All patients underwent transoral resection of the primary tumor and SND, including levels II-IV and ± levels I or V, with resection of additional nonlymphatic tissue (extended SND) as indicated by extent of disease, including the spinal accessory nerve (7%), the internal jugular vein (13%), and the sternocleidomastoid muscle (8%). Two hundred and seventy (83%) patients underwent adjuvant radiation. There were 13 (4%) regional recurrences and 19 (6%) distant recurrences. Regional control following salvage was 98%. On univariable analysis, absence of radiation was associated with regional recurrence (odds ratio [OR] 9.2, 95% confidence interval [CI] 2.9-29.4). On multivariable analysis, adjuvant radiation was associated with improved disease-free survival (DFS) (OR 0.27, 95% CI 0.14-0.53) but lost significance for overall (OS) and disease-specific survival (DSS) (P > 0.05). Five-year Kaplan-Meier estimates for OS, DSS, and DFS were 88% (95% CI 84%-92%), 93% (95% CI 89%-96%), and 83% (95% CI 78%-87%), respectively., Conclusion: In HPV-related OPSCC presenting with clinical neck disease, a SND ± additional tissue resection and adjuvant therapy, when indicated, provides excellent long-term regional control. Omission of radiotherapy increases the risk of regional recurrence, although it may not significantly impact OS or DSS. It appears unnecessary to routinely perform a comprehensive neck dissection., Level of Evidence: 4. Laryngoscope, 127:623-630, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

The purpose of this systematic review was to answer the clinical question "When should elective neck dissection be performed in maxillary gingival and alveolar squamous cell carcinoma with a cN0 neck?" A systematic review, designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, was conducted by two independent reviewers with three rounds of search and evaluation. Ten studies with 506 patients were included in the final review. The overall risk of cervical metastasis was 23.2% for those who did not receive an elective neck dissection (END), which was 3.4 times higher than that in the END group (6.8%). The 5-year survival rate was higher in those who had an END (80.3%) when compared to those who did not receive an END (67.4%). Overall, 14.1% of the cases with cN0 maxillary squamous cell carcinoma (SCC) presented with positive node(s) in pathological specimens after END. The risk of occult cervical metastasis in a cN0 maxillary SCC case with pathological stage pT1, pT2, pT3, and pT4 was 11.1%, 12.1%, 20%, and 36.1%, respectively. It is therefore concluded that END is recommended in patients with cN0 maxillary SCC, especially in stage T3 or T4 cases., (Copyright © 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objectives: The purpose of this work was to report outcomes of patients with nonmetastatic sinonasal squamous cell carcinoma (SNSCC) and to discuss the impact of elective neck irradiation (ENI) and selective neck dissection (SND) in clinically negative lymph node (N0) patients., Methods: Data from 104 nonmetastatic SNSCC patients treated with curative intent were retrospectively analysed. Uni- and multivariate analyses were used to assess prognostic factors of overall survival (OS) and locoregional control (LRC)., Results: Median follow-up was 4.5 years. Eighty-five percent of tumours were stage III-IV. Treatments included induction chemotherapy (52.9 %), surgery (72 %) and radiotherapy (RT; 87 %). The 5‑year OS, progression-free survival, and LRC rates were 48, 44 and 57 %, respectively. Absence of surgery predicted a decrease of OS (hazard ratio [HR] 2.6; 95 % confidence interval [CI] 1.4-4.7), and LRC (HR 3.5; 95 % CI 1.8-6.8). Regional relapse was observed in 13/104 (13 %) patients and most common sites were level II (n = 12; 70.6 %), level III (n = 5; 29.4 %) and level Ib (n = 4; 23.5 %). Management of the neck in N0 patients (n = 87) included 11 % SND alone, 32 % ENI alone, 20 % SND + ENI and 37 % no neck treatment. In this population, a better LRC was found according to the management of the neck in favour of SND (94 % vs. 47 %; p = 0.002) but not ENI., Conclusion: SND may detect occult cervical positive nodes, allowing selective postoperative RT. ENI (ipsilateral level II, ±Ib and III or bilateral) needs to be proposed in selected patients, especially when SND has not been performed.

Objective: The management of patients with recurrent neck cancer invading the carotid artery is controversial. The purpose of this study was to evaluate overall survival rate, primary patency of vascular reconstructions, and quality-adjusted life-years (QALYs) after en bloc resection of the carotid artery and tumor with in-line polytetrafluoroethylene (PTFE) carotid grafting, followed by radiotherapy., Methods: From 2000 to 2014, 31 consecutive patients with recurrent neck cancer invading the carotid artery underwent en bloc resection and simultaneous carotid artery reconstruction with a PTFE graft, which was associated in 18 cases with a myocutaneous flap. The primary tumor was a squamous cell carcinoma of the larynx in 17 patients and of the hypopharynx in 7, an undifferentiated carcinoma of unknown origin in 4, and an anaplastic carcinoma of the thyroid in 3. All of the patients underwent postoperative radiotherapy (50-70 Gy), and 10 of them also underwent chemotherapy (doxorubicin and cisplatin)., Results: None of the patients died or sustained a stroke during the first 30 days after the index procedure. Postoperative morbidity consisted of 6 transitory dysphagias, 3 vocal cord palsies, 2 wound dehiscences, 1 transitory mandibular claudication, and 1 partial myocutaneous flap necrosis. No graft infection occurred during follow-up. Fifteen patients (48%) died from metastatic cancer during a mean follow-up of 45.4 months (range, 8-175 months). None of the patients showed evidence of local recurrence, stroke, or thrombosis of the carotid reconstruction. The 5-year survival rate was 49 ± 10%. The overall number of QALYs was 3.12 (95% confidence interval, 1.87-4.37) with a significant difference between patients without metastasis at the time of redo surgery (n = 26; QALYs, 3.74) and those with metastasis (n = 5; QALYs, 0.56; P = .005). QALYs were also significantly improved in patients with cancer of the larynx (n = 17; QALYs, 4.69) compared to patients presenting with other types of tumors (n = 14; QALYs, 1.29; P = .032)., Conclusions: Aggressive en bloc resection of recurrent neck cancer with PTFE grafting can be curative in patients without metastases at the time of redo surgery. In this subset of patients, extensive neck surgery with carotid artery replacement can lead to excellent local control of the disease with improved quality of survival., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To date, this prospective cohort study is the largest of its kind from a single European academic tertiary care center to report 2-year survival outcomes for head and neck squamous cell carcinoma treated primarily with transoral robotic-assisted resection., Patients and Methods: Fifty consecutive, appropriately staged patients were enrolled prospectively, and underwent transoral robotic surgery (TORS) between September 2011 and August 2013. Overall, 24 patients had a T1 primary tumor, 23 had a T2 primary tumor, 2 had a T3 primary tumor, and 1 had a T4a primary tumor. Eighteen patients had overall stage I-II disease, and 32 patients had stage III-IV disease. Following transoral robotic resection of their primaries and appropriate neck dissection(s) as indicated, adjuvant treatment could be spared for 20 patients; another 5 patients refused the recommended adjuvant treatment. Seventeen patients received 60 Gy adjuvant radiotherapy and 8 patients underwent 66 Gy adjuvant chemoradiotherapy., Results: At the time of the last follow-up visit (median 27 months), overall survival was 94 %, with two disease-specific deaths and one unrelated death (heart attack). The 2-year disease-free and recurrence-free survival rates were 88 and 80 %, respectively; however, the local recurrence rate was only 10 % after 2 years., Conclusion: Using TORS as their primary modality, 40 % of patients did not need adjuvant treatment and showed similar survival rates to that of conventional surgery or primary chemoradiotherapy. In another 34 % of patients, adjuvant chemotherapy could be spared and adjuvant radiotherapy could be reduced by 10 Gy compared with primary chemoradiotherapy of 70 Gy. Further studies are warranted with respect to long-term survival.

Background: We examined the prognostic value of lymph node density in predicting cancer-specific mortality (CSM) for patients with lymph nodes positive (pN+) laryngeal squamous cell carcinoma (SCC) after laryngectomy., Methods: The records of 156 patients with laryngeal SCC who initially underwent curative resection of the primary tumor combined with neck dissection were reviewed., Results: The 5-year cumulative incidence of CSM was 20.4%. N classification and extralaryngeal spread (ELS) were independent variables for CSM in all patients. Univariate analyses in 71 pN+ patients showed that ELS, number of positive lymph nodes >4, and lymph node density >0.044 were significantly associated with increased CSM, whereas pN classification was not (p = .218). On multivariate analysis, lymph node density ≥0.044 remained an independent predictor of CSM (p = .001)., Conclusion: Among the pN+ patients with laryngeal SCC, no pN classification but lymph node density was noted to have an independent impact on CSM., (© 2014 Wiley Periodicals, Inc.)

Objective: The purpose of this study was to retrospectively evaluate the incidence of distant metastasis (DM) after curative surgical treatment and assess the multivariate relationships among various risk factors for DM in patients with oral squamous cell carcinoma (OSCC)., Study Design: Case series with chart review., Setting: Tertiary referral center., Subjects and Methods: The medical records of all patients with OSCC without DM who underwent curative surgery with or without postoperative adjuvant chemoradiation between January 2001 and February 2014 at our institution were retrospectively reviewed. There were a total of 451 patients, including 271 men and 180 women, with a mean age of 65.9 ± 13.5 years., Results: Of these patients, 30 (6.7%) developed DM. During the follow-up period, the 5-year overall survival rate was 76.2%. Sites of DM comprised the lungs (80.0%), skin (13.3%), liver (10.0%), bone (6.7%), and brain (3.3%). We found the T classification and N classification as well as the histologic grade to be significant risk factors associated with the development of DM in the univariate analysis only (P = .003), whereas locoregional failure (odds ratio [OR], 4.03), multiple lymph node metastases (more than 4 positive nodes; OR, 3.32) and positive extracapsular spread (OR, 3.06) were identified to be significant risk factors associated with the development of DM in the multivariate analysis., Conclusion: We demonstrated multivariate relationships among various risk factors for DM in OSCC patients. Clinicians should consider these risk factors and pay special attention to detecting DM early during the postoperative management of OSCC patients with these risk factors., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Neck dissection is an important treatment for metastases from upper aerodigestive carcinoma; an event that markedly reduces survival. Since its inception, the philosophy of the procedure has undergone significant change from one of radicalism to the current conservative approach. Furthermore, nonsurgical modalities have been introduced, and, in many situations, have supplanted neck surgery. The refinements of imaging the neck based on the concept of neck level involvement has encouraged new philosophies to evolve that seem to benefit patient outcomes particularly as this relates to diminished morbidity. The purpose of this review was to highlight the new paradigms for surgical removal of neck metastases using an evidence-based approach., (© 2014 Wiley Periodicals, Inc.)

Background: The evidence base to inform the decision making process in patients with early stage oral cancer and a clinical and radiological N0 neck remains insufficient to answer the question when it is safe to "watch and wait" and when to proceed with a selective neck dissection., Methods: A total of 327 consecutive cases of histopathologically staged T1-2, N0-1 and M0, but clinically N0, squamous cell carcinoma of the tongue were prospectively analysed. Univariate and multivariate analyses were used for statistical analysis and are represented as Kaplan-Meier analyses or Cox proportional hazard regression analysis., Results: In 61 patients (18.65%) lymph node involvement was found in the histopathological processing. The mean survival of all patients was 73.3 ± 48.6 months. The 2-year and 5-year overall survival rates of all patients were 87.5% and 68.4%, respectively. The 2-year and 5-year survival rates for stage N0 were 89.1% and 70.7% compared to 83.3% and 62.9% in N1 situations. The 2-year and 5-year survival rates for stage T1 were 87.9% and 73.6% compared to 87.2% and 65.3% in stage T2, respectively. The time to recurrence in stage N0 was 35.1 ± 30.5 months compared to 25.63 ± 24.6 months in cases with N1 disease. Stage T1 was associated with a time to recurrence of 38.1 ± 33.9 months compared with 27.2 ± 22.7 months in patients classified T2.Variables found to be strongly associated with survival in the univariate analysis included older age, higher tumour and N stage, and grading. Age, tumour stage (p = 0.011, 95% CI, 1.09 to 2.0), nodal stage (p = 0.038, 95% CI, 1.02 to 2.07), and recurrence were independently and significantly associated with survival in the multivariate analysis., Conclusions: This confirms a high overall disease free survival for patients with T1 and N0 treated with single modality surgery and in common with the literature confirms the poor impact on prognosis of the N positive neck.

Objectives: Analyze the effect of ipsilateral submandibular gland preservation on patients undergoing concurrent neck dissection and transoral surgery for oropharyngeal squamous cell carcinoma. Evaluate for (1) intraoperative and postoperative communications between the oropharynx and neck and (2) oncologic outcomes., Study Design: Retrospective chart review of prospectively collected data., Setting: Tertiary academic referral center., Methods and Subjects: Retrospective chart review of patients undergoing transoral laser resection of oropharyngeal squamous cell carcinoma with simultaneous neck dissection(s) for primary, persistent, recurrent, and second primary disease between January 1999 and February 2013. Data analyzed for operative technique, pathologic diagnosis, postoperative course, complications, and oncologic outcomes., Results: Overall 253 patients were identified. Of these, 96 patients underwent ipsilateral submandibular gland preservation and 157 underwent ipsilateral submandibular gland removal at the time of neck dissection. The prevalence of intraoperative communication between the neck and oropharynx was significantly lower in cases with submandibular gland preservation (2/96, 2.08%) compared to those with submandibular gland removal (22/157, 14.13%). No postoperative leaks occurred in the gland preservation group (0/96, 0%) compared to a leak prevalence of 8.92% (14/157) when the gland was removed (P = .0041). There was no difference in local, regional, or distant disease recurrence between submandibular gland preservation and gland removal. Similarly, Kaplan-Meier analysis showed no difference in disease free survival, disease specific survival, or overall survival., Conclusions: Submandibular gland preservation during neck dissection in patients undergoing transoral surgery for oropharyngeal squamous cell carcinoma significantly reduces the risk of intraoperative and postoperative salivary leaks without compromising oncologic outcomes.

Importance: Radiation therapy to the head and neck has traditionally been associated with adverse effects that can affect oral health and physical functioning. Although intensity-modulated radiotherapy (IMRT) has been widely adopted as a means of decreasing toxic effects, limited clinical data exist on its potential effect on long-term quality of life., Objective: To analyze quality of life among long-term survivors of head and neck cancer treated with IMRT., Design, Setting, and Participants: This cross-sectional analysis studied 50 consecutive long-term survivors of head and neck cancer from a comprehensive cancer center who had previously undergone IMRT that required bilateral neck irradiation for locally advanced disease. All patients were clinically without evidence of recurrent disease and had at least 5 years of follow-up., Main Outcomes and Measures: The University of Washington Quality of Life (UW-QOL) scores were reviewed for all study participants. The UW-QOL questionnaire consists of 12 domains that pertain to the degree of quality of life in the categories of pain, appearance, activity, recreation, swallowing, chewing, speech, shoulder function, taste, saliva, mood, and anxiety., Results: Five years after completion of IMRT, 42 patients (84%) reported that their health-related quality of life was "much better" or "somewhat better" than at the time of cancer diagnosis. With respect to recent health-related quality of life during the preceding 7 days at the time of completing the UW-QOL questionnaire, 40 patients (80%) treated with IMRT reported "outstanding" or "very good" levels of functioning. Five years after completion of treatment, 41 (82%) rated their overall quality of life as "outstanding" or "very good." The lowest domain score on the UW-QOL questionnaire at 5 years pertained to salivary dysfunction. However, 42 patients (84%) reported saliva "of normal consistency" or "less saliva than normal but enough" compared with 8 (16%) reporting "too little saliva." No patient reported having "no saliva.", Conclusions and Relevance: Our findings add to the body of literature that supports the acceptance of IMRT as standard treatment for head and neck cancer. The fact that most 5-year survivors were satisfied with their quality of lives points to the ability of IMRT to preserve long-term functioning.

Background: Oropharyngeal squamous cell carcinoma (OPSCC) is increasing in frequency. We reviewed patients with advanced-stage OPSCC treated with chemoradiation to assess the impact of residual neck disease on survival., Methods: We reviewed 202 patients with OPSCC between 1990 and 2010 treated with primary chemoradiation followed by neck dissection. Imaging was analyzed using RECIST (Response Evaluation Criteria In Solid Tumors) 1.1 criteria. Survival was evaluated using both univariate and multivariate analyses., Results: Overall survival at 5 years was 89%. Forty-two patients (21%) had residual disease in the neck (pN+). pN+ was associated with greater locoregional recurrence (LRR) and distant metastasis (DM) and decreased survival. No clinicopathologic factors were predictive of pN+. Contrasted posttreatment CT had low sensitivity and specificity., Conclusions: In advanced OPSCC pN+, patients have higher rates of LRR and DM. Neither clinicopathologic factors nor posttreatment imaging was predictive of pN+, although increased use of modern imaging may reduce the rate of negative neck dissections., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: Bilateral neck treatment in oropharyngeal squamous cell carcinoma (OPSCC) is controversial. This study determined the rate of bilateral neck metastases in OPSCC and formulated a neck treatment algorithrm for OPSCC., Methods: In all, 212 consecutive patients with OPSCC underwent ipsilateral level I-V and contralateral I-III or I-V neck dissections. Pathology results were used to identify factors predicting bilateral neck metastases., Results: A total of 171 patients (81%) had ipsilateral and 41 patients (24%) bilateral neck metastases. Multivariate logistic regression found cT4 and ≥cN2a significantly associated with contralateral neck metastases (p < .05). However, tumor site was not predictive (p > .05). High-risk pathology features predicted contralateral neck disease (p < .05). cN0 and cN1 necks were unlikely to harbor disease in level V (<5%). Both 2- and 5-year contralateral neck recurrence rates were 1% and 2%., Conclusions: Bilateral neck disease in OPSCC is more common than once thought. Patients with OPSCC with cT4 or cN2a+ would benefit from bilateral neck treatment. Posttreatment high-risk features should guide treatment escalation., (Copyright © 2013 Wiley Periodicals, Inc.)

Background: We aimed to study the importance of clinical N classification (cN) in a subgroup of patients with oral cavity squamous cell carcinoma (OSCC) and pathologically negative neck nodes (pN-)., Methods: A total of 2,258 patients from 11 cancer centers who underwent neck dissection for OSCC (1990-2011) had pN- disease. The median follow-up was 44 months. 5-year overall survival (OS), disease-specific survival (DSS), disease free survival, local control, locoregional control, and distant metastasis rates were calculated by the Kaplan-Meier method. cN classification and tumor, node, metastasis classification system staging variables were subjected to multivariate analysis., Results: A total of 345 patients were preoperatively classified as cN+ and 1,913 were classified as cN-. The 5-year OS and DSS of cN- patients were 73.6 and 82.2 %, respectively. The 5-year OS and DSS of cN+ patients were 64.9 and 76.9 %, respectively (p < 0.0001 each). A cN+ classification was a significant predictor of worse OS (p = 0.03) and DSS (p = 0.016), regardless of treatment, depth of invasion, or extent of neck dissection. cN classification was associated with recurrence-free survival (p = 0.01) and locoregional (neck and primary tumor) control (p = 0.004), but not with local (p = 0.19) and distant (p = 0.06) recurrence rates., Conclusions: Clinical evidence of neck metastases is an independent predictor of outcome, even in patients with pN- nodes.

Observation or elective neck dissection (END) for cN0 neck remains controversial for the treatment of T1-2 oral squamous cell carcinoma (OSCC). Perineural invasion (PNI) has been recognized as a poor prognostic factor for OSCC. However, its significance in T1 OSCC remains unclear. A detailed histologic reevaluation of PNI was carried out in 307 patients with T1-2 OSCC who received surgical treatment between June 2001 and January 2009. We found that the presence of PNI correlated with cervical lymph node metastasis in both T1 and T2 OSCC, with a lower PNI-positive rate in T1 (17.1% vs. 36.6%; P<0.001). Importantly, observation for cN0 neck was used twice as often in T1 than in T2 patients (47.4% vs. 22.8%; P<0.001). Although patients with T1 OSCC achieved significantly better outcomes, PNI correlated with neck recurrence and poor disease-specific survival (DSS) only in T1 (P<0.001 and P<0.0001) but not in T2 patients (P=0.399 and 0.1478). Of the 146 patients with T1 OSCC, PNI independently predicted cervical lymph node metastasis, neck recurrence, and poor DSS. END significantly reduced neck recurrence of T1 OSCC in PNI-positive (P=0.001) but not in PNI-negative (P=0.114) patients. In addition, END improved the 5-year DSS of T1 OSCC more in PNI-positive than in PNI-negative patients (16.2% vs. 5.4%). Our results indicate that PNI independently predicts a poor prognosis in T1 OSCC patients who are potentially curable but tend to be treated conservatively. For its efficacy in improving treatment outcomes, aggressive END is indicated for T1 OSCC patients at the presence of PNI.

Importance: Neck dissection is the standard staging procedure to ascertain the pathologic status of cervical lymph nodes in patients with oral cavity squamous cell carcinoma (OSCC), but it results in multiple morbidities., Objective: To examine outcomes of patients with OSCC who underwent sentinel node biopsy (SNB) as the sole neck staging procedure., Design: Retrospective review of patients who underwent SNB during the period 2005 through 2011., Setting: National Cancer Institute–designated comprehensive cancer center., Participants: Thirty-eight patients with clinically T1 or T2N0 OSCC., Interventions: Preoperative lymphoscintigraphy with intraoperative gamma probe localization was used. Sentinel lymph nodes were serially sectioned, formalin fixed, and examined at 3 levels. All patients with positive SNB results underwent neck dissection, and the patients with negative SNB results were observed clinically., Main Outcomes and Measures: Sensitivity and predictive value of SNB, recurrence rates, and disease-specific survival rates., Results: There were 18 T1 and 20 T2 tumors. Five patients had positive SNB results, of whom 3 had additional positive nodes on subsequent neck dissection. Two of 33 patients with negative SNB results developed a regional recurrence. The sensitivity and negative predictive value for staging the neck with SNB alone were 71% (5 of 7) and 94% (31 of 33), respectively. Mean follow-up was 31 months. The mean disease-free survival duration for patients with positive and negative SNB results was 30 and 65 months, respectively (P = .08). The disease-specific survival rate for patients with positive and negative SNB results was 80% and 91%, respectively. There was no significant difference in disease-specific survival between patients with true-negative and false-negative SNB results (34 vs 44 months; P = .38)., Conclusions and Relevance: The majority of patients with positive results on SNB had additional positive nodes on neck dissection. A low rate of isolated neck recurrence was found in patients with negative results on SNB. Individuals with negative results on SNB exhibited better overall and disease-specific survival than those with positive results.

Objective: To determine the value of positron emission tomography (PET) with contrast-enhanced computed tomography (CT) in assessing the need for neck dissection by retrospectively reviewing the pathology reports of patients with human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma (SCC)., Design: Retrospective cohort study., Setting: Tertiary medical center., Patients: Seventy-seven patients with HPV-related SCC., Main Outcome Measures: Seventy-seven consecutive patients with a diagnosis of HPV-related SCC who were treated with radiotherapy as the primary treatment between August 2007 and October 2010 were retrospectively evaluated for radiologic and pathologic rate of persistence of nodal metastasis after completion of definitive radiotherapy. Pretreatment and posttreatment imaging included contrast-enhanced CT and PET. Response to treatment was measured on CT, PET at standardized uptake value (SUV) thresholds of 2 and 2.5, and PET/CT by a neuroradiologist in a blinded fashion. Then, the pathology report of the patients who underwent neck dissections was reviewed for nodal status after resection and correlated with the imaging findings., Results: Of the 77 patients, 67 met the study criteria, with an average follow-up PET/CT scan at 90.5 days after completion of radiotherapy. Ten patients did not undergo follow-up PET/CT imaging. Twenty patients underwent neck dissections after completion of radiation therapy. Of these 20 patients, 4 had persistent tumor and 16 did not have viable tumor. Using the final pathology report to correlate with imaging responses, CT had a negative predictive value (NPV) of 85.7% (95% CI, 48.7%-97.4%), PET with SUV thresholds of 2 had an NPV of 91.7% (95% CI, 64.6%-98.5%), PET with a cutoff SUV of 2.5 had an NPV of 85.7% (95% CI, 60.1%-96.0%), PET/CT with an SUV of 2 had an NPV of 100% (95% CI, 59.8%-100.0%), and PET/CT with an SUV of 2.5 had an NPV of 85.7% (95% CI, 48.7%-97.4%). The 47 patients who did not undergo neck dissection had a median follow-up of 26 months without an isolated neck failure. Analysis of all 67 patients in the cohort revealed the following values: CT had an NPV of 95.7% (95% CI, 85.8%-98.8%), PET with an SUV of 2 had an NPV of 98.2% (95% CI, 90.4%-99.7%), PET with an SUV of 2.5 had an NPV of 95.0% (95% CI, 86.3%-98.3%), PET/CT with an SUV of 2 had an NPV of 100.0% (95% CI, 92.0%-100.0%), and PET/CT with an SUV of 2.5 had an NPV of 95.7% (95% CI, 85.8%-98.8%)., Conclusions: Positron emission tomography combined with contrast-enhanced CT has a better NPV than either imaging modality alone in patients with HPV-associated oropharyngeal SCC. Furthermore, PET/CT with an SUV threshold of 2 used in patients with HPV-related SCC offers an imaging modality with a high NPV that may obviate the need for unnecessary neck dissections.

Both diffusion-weighted magnetic resonance imaging and fluorodeoxyglucose positron emission tomography/computed tomography are oncological imaging techniques. The aim of this study was to assess any correlation between apparent diffusion coefficients and standardized uptake value in metastatic neck lymph nodes of head and neck squamous cell carcinomas., (Copyright © 2012. Published by Elsevier Inc.)

Objective: Head and neck squamous cell carcinomas readily metastasize to adjacent cervical lymph nodes. This is seen frequently in laryngeal squamous cell carcinoma (LSCC), and neck dissection may be performed in addition to excision of the primary lesion. The aim of this study was to define the frequency of level IIb metastasis to the lymph nodes in patients who underwent selective neck dissection because of LSCC., Study Design and Setting: Cross-sectional study with planned data collection in a tertiary referral hospital., Subjects and Methods: Eighty-one patients diagnosed with LSCC were accepted into the study. One hundred forty-eight neck dissection specimens were examined histopathologically, and those with level IIb metastasis were identified. The frequency of level IIb metastasis was evaluated in accordance with the primary tumor site, clinical N stage, central tumor presence, and T stage., Results: Forty-seven of 81 patients were clinically N-, and 34 patients were clinically N+. Level IIb metastasis was seen in 5 (6%) of 81 patients, representing 5 of 148 neck dissection specimens. Two of these 5 patients were clinically N+ (6%), and 3 were clinically N- (6%). The relationship between level IIb metastasis and clinical N stage was not statistically significant (P ≥ .05). Likewise, no statistically significant relationships between the other parameters and level IIb involvement were found., Conclusion: Level IIb nodal involvement is very rare in LSCC. Therefore, the area can generally be preserved in elective neck dissection to lessen morbidity and, specifically, to avoid damaging the function of the spinal accessory nerve.

Objective: To investigate the clinical therapeutic outcomes and neck node control of a pretreatment neck dissection in the chemoradiation protocol of organ preservation for N2-N3 of supraglottic and hypopharyngeal carcinoma., Methods: Forty-six patients (group A) with untreated N2 or N3 squamous cell carcinoma of the supraglottis or hypopharynx underwent pretreatment neck dissection in a chemoradiation protocol, while 39 patients (group B) did not undergo pretreatment neck dissection in a chemoradiation protocol. Salvage surgeries were used for local or cervical node residual tumor or recurrence after chemoradiotherapy., Results: In group A, the mean time between neck dissection and chemoradiation was 21 days (range 15-29). Only 3 patients (6.5%) experienced wound complications. A 'boost' of radiation of 12 Gy was delivered after 33 neck dissections (64.8%) in patients with extracapsular spread. The Kaplan-Meier 5-year overall survival rate was 42.5%. The 5-year overall survival rate and disease-specific survival rate in group A was 42.5 and 46.4%. The rate of neck node control in group A was better than that in group B (86.3 vs. 65.9%, p = 0.02)., Conclusions: Pretreatment neck dissection in a chemoradiation protocol for supraglottic or hypopharyngeal carcinoma showed low complication rates, no delay for radiation, optimal radiation doses, and a high nodal disease control., (Copyright © 2012 S. Karger AG, Basel.)

Background: Our aim in carrying out this study was to determine the efficacy of selective neck dissection (SND) for cervical metastases with clinical involvement of adjacent nonlymphatic structures., Methods: In all, 39 patients were retrospectively analyzed with respect to 43 extended selective neck dissection (ESND) procedures., Results: Eighteen procedures were performed as part of the primary treatment and 25 for salvage following (chemo)radiation. Although most patients (84%) had nodal disease ≥N2, 91% had disease clinically confined to ≤2 neck levels. SND (levels II-IV) was most commonly performed and the internal jugular vein was the nonlymphatic structure most often sacrificed. Recurrence rate in the ipsilateral targeted neck was 0% and 13% in the primary surgery and postradiation groups, respectively., Conclusions: SND that is extended to include adjacent nonlymphatic structures appears to be effective for advanced nodal metastasis confined to ≤2 nodal levels. We support the use of the term "extended selective neck dissection (ESND)" to describe this modification of neck dissection., (Copyright © 2010 Wiley Periodicals, Inc.)

There is still no consensus on the optimal treatment of the neck in oral cavity cancer patients with clinical N0 neck. The aim of this study was to assess a possible benefit of elective neck dissection in oral cancers with clinical N0 neck. A comprehensive search and systematic review of electronic databases was carried out for randomized trials comparing elective neck dissection to therapeutic neck dissection (observation) in oral cancer patients with clinical N0 neck. A meta-analysis of the studies which met our defined selection criteria was performed using disease-specific death as the primary outcome, and the relative risk (RR) of disease-specific death was calculated for each of the identified studies. Both fixed-effects (Mantel-Haenszel method) and random-effects models were applied to obtain a combined RR estimate, although between-study heterogeneity was not found to be significant as indicated by an I(2) of 8.5% (p=0.350). Four studies with a total of 283 patients met our inclusion criteria. The results of the meta-analysis showed that elective neck dissection reduced the risk of disease-specific death (fixed-effects model RR=0.57, 95% CI 0.36-0.89, p=0.014; random-effects model RR=0.59, 95% CI 0.37-0.96, p=0.034) compared to observation. This reduction in disease-specific death rate supports the need to perform elective neck dissection in oral cancers with clinical N0 neck., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The objective of this study was to evaluate whether elective neck dissection could improve regional control or survival time in clinical stage I squamous cell carcinoma of the oral tongue (OTSCC). This was a retrospective study of patients with surgical treatment between January 1991 and December 2003. A total of 131 patients were included in the study, and all of them received operation of the primary site, while 88 cases underwent selective neck dissection simultaneously including level I-III neck dissection in 49 patients and level I-V neck dissection in 39 patients. In all these cases, the rate of occult neck metastases was 23.7%. The 4-year local control rates in patients with only primary site treatment, patients with level I-III neck dissection and patients with level I-V neck dissection were 81.0%, 83.6% and 89.1%, respectively. By univariate analyse, neck dissection did not increase regional control rate, disease free survival (DFS) or overall survival (OS). Multivariate analyses showed that neck dissection was not an independent factor for DFS or OS. This study showed that the occult neck metastases rate was 23.7% in clinical stage I OTSCC. Elective neck dissection did not significantly improve regional control, DFS and OS in clinical stage I patients. There is a need for accurate and valid methods to select the patients who would benefit from elective neck treatment., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Data was retrospectively analysed on 72 consecutive patients treated primarily with resection and concomitant neck dissection for intraoral carcinomas. Twenty prognostic variables were assessed by univariate analysis to assess their influence on survival. Seven variables were significant at the 5% level. Survival was negatively influenced by six tumour related factors, increasing T stage (P=0.039), increasing N stage (P=0.004), greater than two nodes histologically positive nodal disease (P=0.017), tumour size > 4 cm (P=0.022), residual disease at the primary site (P=0.012), extracapsular nodal spread (P=0.01) and the one treatment related factor analysed, adjuvant radiotherapy (P=0.039). Subsequent multivariate analysis was performed via the cox stepwise regression method to assess the influence on survival of all factors which achieved significance at the 20% level. There were only two variables which made a significant difference (P<0.05) to the multivariate model. The presence of lymphovascular invasion (P=0.015) and histological evidence of mandibular invasion (P=0.047). Lymphovascular invasion appeared in the final model despite not achieving statistical significance at the 5% level on univariate analysis. A final cox survival model was constructed. The relative risk of death for those with cervical metastases (N2 and above) at diagnosis was 3.74 (P=0.005). The addition of lymphovascular invasion to the cox model revealed an increase in the relative risk of death in the presence of lymphovascular invasion of 2.99 (P=0.015). Patients with nodal negative disease and one single node positive provided the baseline risk as there was no significant difference between these two groups. The presence of histological evidence of lymphovascular invasion in oral carcinoma surgical specimens has a significant impact on survival outcome in oral carcinoma patients.

It is now possible to limit the extent of selective neck dissection for mucosal squamous cell carcinoma of the head and neck by sparing selected lymphatic levels thereby reducing the morbidity. This has been brought about by our improved understanding of the metastasis behavior of these cancers. Studies have demonstrated similar rates of neck recurrences and survival after selective neck dissection compared to modified radical neck dissection. The purpose of this study was to evaluate the efficacy of selective neck dissection (SND) in managing the N0 neck in oral cavity carcinomas. A retrospective analysis of Squamous cell carcinoma of oral cavity with N0 neck from 1998 to 2004 was performed. Statistical analysis was done using SPSS software. The chi-square test was used to compare the various proportions. The overall and disease-free survival were estimated using the Kaplan-Meier method and statistical significant difference in survival was tested by log rank test. Out of the 219 cases, 84% were in the early stage and 16% were in the late stages. Seventy two percent of the patients had primary tumors in the anterior two-thirds of the tongue. One hundred and sixty one patients were pathologically node negative. There was no statistically significant difference in the regional recurrence between the pN0 and pN+ patients. There was no difference in the regional recurrence inside and outside the surgical field. The pathological node positive patients had a worse disease-free survival (DFS) compared to the node negative patients, and the patients with nodal recurrence had a significantly worse DFS compared to patients without nodal recurrence. SND (I-III) is a sound and effective procedure in the management of clinically negative neck in squamous cell carcinoma of the oral cavity. Clinically N0 neck but pathologically N+ neck requires adjuvant radiation therapy. It probably has a therapeutic role in the selected cases of squamous cell carcinoma of the oral cavity with N1 neck, and in these cases an extension of dissection to levels IV and V is beneficial.

Background: The aim of this work was to determine whether or not patients treated with therapeutic selective neck dissection for head and neck squamous cell carcinoma were oncologically disadvantaged compared with those having comprehensive procedures., Methods: The study involves a retrospective review of 232 therapeutic neck dissections with a minimum of 2 years follow-up., Results: Patients having selective neck dissection had fewer adverse prognostic factors compared with patients having comprehensive dissection (pN2/3, p = .001; and extracapsular spread, p = .001). There were trends toward improved control in the dissected neck (96% vs 86%, p = .06), and disease-specific survival (59% vs 43%, p = .06) following selective neck dissection. Disease-specific survival for all patients was adversely affected by pN classification (p <.001) and extracapsular spread (p <.001)., Conclusions: Patients undergoing aggressive neck surgery had more extensive disease. Selective neck dissection can be used to effectively treat clinically positive nodal disease in selected patients.

Objectives: The aims of this study were to analyze the pattern of regional recurrence in laryngeal cancer, evaluate the role of surgical salvage, and identify factors affecting salvage outcome., Methods: Retrospective analysis was conducted on medical records from a 16-year period. Of 463 patients diagnosed with laryngeal cancer, 25 patients with regional recurrence managed with salvage neck dissection were identified and subject to study. Isolated local recurrences and all distant metastases were excluded., Results: All patients were male with a median age of 61 years. The overall rate of regional recurrence was 5.4%. Median time to regional recurrence was 13 months. Isolated regional recurrence occurred in 76% of cases, whereas locoregional recurrence occurred in 24%. A 5-year survival rate for patients undergoing neck dissection as salvage management was 61.2%. Patients with recurrence in the contralateral neck were definitely associated with poor prognosis. Although standard statistical significance was not met, trends for poorer salvage result were identified in patients with a history of local recurrence before regional recurrence, recurrence in a previously dissected neck, and recurred node size of 3 cm or above., Conclusions: Our study shows that salvage neck dissection for regional recurrence in laryngeal cancer is an acceptable approach. Surgical eradication of disease should be warranted whenever possible. Prudent planning of management is mandatory in the presence of history of local recurrence before regional recurrence, previously dissected neck, large size of recurrent node, and contralateral neck recurrence.

Recent times have witnessed significant improvements in outcome for head and neck squamous cell carcinomas. Nevertheless, the major pattern of failure continues to remain loco-regional. Isolated neck recurrence, although uncommon, occurs in 5-7% of patients after radical treatment. The options for this subgroup are somewhat limited and are often guided by empiricism rather than evidence. This review attempts to systematically analyze the therapeutic options for patients with isolated neck recurrence following radical treatment for the primary and draining cervical lymph nodes, with a special emphasis on re-irradiation. Salvage neck dissection offers the best chance of cure to patients with resectable neck recurrences. The perceived increased risk of complications of re-irradiation following previous curative dose irradiation has precluded optimal evaluation of its potential in this setting. Post-operative adjuvant re-irradiation should be based on histo-pathological findings of the salvage surgery. Re-irradiation with or without chemotherapy may be considered for unresectable neck recurrences. The role of chemotherapy continues to evolve and is presently not optimally defined. There is lack of high-quality evidence pertinent to salvage therapy leading to vast variations in practice. More patients with recurrent disease should be enrolled onto prospective clinical trials with relevant and meaningful endpoints.

Introduction: This report analysed the outcome of patients undergoing surgery for oral squamous cell carcinoma in order to identify the prognostic value of several factors., Patients: A total of 245 patients were studied who had undergone surgery for oral squamous cell carcinoma between 1989 and 2002, of whom 109 had received postoperative radiation therapy., Methods: For each patient, personal data, alcohol and tobacco consumption, symptoms, histological findings, treatment, and outcome were recorded and analysed statistically. Survival curves were calculated using the Kaplan-Meier algorithm, and the difference in survival among subgroups was examined., Results: The overall 5-year survival rate in the 245 patients was 63% (72.5% at 3 years). The differences in the 5-year survival were significant (p<0.05) for the site of origin, N and pN status, TNM stage, grading, status of the resection margins, osseous infiltration, and perineural invasion. Vascular involvement as a discriminator was not statistically significant. In patients undergoing radiation therapy, only perineural invasion negatively influenced the 5-year survival prognosis (p<0.01)., Conclusion: The overall survival rate was within the (previously) reported range. The prognostic value of many parameters is widely recognized; the combined evaluation of 'composite factors' is promising.

Objective/hypothesis: The utility of elective neck dissection in the management of patients with oral cavity and oropharyngeal cancer who present without neck metastases remains controversial. The study addressed the question of whether elective neck dissection improves regional control and survival in patients with squamous cell carcinoma of the oral cavity and oropharynx presenting with T1/T2 node-negative disease., Study Design: A nonrandomized, uncontrolled retrospective chart review., Methods: A nonrandomized, uncontrolled retrospective chart review was performed. Resection of the primary tumor was performed in all patients. The neck was observed in one group, and elective neck dissection was performed for patients in another group., Results: The study data indicated that elective neck dissection significantly improves regional control and regional recurrence-free survival. Elective neck dissection when compared with observation of the neck did not improve overall survival., Conclusion: Elective neck dissection reduces regional recurrence and may extend disease-free survival.

Objective: To develop a simple prognostic survival rule from easily obtained characteristics of patients undergoing potentially curative resection of head and neck squamous cell carcinoma using classification and regression trees., Design: Inception cohort., Setting: Tertiary care center., Patients: Consecutive patients undergoing resection lasting at least 2 hours, from July 1993 through June 1997., Main Outcome Measure: Survival, age, TNM tumor stage, functional class, systolic and diastolic blood pressure, body mass index, and serum albumin concentration were evaluated as predictors., Results: Four hundred six patients were followed up for 5 to 1446 days (median, 391 days), during which time 172 deaths occurred. Median survival was 687 days. Patients with TNM stage I, II, or III squamous cell carcinoma had a mean survival of 1068 days. Patients with TNM stage IV or recurrent disease were further stratified. Those with a serum albumin concentration less than 3.85 g/dL had a median survival of 404 days (95% confidence interval, 286-532 days), and those with an serum albumin concentration of 3.85 g/dL or above had a median survival of 625 days (95% confidence interval, 536-1032 days). A similar survival was found using age younger than 66.5 years as a predictor instead of serum albumin concentration less than 3.85 g/dL., Conclusions: At our institution, patients with stage I, II, or III squamous cell carcinoma had a mean survival of approximately 3 years. Those with stage IV or recurrent squamous cell carcinoma could be stratified by either serum albumin concentration or by age into 2 groups with a median survival of 1 or 2 years.

The present study examined the Liverpool database in an attempt to determine what proportion of N0 necks for various head and neck primary sites harbored subclinical squamous cell carcinoma and whether empiric treatment of occult disease improved survival over and above a "wait-and-watch policy" (treatment when metastasis becomes manifest). One hundred seventeen neck dissections were carried out for N0 necks, with 32% of specimens found to contain squamous cell carcinoma. The risk of carcinoma was highest in the hypopharynx, with 50% of specimens associated with a pyriform fossa primary cancer. Twenty-nine percent of neck dissection specimens for oral cavity cancer contained carcinoma and this was commonly associated with lateral border of tongue or anterior floor of mouth carcinomas. Twenty-five percent of specimens when primary tumor was in the oropharynx contained carcinoma and were due to tonsillar carcinoma. Twenty-one percent of laryngeal cancers produced histologically positive nodes and were mostly associated with posterior epiglottic tumors. Two hundred forty-six patients had a pyriform fossa cancer and of these only 37 had N0 disease and surgical treatment. Of these, 23 patients had radical neck dissections, whereas in 14 the necks were not treated. There was no difference in survival between the two groups (chi 1(2) = 0.787, P = NS). The Liverpool database also contained 1631 previously untreated patients with no clinical evidence of neck node metastases. Of these only 107 had a neck dissection. There was no difference in survival (chi 1(2) = 2.79, P = NS).(ABSTRACT TRUNCATED AT 250 WORDS)

The survival rates of 58 patients treated for squamous carcinoma of the tongue between 1972 and 1985 were evaluated. The overall 5-year survival rate was 41.6%; for stage I it was 61.8%; stage II 59.5%; and stage III, 27.7%. No patient survived for more than 2 years when their tumour was stage IV on presentation. A composite pull-through resection with radical neck dissection gave a 5-year survival rate of 50.7%, which was significantly (P less than 0.01) higher than the 13.8% achieved by other treatments, mainly local tumour excision combined with radiation therapy. The same trend in favour of radical surgery was also seen stage by stage. In 45% of the patients regional neck metastases (palpable in 35% and occult in 10%) were present and predicted a poor prognosis. Among T1-T2 cases the 5-year survival of 58.5% in the N0 group was significantly (P less than 0.01) higher than the 15.1% among those with nodal involvement. The location of the primary tumour did not affect the survival rates.

We reviewed the records of 94 patients with cancer of the floor of the mouth who were treated during a 15-year period to assess the results of an aggressive regional surgical approach. The primary tumor was excised with a 2 cm margin of normal tissue. A marginal or segmental mandibulectomy was performed in 84 of 94 patients. An ipsilateral radical neck dissection was performed in 86 of 94 patients. Contralateral suprahyoid dissection was combined with ipsilateral radical neck dissection in 52 patients. Bilateral radical neck dissection was performed in 10 patients. In the 1 to 16-year follow-up period, local/regional control was achieved in 91% of stage I patients, 83% of stage II patients, 68% of stage III patients, and 48% of stage IV patients. Determinant 5-year survival rates were T1--72%, T2--47%, T3--25%, and T4--28%.

An account is given of the use of radical neck dissection in a consecutive series of 147 patients treated during the years 1967-76 in the Head and Neck Unit of the Royal Marsden Hospital. The majority had received previous treatment principally by irradiation to full dosage, some by previous surgery, and a minority by induction cytotoxic chemotherapy. The 5-year determinate survival results for surgical salvage are 28.03%, and 20.5% at 10 years. Prevention of recurrent cancer in the neck was achieved in 70% of all those who later succumbed to their disease.

This series of 307 patients who underwent radical neck dissection showed an overall recurrence rate of 19 percent. Clinical staging of disease was an accurate predictor of both recurrence and survival. Extranodal disease dramatically increased recurrence and decreased survival. Although our recurrence rate after radical neck dissection was lower than that previously reported for surgery alone, it was still significantly higher than that after adjuvant radiotherapy. We conclude that histologically proved neck disease should be treated by radical neck dissection, followed by adjuvant radiotherapy to decrease recurrence and, it is hoped, improve survival.