RTP On Demand — Head & Neck/Thyroid | Research To PracticeElective versus therapeutic neck dissection for early squamous cell carcinoma of the oral cavity
4:31 minutes.
TRANSCRIPTION:
DR COHEN: For this paper, I think, the first thing to say is we really have to commend the investigators for even doing this study. This is a study that would not be possible in North America, likely not possible in Europe. And so with oral cavity cancers being such an endemic disease in India and being such a major health problem, the investigators really took this on and decided to prospectively answer this very important question. So they really do need to be commended. And the question was, should we be doing an elective neck dissection in these early-stage oral cavity cancers? The dilemma we face in the clinic is, we see these T1, T2 tumors, usually of the oral tongue, sometimes of the buccal mucosa, and we often do an elective neck dissection for these patients with the thought that, depending on the different parameters, there’s about a 10% to maybe 30% chance of microscopic metastatic disease in the lymph nodes. And so we accept that threshold to do a neck dissection. But, of course, the neck dissection does carry some morbidity. And it does, in some patients, carry some long-term toxicity as well. And so what this study did in patients from India is that it randomized patients to either do the elective neck dissection or to essentially watch patients and do a therapeutic neck dissection, if there was disease recurrence or disease in the lymph nodes that manifested down the road. And what they found was essentially that the elective neck dissection yielded an improvement in overall survival and improvement in disease-specific survival. It did lead to a higher toxicity rate, higher rates of morbidity, but only slightly higher. And the morbidity was, in general, not serious. And so I think now we can say, with prospective Phase III data, that in patients with early-stage oral cavity cancers, that an elective neck dissection is, indeed, the most effective therapy, with Level 1 evidence. DR LOVE: It’s interesting. Obviously it’s a very important, practical, quality-of-life question. But also, kind of just looking at it, I was thinking, “Halstead is still alive.” You forget that surgery can cure people. DR COHEN: Mm-hmm. And for early-stage head and neck cancer, it usually does. DR LOVE: What about the issue of sentinel node? DR COHEN: Yes. And so these are the issues that begin to come up in a study like this, because there may be practice patterns in other parts of the world and even in locations where the study was done, that are different than in that study population. So, for instance, you bring up sentinel node dissection. And although it’s not widely used in North America, it is validated in prospective studies. And so, obviously, that was not incorporated in the study. It’s something that we do use at our center. And that can dramatically reduce the morbidity of an elective neck dissection, just as it has done in other diseases, primarily breast cancer. And then, of course, the other issue is more sophisticated radiographic techniques that are being employed in many centers around the world than were necessarily employed in that study. So I think the study does have real-world implications, without a doubt. But we have to realize that, in the time that the study was being done and in the time it took for the data to mature, things have come up. And one of those is sentinel lymph node biopsy. And the other one, major one, is more sophisticated radiographic techniques. |