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Comparing Management Options of Neck Nodal Regions in Early-Stage Head and Neck Cancer

Op-Med is a collection of original articles contributed by Doximity members.

Dr. Zhen Gooi is a 2020–2021 Doximity Research Review Fellow. Nothing in this article is intended nor implied to constitute professional medical advice or endorsement. The views expressed in this article are those of the author and do not necessarily reflect the views/position of Doximity. 

Management options of the neck nodal regions at risk of metastasis from early-stage oral cavity cancer include observation, neck dissection, or sentinel lymph node biopsy (SLNB). Currently, there is a paucity of high-level data comparing the effectiveness of SLNB with neck dissection.

In a recent trial, researchers compared recurrence-free survival in patients undergoing SLNB versus neck dissection for early-stage oral cavity and oropharyngeal cancers. Patients were randomized to undergo either SLNB or neck dissection at the time of surgery and primary cancer resection. Completion neck dissection was performed if metastasis was identified in the sentinel lymph node. The primary outcome of interest was two-year neck nodal recurrence-free survival. 

Of the 140 patients who met criteria for analysis in the SLNB arm, 24% underwent completion neck dissection. There was no difference in the two-year nodal recurrence-free survival between the SLNB and neck dissection arms (90.7% versus 89.6%). There were also no significant differences in the two- and five-year recurrence-free survival rates, or in overall survival rates—but patients undergoing neck dissection had worse shoulder functional outcomes up to six months after treatment. 

Conducting randomized clinical trials involving surgical intervention is a challenge, reflected by the slightly lower than intended enrollment of subjects in this case (notwithstanding an extension of the trial period). Additionally, the inclusion of patients with oropharynx cancer is interesting. Garrel et al. did not give further information on subsite involvement or HPV status for these patients, but one can imagine that any radiotracer injection at the base of tongue region would require a separate procedure under general anesthesia. Most of the neck recurrences occurred during the first two years, which validates measurement of two-year recurrence-free survival as the primary outcome of interest. 

Overall, this trial demonstrates the viability of sentinel lymph node biopsy for management of the neck in a selected group of early-stage head and neck cancer patients.  

Dr. Zhen Gooi is a head and neck oncologic surgeon in academic practice at the University of Chicago. He completed his residency and fellowship training at Johns Hopkins University.

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