Elsevier

Seminars in Oncology

Volume 31, Issue 3, June 2004, Pages 382-393
Seminars in Oncology

Lymphatic mapping for staging of head and neck cancer

https://doi.org/10.1053/j.seminoncol.2004.03.009Get rights and content

Abstract

Lymphatic mapping with sentinel lymph node (SLN) biopsy can accurately stage the nodal basins in patients with melanoma of the trunk and extremities and has become a routine, well-accepted diagnostic method for melanoma at these anatomic locations. Melanoma of the head and neck (16% of all cases of melanoma) is complex and difficult to manage because of the rich abundant interlacing lymphatic drainage patterns, as well as watershed areas, which can lead to unusual and unexpected drainage patterns. Radioguided surgery in combination with blue dye facilitates localization of the SLN in the head and neck; however, this type of radioguided surgery is an evolving technique of some difficulty and thus requires careful coordination among the surgeon, nuclear medicine physician, and pathologist. Applications of this technique to other sites in the head and neck are currently being investigated for conditions including squamous cell carcinoma (SCC) of the oral cavity, thyroid cancer, and Merkel cell cancer. More studies of patients with head and neck cancer are needed—and technical issues must be resolved—before radioguided surgery can be recommended as the standard of care for these patients.

Section snippets

Preoperative lymphoscintigraphy

Use of preoperative lymphoscintigraphy has greatly improved our ability not only to identify all the nodal basins at risk but also to identify multiple SLNs and their location within each nodal basin (Table 2). Preoperative lymphoscintigraphy of the head and neck shows between one and three lymph node basins and one to five SLNs per patient. Balkissoon (unpublished data, 2002) has reported visualizing 1.31 nodal basins and 1.75 SLNs per patient with melanoma of the head and neck area. Rasgon4

Intraoperative lymphatic mapping and SLN biopsy

The surgeon and the nuclear medicine physician must both review lymphoscintigrams before beginning the planned surgery. This procedure enables the surgeon to discuss with the patient any additional findings that could affect informed consent (eg, if an SLN is located over the parotid or submandibular area and thus increases the risk of facial nerve injury). Another example is drainage to parotid lymph nodes, an event that can occur in 30% to 50% of cases: Being aware of this finding would lead

Discordant rates for lymphatic mapping

Lymphatic mapping in the head and neck is technically challenging and can show many unusual and unexpected drainage patterns. The highest rates of discordance are seen in the head and neck area9 and can range from 34% to 84%.8, 18 Balkissoon (unpublished data, 2002) found discordance in 44% of patients. O’Brien et al8 reported that 22% of patients had SLNs in other anatomic sites than the parotid area or in the five standard neck levels. That most of these SLNs were located in the posterior

Sentinel lymph node biopsy for squamous cell carcinoma of the oral cavity

Squamous cell carcinoma (SCC) is the most common cancer of the oral cavity, where the condition most often affects the tongue. The most important prognostic factor in SCC of the oral cavity is the status of regional lymph nodes. In cases where these nodes test positive, the cure rate is decreased by half.

Management of the neck that is clinically negative for SCC of the oral cavity continues to evolve. In the past, the main treatment was radical neck dissection, as first described by Crile in

Lymphatic mapping and SLN biopsy for thyroid cancer

The utility of SLN biopsy for treating well-differentiated thyroid cancer has yet to be determined. At present, thyroidectomy without lymph node dissection is the standard treatment for papillary thyroid cancer in a patient whose neck is clinically negative for pathology. However, 82% of patients may have occult metastasis.46

Using blue dye only, Dixon et al47 found SLNs in 65% of patients with thyroid neoplasms. The series included two SLNs that yielded false-negative results. Other

Lymphatic mapping and SLN biopsy for merkel cell cancer

Merkel cell cancer is an uncommon, highly malignant neuroendocrine tumor of the skin. Treatment for this neoplasm is controversial and has included surgery with wide excision alone or combined with elective lymph node dissection. Radiation therapy and chemotherapy also have been used. Despite our best efforts at treatment, overall survival has not improved, and recurrence rates remain clinically significant. Most surgeons would agree that Merkel cell cancer in the head and neck must be treated

Conclusions

SLN biopsy remains an evolving treatment for melanoma of the head and neck. Clinicians should present all treatment options to patients diagnosed with intermediate-thickness melanoma in the head and neck. To reduce operative morbidity, lymphatic mapping and SLN biopsy using a combined technique can be offered as an alternative to elective lymph node dissection in patients with clinically negative nodes. However, close follow-up is necessary. Patients must be informed that this technique is not

Acknowledgements

The Medical Editing Department, Kaiser Foundation Hospitals, Inc, provided editorial assistance.

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