Management of the Neck in Oral Cavity Cancer
Oral cancer is unusual in the Western countries, with an estimated 27,450 new cases for 2013 in the USA [1]. There has been a significant increase in 5-year relative survival rate between 1975–1978 and 2002–2008 of 53 % vs 65 % for all races, 54 % vs 67 %
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Management of the Neck in Oral Cavity Cancer Robert A. Ord and J. Lubek
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Introduction
Oral cancer is unusual in the Western countries, with an estimated 27,450 new cases for 2013 in the USA [1]. There has been a significant increase in 5-year relative survival rate between 1975–1978 and 2002–2008 of 53 % vs 65 % for all races, 54 % vs 67 % for whites, and 36 % vs 45 % for blacks. All of these were statistically significant (p 1.5 cm or any other cervical node >1 cm; shape, metastatic nodes are more rounded or spherical; and appearance, central nodal necrosis is always pathologic (Fig. 7.1). Ultrasound imaging of the neck has been advocated as inexpensive and can be combined with fine needle aspiration to improve accuracy; however, it is time-consuming and very technique sensitive. In 1993 Erkan et al. reported a sensitivity of 94.4 % and a specificity of 95.7 % for ultrasound imaging of cervical metastases [12]. When the PET scan was developed, it seemed to give the clinician even greater ability to accurately diagnose and stage head and neck cancer (Fig. 7.2). In addition the whole body imaging of PEt allows diagnosis of distant metastases or second primary cancers. As fused PET/CT and PET/MR have become available, the number of options for imaging has increased; however, in critical areas of concern especially the N0 neck, recent studies do not indicate that imaging has superseded surgical staging. A number of studies in the last 10 years have shown that PET scans in N0 necks cannot be used to define surgical management due to a limited sensitivity for small deposits and a relatively high number of false positives [13, 14]. These findings have not changed in recent published work with research in 2012 showing PET/CT
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Fig. 7.2 Axial cut fused PET/CT shows node with increased SUV on the right side adjacent to the external thyroid cartilage of the larynx
having a much reduced rate of efficiency for N0 necks as opposed to N+ necks and concluding that it has little advantage in staging N0 necks [15]. PET/MR seems to have no advantage over PET/CT [16]. In comparing different imaging techniques, conclusions are somewhat varied. One 2014 prospective study examined patients deemed N0 by CT and/or MR who were then examined with ultrasound (US) and found that the number of patients with undiagnosed occult metastases decreased from 31 to 16 %, while 6 % of patients were over-staged by US [17]. In another study using multiple studies, it was concluded that fusion of (18)F-FDG-PET/MRI and (18)F-FDG-MRI plus DWI (diffusion-weighted imaging) may not increase nodal detection and N staging in oral cancer compared to US and (18) F-FDG-PET/CT [18]. Chaukar et al. found contrast-enhanced CT to give better concordance with histology in the N0 neck than either US or PET/CT [19]. In 2012 a meta-analysis comparing imaging modalities for the N0 neck identified 168 articles of which 7 studies fulfilled the inclusion criteria for CT, 6 studies for MR, 11 studies for PET, and 8
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