Management of clinically node-negative early-stage oral cancer: network meta-analysis of randomized clinical trials.

The best treatments for the clinically node-negative (cN0) neck in early-stage oral squamous cell carcinoma (OSCC) patients are a subject of ongoing debate and there is no consensus. A network meta-analysis (NMA) of randomized clinical trials (RCTs) was conducted to determine the most effective treatment and to rank treatments based on their effectiveness. A systematic search was performed in accordance with the PRISMA guidelines to retrieve RCTs that compared therapeutic neck dissection (TND), sentinel lymph node biopsy (SLNB), and elective neck dissection (END). The outcomes analysed were overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS), and nodal recurrence. Hazard ratios and risk ratios were calculated by direct meta-analysis and NMA. Ten RCTs with a total of 1858 patients were eligible for inclusion. Direct meta-analysis showed END to be superior to TND and comparable to SLNB. The NMA revealed no statistically significant difference between END and SLNB (very low quality evidence) regarding OS, DSS, DFS, and nodal recurrence. However, END was found to significantly improve OS and DFS, and reduce nodal recurrence when compared to TND (moderate quality evidence). END ranked as probably the top treatment option for maximizing OS and DSS, and reducing nodal recurrence in early-stage OSCC, followed by SLNB and TND. There was very low quality evidence supporting SLNB as non-inferior to END for patients with early-stage OSCC. This NMA yielded favourable results for the use of END (with moderate quality evidence) in early-stage OSCC patients, although excellent results have also been obtained with SLNB. However, data in the literature for SLNB are scarce, as this technique has not yet been formalized in many countries. There is a need to further explore SLNB for early-stage OSCC patients, as well as its value in detecting occult lymph node metastases on the contralateral side. More studies comparing morbidity, quality of life, and costs between the different management strategies for the clinically negative neck in early-stage OSCC patients are needed.

Guidelines from the Brazilian society of surgical oncology regarding indications and technical aspects of neck dissection in papillary, follicular, and medullary thyroid cancers.

Objective: The purpose of these guidelines is to provide specific recommendations for the surgical treatment of neck metastases in patients with papillary, follicular, and medullary thyroid carcinomas. Materials and methods: Recommendations were developed based on research of scientific articles (preferentially meta-analyses) and guidelines issued by international medical specialty societies. The American College of Physicians' Guideline Grading System was used to determine the levels of evidence and grades of recommendations. The following questions were answered: A) Is elective neck dissection indicated in the treatment of papillary, follicular, and medullary thyroid carcinoma? B) When should central, lateral, and modified radical neck dissection be performed? C) Could molecular tests guide the extent of the neck dissection? Results and conclusion: Recommendation 1: Elective central neck dissection is not indicated in patients with cN0 well-differentiated thyroid carcinoma or in those with noninvasive T1 and T2 tumors but may be considered in T3-T4 tumors or in the presence of metastases in the lateral neck compartments. Recommendation 2: Elective central neck dissection is recommended in medullary thyroid carcinoma. Recommendation 3: Selective neck dissection of levels II-V should be indicated to treat neck metastases in papillary thyroid cancer, an approach that decreases the risk of recurrence and mortality. Recommendation 4: Compartmental neck dissection is indicated in the treatment of lymph node recurrence after elective or therapeutic neck dissection; "berry node picking" is not recommended. Recommendation 5: There are currently no recommendations regarding the use of molecular tests in guiding the extent of neck dissection in thyroid cancer.

Lateral Neck Dissection for Well-Differentiated Thyroid Carcinoma: Is Prophylactic Level V Neck Dissection Necessary? A Retrospective Cohort Study.

OBJECTIVE: The presence of clinically detectable papillary thyroid carcinoma (PTC) metastases in the lateral neck is an indication for neck dissection (ND) and thyroidectomy. Although there is a consensus regarding the importance of therapeutic selective ND of involved levels II to IV in patients with clinically evident locoregional metastatic disease, the prognostic benefit of level V prophylactic ND remains debatable. METHODS: All patients who underwent thyroidectomy with ND for metastatic PTC between 2006 and 2019 were included in a single-institution retrospective study. Preoperative characteristics at initial presentation, imaging workup, intraoperative findings, and the final histopathological reports were retrieved from the institutional database. RESULTS: A total of 189 patients with locally advanced PTC were identified, of whom 22 (11.6%) patients underwent therapeutic selective ND at levels II to IV together with level V dissection due to clinical involvement. Comparison of the patients who were operated on level V to those who were not revealed no significant difference. The disease recurrence rate was 20.1% throughout an average follow-up of 5.1±3.1 years. No significant differences in recurrence rate were found between patients who underwent and those who did not undergo level V ND (22.7% vs 19.8%, P = .648). No recurrence at resected level V was detected during follow-up, while recurrence at level V was found in 4 (2.1%) patients who did not undergo level V dissection. Evidence of macroscopic and microscopic extrathyroidal extension was significant predictors of disease recurrence risk. CONCLUSION: There were no significant associations between level V dissection and risk for recurrence. Recurrence at level V was rare (4/189 patients, 2.1%). Our study's findings suggest a low prophylactic benefit of an elective level V ND. Elective level V ND should not be done routinely when lateral ND is indicated but should rather be considered after careful evaluation in high-risk patients.

Guidelines from the Brazilian society of surgical oncology regarding indications and technical aspects of neck dissection in papillary, follicular, and medullary thyroid cancers

ABSTRACT Objective: The purpose of these guidelines is to provide specific recommendations for the surgical treatment of neck metastases in patients with papillary, follicular, and medullary thyroid carcinomas. Materials and methods: Recommendations were developed based on research of scientific articles (preferentially meta-analyses) and guidelines issued by international medical specialty societies. The American College of Physicians' Guideline Grading System was used to determine the levels of evidence and grades of recommendations. The following questions were answered: A) Is elective neck dissection indicated in the treatment of papillary, follicular, and medullary thyroid carcinoma? B) When should central, lateral, and modified radical neck dissection be performed? C) Could molecular tests guide the extent of the neck dissection? Results/conclusion: Recommendation 1: Elective central neck dissection is not indicated in patients with cN0 well-differentiated thyroid carcinoma or in those with noninvasive T1 and T2 tumors but may be considered in T3-T4 tumors or in the presence of metastases in the lateral neck compartments. Recommendation 2: Elective central neck dissection is recommended in medullary thyroid carcinoma. Recommendation 3: Selective neck dissection of levels II-V should be indicated to treat neck metastases in papillary thyroid cancer, an approach that decreases the risk of recurrence and mortality. Recommendation 4: Compartmental neck dissection is indicated in the treatment of lymph node recurrence after elective or therapeutic neck dissection; "berry node picking" is not recommended. Recommendation 5: There are currently no recommendations regarding the use of molecular tests in guiding the extent of neck dissection in thyroid cancer.

Extent and Indications for Elective and Therapeutic Neck Dissection for Salivary Carcinoma.

Although salivary gland malignancies account for only a small percentage of all head and neck cancers, the incidence is increasing. Furthermore, there is a wide variety of histologic subtypes which must be taken into account in the context of their location. Each is associated with a different rate of regional metastasis and overall survival. This article examines the incidence of salivary gland malignancies and provides evidence for the indications for and extent of elective or therapeutic neck dissection based on location, pathologic type, and histopathologic characteristics.

Elective versus therapeutic neck dissection in node-negative oral cancer: Evidence from five randomized controlled trials.

The aim of this study was to compare the outcomes of elective neck dissection (END) with that of a more conservative approach comprising of observation plus therapeutic neck dissection for nodal relapse (OBS), by conducting a meta-analysis of randomized controlled trials (RCTs) that compare these two surgical approaches in patients. RCTs conducted prior to May 2015 were identified from electronic databases such as MEDLINE EMBASE and Cochrane Library. Reference lists within the retrieved articles were used as secondary reference sources. Disease-free survival (DFS) and overall survival (OS) were the primary outcome measures. Five RCTs with a combined subject population of 779 patients were included. Meta-analysis of these 5 RCTs showed that DFS in END group was higher than that in the OBS group with a significant inter-group difference (Risk Ratio [RR]:1.33; 95% Confidence Interval [CI] 1.06, 1.66); P=0.01; five trials, 779 participants]. However, there was a significant statistical heterogeneity among the studies (I-squared=56%, P=0.06). Four studies had reported on OS. Meta-analysis of these 4 RCTs revealed a higher OS in the END group as compared to that that in the OBS group with a significant inter-group difference (RR: 1.18; 95% CI 1.07, 1.29); P=0.0009; four trials, 708 participants]. The statistical heterogeneity of these 4 studies is small (I-squared=14%, P=0.32). The results of this meta-analysis suggest that END at the time of resection of the primary tumor confers a DFS and OS benefit in patients with clinically node-negative oral cancer.

Detection and management of cervical lymph nodes in papillary thyroid cancer.

Lymph node metastases in papillary thyroid cancer are a common occurrence; however, the management of clinically negative cervical lymph nodes remains controversial. Preoperative neck ultrasound mapping is crucial, and complete dissection of a nodal compartment is recommended for any metastatic lymph nodes. The role of prophylactic central neck dissection remains controversial. The BRAF V600E mutation is a common mutation in papillary thyroid cancer, and has been associated with more aggressive tumor behavior. Evaluating the BRAF status of tumors may have implications for treatment and surveillance. New areas of research continue to focus on risk stratification and identifying which patients benefit from a more aggressive treatment, such as prophylactic central lymphadenectomy and radioiodine ablation and more intense surveillance strategies.

Selective Neck Dissection for Clinically Node-Positive Oral Cavity Squamous Cell Carcinoma

PURPOSE: The treatment of a clinically node-positive (cN+) neck is important in the management of oral cavity squamous cell carcinoma (OSCC). However, the extent of neck dissection (ND) remains controversial. The purpose of our study was to evaluate whether level IV or V can be excluded in therapeutic ND for cN+ OSCC patients. MATERIALS AND METHODS: We performed a retrospective chart review of 92 patients who underwent a comprehensive or selective ND as a therapeutic treatment of cN+ OSCC from January 1993 to February 2009. RESULTS: The incidence rate of metastasis to level IV or V was 22% (16 of 72) on the ipsilateral neck. Of 67 cases without clinically suspicious nodes at level IV or V, 11 cases (16%, 11 of 67) had pathologically proven lymphatic metastasis to level IV or V. Only a nodal staging above N2b was significantly relevant with the higher rate of level IV or V lymph node metastasis (p=0.025). In this series, selective ND, combined with proper adjuvant therapy, achieved regional control and survival rates comparable to comprehensive ND in patients under the N stage of cN2a OSCC. CONCLUSION: In conclusion, level IV and V patients can avoid recurrence under cN2a OSCC.