A Meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative neck [Elektronische Ressource] / Ayotunde James Fasunla. Betreuer: A. M. Sesterhenn

Dr J.A. Fasunla

Description

Aus der Klinik für Hals-, Nasen- und Ohrenheilkunde der Philipps-Universität Marburg Geschäftsführender Direktor: Prof. Dr. J.A. Werner in Zusammenarbeit mit dem Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg A Meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative neck Inaugural–Dissertation zur Erlangung des Doktorgrades der gesamten Humanmedizin dem Fachbereich Medizin der Philipps – Universität Marburg vorgelegt von Ayotunde James Fasunla aus Benin-city, Nigeria Marburg 2011 Angenommen vom Fachbereich Humanmedizin der Philipps-Universität Marburg Am: 09.03.2011. Gedruckt mit Genehmigung des Fachbereiches Dekan: Prof. Dr. M. Rothmund Referent: Prof. Dr. A.M. Sesterhenn Korreferent: Prof. Dr. A.

Sujets

• Gesundheit

Informations

• Publié par: philipps-universitat_marburg
• Publié le: 01 janvier 2011
• Nombre de lectures: 6
• Langue: English

Extrait

 

 

Aus der Klinik für Hals-, Nasen- und Ohrenheilkunde der Philipps-Universität Marburg Geschäftsführender Direktor: Prof. Dr. J.A. Werner in Zusammenarbeit mit dem Universitätsklinikum Gießen und Marb Standort Marburg  

 

urg GmbH,

A Meta-analysis of the randomized controlled trials o n

elective neck

dissection versus therapeutic neck

dissection in oral cavity cancers with clinically nod e-

negative neck

      Inaugural–itno iDssreat zur Erlangung des Doktorgrades der gesamten Humanmedizin  

  dem Fachbereich Medizin der Philipps–Universität Marburg vorgelegt von       Ayotunde James Fasunla aus Benin-city, Nigeria  

  Marburg 2011

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Angenommen 

Marburg 

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Am: 09.03.2011.

 

Fachbereich 

Humanmedizin 

Gedruckt mit Genehmigung des Fachbereiches

Dekan: Prof. Dr. M. Rothmund

Referent: Prof. Dr. A.M. Sesterhenn

Korreferent: Prof. Dr. A. Torossian

 

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Sternocleidomastoid muscle Selective neck dissection

Spinal accessory nerve

Ultrasound 

RND

 

SAN

RT

SND

SCM

Radiotherapy 

Radical neck dissection

 

 

 

 

 

 

US

 

Meta-

analyses  

Preferred Reporting Items for Systematic reviews and

OBS

PET

PRISMA 

 

 

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Internal jugular vein

Intensity modulated radiation therapy

International union against cancer

Magnetic resonance imaging

Modified radical neck dissection

Observation or therapeutic neck dissection

Positron emission tomography

DNA

 

EBT

 

Computerised tomography

Elective neck dissection

External beam therapy

Deoxyribonucleic acid

AJCC

American Head and Neck Society

AHNS  

American Academy of Otolaryngology-Head and Ne ck Surgery

END

CCRT  

Concurrent chemoradiotherapy

American Joint Committee on Cancer

IJV

IMRT  

 

CT

MRND 

AAO-HNS 

IUCC  

MRI

 

 

Lists of abbreviations

                       

                       

                       

                       

Contents        1 Introduction 1.1 Relevant anatomy of the oral cavity 1.2 Lymphatic drainage of the oral cavity 1.3 Statements of problem 1.4 Justification of the study 1.5 Research question 1.6 Hypothesis 2 Study objectives 3 Materials and method 3.1 Type of study 3.2 Study design 3.3 Type of participants 3.4 Topography, nomenclature and physiology of the lymp hatic system of the neck 3.5  Staging of oral squamous cell carcinoma     3.6 Diagnosing the node-negative neck 3.7 Criteria for inclusion 3.8 Exclusion criteria 3.9 Search strategy and method for identification of stud y   3.10 Validity method of assessment 3.11 Type of intervention 3.12 The development of surgical procedures for treatment of cervical lymph node metastases 3.13 Classification of neck dissection 3.14 Data extraction 3.15 Outcome measures         3.16 Statistical analyses 4 Results 5 Discussion 6 Summary 7 Zusammenfassung   5

 

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1

Introduction

Oral squamous cell carcinoma is the most prevalent of all m alignancies arising

from the oral cavity and could result in severe morbiditi es and mortality if not

promptly identified and treated. It accounted for 30% o f all head and neck

cancers [90]. The rich lymphatic drainage in this region makes these tumors to

show a high incidence of metastasis to regional cervical lym ph nodes [30].

Cancers arising in the oral cavity have been demonstrated to have a high

metastatic rate of well over 50% [140]. Neck node status i s the single most

important prognostic factor in oral cancers and other head and neck cancers

[26]. The incidence of lymph node metastases of these canc ers depends

largely on histo-pathologic factors like tumor thickness, perine ural and

microvascular invasions, lymphocytic inflammatory infiltratio n, pattern of tumor

invasion and differentiation, and molecular tumor markers [45,58,140,150].

Tumor size greater than 2cm and tumor invasion depth of more than 4mm are

known risk factors for nodal metastasis [97,135]. The degree o f histologic

differentiation and tumor staging also play a significant role in nodal

metastases. The incidence of nodal metastases is higher in poorly

differentiated and late stage diseases [140]. However, in the American Joint

Committee on Cancer (AJCC) 2010 classification system, pT1-2 N0 oral cavity

squamous cell carcinomas are considered to be the early stage can cer [41].

The staging system is similar to that of the International Union Against Cancer

(IUCC) 2009 [141].

 

A subset of oral cancer patients without clinical evidence o f regional

metastases is known to harbor occult metastases. Unfortunately , there is still

no examination method that can validly detect micro-me tastasis in

cervical lymph nodes during evaluation of these patients . Available imaging

methods such as computed tomography (CT) scan, magnetic resona nce

imaging (MRI), positron emission tomography (PET) and ultrasoun d-guided fine

needle aspiration biopsy have been shown to have sign ificant false-negative

and false-positive rates [35]. Also, there has not been accurate biomarker that

can reliably identify or predict the presence of occult ce rvical metastases.

 

7

Therefore, histologic examination of the neck specimen is th e single most

important and reliable investigation to detect neck nodal metastasis.

 

The great challenges in the management of these patie nts by surgeons and

radiotherapists include the identification of the patien ts with true clinically node-

negative neck (N0 neck) and determination of the extent of appropriate therapy

that will not be regarded as over treatment. Optimal treatment for carcinomas of

the oral cavity with clinical N0 neck remained a controversia l issue. Primary

tumor control can be achieved by an appropriate surgical opera tion with or

without radiotherapy. However, controversies exist on the ma nagement of the

neck in clinically node-negative neck (N0) patients although ; the available

management policies include observation, elective neck di ssection, or

irradiation [71,99,169]. Even though there is no unive rsal consensus guideline

on the management of the neck in squamous cell carcinoma o f oral cavity with

clinical N0 necks, the predominant opinion is elective neck dissection

[117,136]. Elective neck dissection refers to dissection of cervi cal lymphatics

and fibrofatty tissues in the absence of an obvious clini cal or radiological

evidence of neck node metastasis for either staging or therape utic purposes.

Those who advocate for neck treatment stated that most of t hose patients

whose necks are observed eventually develop nodal metastasi s and are

usually detected at an advanced stage of the disease wit h poor management

outcome. The benefits of neck dissection as advocated by this group include

successful reduction of regional recurrence, pathological stagi ng of neck,

avoidance of unnecessary neck irradiation and indication of cases where

adjunct therapy should be employed [45,58,71,97,99,1 40,150,169].

Nevertheless, there is still an unresolved controversy on it s benefits in the

eventual regional control and survival compared with the p olicy of observation

[46,157]. The advocators of observation or ‘watchful wait ing’ policy after the

removal of the primary tumor have stated that elective ne ck dissection in

clinically N0 necks is just a diagnostic staging procedure rather than a

therapeutic operation hence unjustifiable [66]. They recom mended close

watching of the neck during follow-up of these patients a nd performance of

therapeutic neck dissection only if cervical metastases develo ped [116]. 8