Controversies on the management of the clinically negative neck

Adequate management of the clinically negative neck is vital and should be balanced between over and undertreatment. Compared to clinical examination ultrasound-guided fine-needle aspiration cytology (USgFNAC) at initial staging can reduce the risk of occult metastases for T1-T2 squamous cell carcinoma of the oral cavity or oropharynx considerably to 20%, which justifies local excision of the tumour and a wait-and-see policy for the neck. SN identification and aspiration did not decrease the false-negative rate, and we have therefore abandoned its use in this setting. Using USgFNAC for follow-up enabled early detection of a significant percentage of neck failures and a high salvage rate with therapeutic neck dissection of 80%. Detecting subclinical neck metastases continues to challenge clinicians and debate continues

Quantitative molecular detection of minimal residual head and neck cancer in lymph node aspirates

Purpose: Staging of the clinically N0 neck in patients with head and neck squamous cell carcinoma (HNSCC) using ultrasound-guided, fine needle aspiration cytology (USgFNAC) has a false-negative rate of ∼ 20% that might be caused by inaccurate cytology. Molecular analysis of aspirate residues might reduce the false-negative rate, and we therefore set up a quantitative reverse transcription-PCR (Q-RT-PCR) assay based on TaqMan technology using the squamous cell-specific antigen E48 (Ly-6D) as molecular marker. Experimental design: The detection limit of the assay was determined in reconstruction experiments. The sensitivity of the assay was tested on cytological tumor-positive aspirate residues and the specificity on lymph node aspirate residues of noncancer controls. Subsequently, 235 lymph node aspirate residues of 64 HNSCC patients staged with USgFNAC were examined for the presence of E48 mRNA. E48 Q-RT-PCR results of the aspirated lymph nodes were compared with cytology and clinical outcome. Results: The detection limit of E48 Q-RT-PCR was a single tumor cell in a background of 106 peripheral blood mononuclear cells. From the 41 aspirates that were not evaluable at cytology, 24 (59%) could be diagnosed with E48 Q-RT-PCR. In the 191 aspirates that were tumor negative or not evaluable at cytology, 8 samples from 6 patients were E48 positive. These results were confirmed by histology or clinical outcome in 3 of 6 patients. E48 Q-RT-PCR showed an increase in sensitivity from 56 to 67% and an increase in frequency of reached diagnosis from 97 to 100% compared with cytology. The specificity decreased from 100 to 92%. Conclusions: Real-time E48 Q-RT-PCR is an accurate technique for squamous cell detection in lymph node aspirates of HNSCC patients. The assay shows an increase in sensitivity and frequency of reached diagnosis compared with cytology. The test could be implemented routinely in USgFNAC to diagnose cases for which cytological examination is not conclusive