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[22]
evaluated by USgFNAC and the patients were stratified for Vijayakumar et al. found that about 50% of patients with
T-staging classification. Observation of the neck consisted of tongue tumor depth more than 4 mm had grade III and IV
ultrasonographic examination every 3 months during the first tumors. The incidence of occult metastasis was 62.2%, which
3-year follow-up, which strongly resembles our wait and scan is significantly higher than for other subsites of the oral
follow-up policy. Although the sample size was limited, this cavity. Thirty eight (33.9%) patients with occult metastasis
study had the preferable study design to compare the outcome had ECS, which is a poor prognostic feature. Another poor
of elective neck treatment with observation. The reported 5-year prognostic indicator they detected was multiple levels of
disease-specific survival rates were not significantly different nodal involvement in 79 (70.5%) patients. As expected most
(observation arm 87%, END arm 89%). [14] of the lymph nodes were localized to levels I, II and III. But
level IV was involved in 23 patients. [22]
In the study of Feng et al. total regional recurrence rate of the
[16]
[13]
untreated N0 neck was found to be 19.2% for stage T1 (8/48, In the study of Huang et al. neck recurrence rate in the
16.7%) and stage T2 (6/25, 24.0%), respectively. 92.9% of them OBS group (28.6%) was significantly higher compared with
occurred in the early postoperative period (within 2 years). Of these that observed in the END group (12.7%, P = 5.004). Although
regional recurrences, only 41.7% patients were successful salvaged due contralateral regional metastases have been described in
to advanced neck disease. In their department, observation policy for some series of patients with early stage tumors of the oral
clinically N0 neck was more common in patients with the stage T1 cavity, [26,66] their data show that neck recurrence is mainly
tumours, so that the T1/T2 ratio for the randomized controlled study ipsilateral in patients treated with glossectomy alone. Among
was unbalanced (T1/T2 ratio in “END vs. observation”: 0.6 vs. 1.9). patients treated with END, 12.7% developed a regional
Although the patients from the observation group had a higher recurrence. Contralateral level I lymph nodes were the most
proportion of stage T1, They found that the patients from END group frequent site of regional recurrence. This finding was in line
[66]
exhibited significantly better DSS rates than those from observation with previous data. It is posited that this phenomenon may
group. They further analysed the prognosis of subgroups (T1/T2) be due to an afferent communicating pathway that drains from
[67]
in each group, the results showed that the patients from the END the floor of the mouth into the contralateral lymph nodes.
group with stage T2 tumours had a higher survival rate than those This may also occur silently before surgery. The second most
from the observation group. [16] common site of regional recurrence was ipsilateral level I
nodes. In their study, the 5-year cervical control rates was
much better for patients treated by END compared with OBS.
Weiss et al. suggested that END is necessary if the incidence of
[3]
occult metastasis is greater than 20%. The proponents of wait In addition, the 5-year OS in the END group was superior
and watch policy argue that 80% of patients with N0 neck would compared with patients who had a subsequent therapeutic
be over treated, and subjected to additional morbidity and costs. neck dissection. These data are in line with previous studies
in early-stage tongue cancer. It is thus posited that END
[65]
Though this argument may apply to most oral cavity tumors, the might improve both neck control and OS. Indeed, application
cancer of the tongue must be viewed as a separate entity. The of this technique might improve the chance of clearance
incidence of nodal metastasis is higher for early cancer of the of micrometastasis that cannot be detected by histology
tongue when compared with other sites of the oral cavity. [62,63] or imaging. However, their data provide evidence that, in
D’Cruz et al. found the incidence of nodal metastasis to be the group of patients treated by END, the incidence of skip
[15]
37.5% in T1 lesions and 62.5% in T2 lesions of the oral tongue. metastasis to level IV in the absence of level I/II lesions is as
Andersen et al. studied the results of neck failure following low as 2.7% (1 case out of 37 patients). In the OBS group,
[64]
observation of N0 necks. They found that 60% of patients had the skip metastasis rate was 5.4% (3 of 56) in patients with
N2 disease and 49% had extracapsular spread (ECS). Either or regional recurrence who received salvage neck dissection.
both these adverse prognostic factors were present at the time In their report the skip metastatic rate was lower compared
of surgery in 77% of patients. [22,62-64] with that reported in previous studies. [68-71] However, in their
study all patients were staged with the use of CT/MR imaging.
Four RCTs have been performed to compare END with wait In the light of our data, routine dissection of level IV lymph
and watch policy. Two of the trials were conducted purely on node alongside supraomohyoid neck dissection can provide
early oral tongue cancers. Fakih et al. in a series on T1 and little benefit to patients with early-stage tongue cancer.
[65]
T2 lesions, compared END with observation. They found that It is concluded that level IV nodes should not be routinely
there was no survival difference between the two groups. They included in the neck dissection for patients with negative
found that a tumor depth of more than 4 mm was associated neck as assessed by CT/MRI scans.
with higher rates of involved nodes and suggested that these
set of patients may benefit from END. A more recent RCT from In the study of Dias et al. analyzing the two groups of patients
[6]
Hong Kong compared END versus observation for T1 and T2 (resection of the primary tumor alone-RA and resection of
lesions of the oral tongue. The authors had a robust follow- the primary tumor "plus" elective neck disection-XR+END)
up protocol of clinical and ultrasonographic examination of according to the incidence of regional recurrence, they
the neck to detect recurrences. They were able to salvage all found a 24% incidence in the RA group compared with a 4%
neck recurrences in the observational arm and thus found no incidence in the R+END group. The 20% difference between the
survival differences between the two arms. All the above two groups was statistically significant (P = 0.03). Differences
[14]
RCTs had small numbers and consisted of methodology flaws between disease-free survival of 97% for the R+END group and
making their conclusions difficult to inculcate into clinical of 74% for the RA group were also statistically significant (P =
[34]
practice. 0.05). These findings confirm the results of Kligerman et al. in
170 Plast Aesthet Res || Volume 3 || May 25, 2016