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Background

Lymphoscintigraphy for the Evaluation of Nodal Metastasis in Head and Neck Squamous Cell Carcinoma. Background. High predilection for nodal metastasis (2/3) High prevalence of occult metastasis (30%). Current standard of care of neck metastasis. Hypothesis.

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Background

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  1. Lymphoscintigraphy for the Evaluation of Nodal Metastasis in Head and Neck Squamous Cell Carcinoma

  2. Background • High predilection for nodal • metastasis (2/3) • High prevalence of occult • metastasis (30%)

  3. Current standard of care of neck metastasis

  4. Hypothesis Lymphoscintigraphy can reliably used to detect Sub-clinical metastasis in head and neck squamous cell ca

  5. Concept… Tumor Sentinel node

  6. Concept…

  7. Previous study Kuriakose M.A. et al., Proceedings of 6th Int. Head Neck Cancer Con. Washington, Aug 2004.

  8. T1-4 N0 N=25 SLN identified? Yes: 23 No: 2 H & E Macrometastasis (>2mm) n=4 Micrometastasis (<2mm) n=4 No metastasis n=13 False Negative n=2 IHC 4 positive 13 negative 2 negative Status, F/U 12 to 60 months 2 NED 2 NED 4 NED 2 AWD 13 NED 1 DOD 1 AWD

  9. Objectives • Primary Objective: • (1)To determine the effectiveness of lymphoscintigraphy to evaluate lymphatic metastasis of head and neck squamous cell carcinoma • Secondary Objectives: • (1)Effectiveness of frozen section examination for pathological evaluation of sentinel lymph node. • (2)Comparison of quality of life of patients undergoing sentinel node biopsy and Elective neck dissection. • (3)Significance of submicroscopic cervical nodal metastasis.

  10. Study Schema

  11. Inclusion/Exclusion Criteria

  12. Sentinel Lymph-node mapping • Dynamic lymphoscintigraphy • Hand-held gamma probe

  13. Dynamic Lymphoscintigraphy Filtered Tc 99m sulfur colloid Injected at 3-4 locations at tumor periphery Total dose < 200 Ci Immediately after injections, patient positioned under wide-field-of-view gamma camera

  14. Dynamic Lymphoscintigraphy Anterior Lateral

  15. Hand Held Gamma Probe • 2-3 cm incisionat site(s) predicted by dynamic imaging • Probe point away from primary site • The nodes with counts 3 times the background is considered SLN • Counts obtained in-vivo, ex-vivo and at surgical bed

  16. Histopathological Evaluation • Intra-op evaluation by frozen section and imprint cytology • SLN evaluation • Nodal basin (SND) examined by H&E • IHC for cytokeratin using AE-1/AE-3 antibody Serial section at 1.5 µm For pN0- H&E and IHC on alternate sections

  17. Positive by H&E Positive by AE-1/AE-3

  18. Risk/ Benefit • RISK • Discomfort at injection site • 200 Ci Tc Colloid = Diagnostic x-ray • BENEFIT • No established direct benefit • COST • Cost of lymphoscintigraphy and Selective neck dissection are equivalent

  19. Time Schedule End Points: 1.Reliability of frozen section to determine the nodal metastasis 2.Quality of life at 1 month, 2 years 3.Primary tumor characteristics which predicts nodal metastasis (volume, depth, pathology, molecular markers) 4.Significance of sub-microscopic metastasis.

  20. Grant/Sponsorship • Departmental • After IRB approval project will be submitted for a DST grant

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