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In Reply:

Department of Maxillofacial Plastic Surgery, Johann Wolfgang Goethe-University Medical School, Frankfurt am Main, Germany

I very much appreciate the criticism of Smith et al. They are absolutely right in stating that the title of our article is the summary of our single-center experience, which needs further validation. We ended our text with the expression of our hope that "the benefit for the patients is evident if the results were lasting and could be affirmed by other working groups." ¹

However, our experience of a comparison of positron emission tomography (PET) and computed tomography (CT) with regard to neck staging is much older dating back to 1994, and results were published in 1998 and 2000.^2,3 The specificity of PET proved to be higher, and we started staging the neck in oral and oropharyngeal cancer patients as described in our more recent publication. Decision making for the neck using PET is extremely simple as compared to CT, not to speak of the detection of second primaries and distant metastases in a large portion of patients without additional examinations (panendoscopy, abdominothoracic CT).

All other considerations of Smith et al ignore the main support (and concurrent greatest weakness) of our study: the observation time without neck relapses (to date, 33 months; desirable end point, 60 months). In avoiding elective neck dissections and pathohistological work-up, we have to rely on time, which may or may not approve our results. If there will be a rate of neck recurrences > 10% in sentinel node biopsy (SNB) -negative patients, we have to re-evaluate the method. If SNB is correctly staging the neck and no neck metastases will become clinically evident in these patients in the future, all apprehensions of Smith et al with regard to the relevance of the different treatment methods of the neck will be dispelled.

In the last paragraph of their letter, the major concern of Smith et al becomes manifest. It does not seem so much to be the method of SNB but the estimation of CT in comparison to PET. We surely know that PET is a cost-intensive method, which is not as widely used as the more conventional CT. Therefore, the CT + SNB approach claimed by the colleagues was already executed. The initiators of the first multicenter trial on SNB (Plastic Surgery Unit, Canniesburn Hospital, Glasgow, United Kingdom) decided that patients should be "classified as clinically N0 by either clinical palpation or radiological imaging techniques such as positron emission tomography or computed tomography."⁴ In 72 patients staged by SNB alone, 20 positive sentinel nodes were detected (28%), and in 53 patients examined by SNB assisted elective neck dissection, the rate has been 41% (22 of 53 patients). Other relevant studies (> 10 patients) on SNB in cancer of the head and neck^5-13 similarly relied on elective neck dissections as reference, staged the neck using CT or ultrasound, and had rates of positive sentinel nodes between 10% and 61%, with a median of 27%. All had an excellent small rate of false-negative SNB results in comparison with pathohistology. We, therefore, willingly acknowledge the possibility of using CT as prerequisite for SNB, but with the consequence of higher rates of positive sentinel nodes, and, consequently, a higher rate of consecutive neck dissections. This rate, however, will still have the chance to be lower due to SNB as compared to conventional surgical treatment of the neck. As far as we know, conventional treatment of oral and oropharyngeal cancer patients in most centers of the world always comprises a neck dissection of some type.

The speculation that intra-arterial local chemotherapy might have "sterilized microscopic disease" in the neck nodes would be, of course, a fantastic point in favor of that method but is not proven at all. Our own investigations to date concerning this problem demonstrated only small plasma concentrations of cisplatin,¹⁴ and will be continued because of the relevance of this issue. According to our state of knowledge, it is the selection by PET that has to be the reason for the low rate of positive sentinel nodes in our sample.

To conclude, the main goal pursued with our article was to demonstrate the possibility of reducing the rate of elective neck dissections in oral and oropharyngeal cancer patients by combination of imaging techniques and SNB. The emphasis lies on the use of SNB. If other groups are able to demonstrate this using CT and SNB, we will be happy. However, we believe that PET is the optimal method of selection for SNB, and it is our task as members of a university hospital to investigate the best possible method.

Author's Disclosure of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.

Acknowledgment

The authors whish to acknowledge Dr Gabriel N. Hortobagyi for reviewing this letter.

REFERENCES

1. Kovács AF, Dobert N, Gaa J, et al: Positron emission tomography in combination with sentinel node biopsy reduces the rate of elective neck dissections in the treatment of oral and oropharyngeal cancer. J Clin Oncol 22:3973-3980, 2004[Abstract/Free Full Text]

2. Adams S, Baum RP, Stuckensen T, et al: Prospective comparison of 18F-FDG PET with conventional imaging modalities (CT, MRI, US) in lymph node staging of head and neck cancer. Eur J Nucl Med 25:1255-1260, 1998[CrossRef][Medline]

3. Stuckensen T, Kovács AF, Adams S, et al: Staging of the neck in patients with oral cavity squamous cell carcinomas: A prospective comparison of PET, ultrasound, CT and MRI. J Craniomaxillofac Surg 28:319-324, 2000[Medline]

4. Ross GL, Soutar DS, MacDonald DG, et al: Sentinel node biopsy in head and neck cancer: Preliminary results of a multicenter trial. Ann Surg Oncol 11:690-696, 2004[CrossRef][Medline]

5. Chiesa F, Mauri S, Grana C, et al: Is there a role for sentinel node biopsy in early N0 tongue tumors? Surgery 128:16-21, 2000[CrossRef][Medline]

6. Mozzillo N, Chiesa F, Botti G, et al: Sentinel Node Biopsy in Head and Neck Cancer. Ann Surg Oncol 8:103S-105S, 2001 (suppl 9)

7. Dünne AA, Kulkens C, Ramaswamy A, et al: Value of sentinel lymphonodectomy in head and neck cancer patients without evidence of lymphogenic metastatic disease. Auris Nasus Larynx 28:339-344, 2001[CrossRef][Medline]

8. Shoaib T, Soutar DS, MacDonald DG, et al: The accuracy of head and neck carcinoma sentinel lymph node biopsy in the clinically N0 neck. Cancer 91:2077-2083, 2001[CrossRef][Medline]

9. Stöckli SJ, Steinert H, Pfaltz M, et al: Sentinel lymph node evaluation in squamous cell carcinoma of the head and neck. Otolaryngol Head Neck Surg 125:221-226, 2001[CrossRef][Medline]

10. Barzan L, Sulfaro S, Alberti F, et al: Gamma probe accuracy in detecting the sentinel lymph node in clinically N0 squamous cell carcinoma of the head and neck. Ann Otol Rhinol Laryngol 111:794-798, 2002[Medline]

11. Ionna F, Chiesa F, Longo F, et al: Prognostic value of sentinel node in oral cancer. Tumori 88:S18-S19, 2002[Medline]

12. Werner JA, Dünne AA, Ramaswamy A, et al: Sentinel node detection in N0 cancer of the pharynx and larynx. Br J Cancer 87:711-715, 2002[CrossRef][Medline]

13. Civantos FJ, Gomez C, Duque C, et al: Sentinel node biopsy in oral cavity cancer: Correlation with PET scan and immunohistochemistry. Head Neck 25:1-9, 2003[CrossRef][Medline]

14. Tegeder I, Bräutigam L, Seegel M, et al: Cisplatin tumor concentrations after intra-arterial cisplatin infusion or embolization in patients with oral cancer. Clin Pharmacol Ther 73:417-426, 2003[CrossRef][Medline]

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Related Correspondence

• Do PET and SNB Reduce the Rate of Elective Neck Dissection? A Hypothesis Still in Need of Validation
  Benjamin D. Smith, Brian E. Lally, Bruce G. Haffty, and Lynn D. Wilson
  JCO 2005 23: 2874-2875 [Full Text]

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