An insight into the management and assessment of head and neck cancer
Prof Michiel van den Brekel - Netherlands Cancer Institute, Amsterdam, The Netherlands
Can you tell us about your discussion topic?
We had to organise a session together with the Netherlands Cancer Institute and the Memorial Sloan Kettering Cancer Institute in New York. The topic of the panel discussion was the management and the assessment of the N0 neck. That’s a very controversial issue which has been controversial for decades already; since I’m in the field it has always been an issue. The issue is very important because it plays in more than half of your patients with oral cancer who come in and you don’t find apparent lymph node metastases in the neck so you think the neck has no lymph node metastases but then still we know from all kinds of studies that 30-40%, sometimes even 50% of these patients still harboured metastases, so metastases that we cannot find. That’s the issue – how do we manage that? Do we have to treat all the patients electively, for example prophylactic neck dissection or prophylactic radiotherapy? Or can we just wait and see or do imaging to find them or nowadays a new thing since a couple of years is can we replace this elective neck treatment, which has been the policy for many, many years, with a sentinel node biopsy?
What are the options to modernise the treatment?
In imaging there is always a lot of evolution and a lot of development so MR imaging has become much better than in the beginning and now we have PET-CT which is a new technique. We have PET scan together with the CT scan and we can look metabolically at lymph nodes. The holy grail, of course, is that we will find small markers that we can detect in lymph nodes with metastases. So we need markers that go into metastases and we can detect them with any imaging technique. But that’s the holy grail which many people are working on, maybe with monoclonal antibodies, maybe with other markers but we didn’t find it yet. So that’s one part of the development, the other part is the sentinel node biopsy. The sentinel node has been popularised since the last five years, it came more from breast and melanoma cancer. In the sentinel node biopsy what you do is you inject some contrast agent around the tumour and then you take out the lymph nodes that take up this contrast. But it is a surgical procedure so it’s not really assessment, it’s something in between elective surgery and imaging. So it’s invasive and it also has a lot of disadvantages, it costs a lot of money and it takes a lot of time for the patient. In these sentinel node biopsies there are also a lot of developments, it used to be only with radioactivity but now we can also do it with fluorescent markers so we can not only detect them with the Geiger teller or with SPECT scans but we can also see them with special cameras that can detect this fluorescence. So those are very new developments and they really give improved results. So more and more people are now trying to assess it with sentinel nodes or with modern imaging techniques and not do elective treatment.
What key messages would you pass on to doctors?
There is still a lot of controversy if this elective treatment has better prognosis than wait and see or good imaging because recently a study came out from India and they showed that elective treatment has a better prognosis. But there are also a couple of flaws in this study and patient populations are not completely comparable between India and the Western world. So the definitive answer is not out there yet. If you want to play on the safe side you just do elective treatment. I think that’s a very important message. Only if you are really interested in improving your accuracy you train your radiologists or you want to do special procedures like sentinel node you can embark on these modern techniques. But for routine practice I think elective treatment is still something we advise, it’s very safe. We know for sure that for the prognosis of the patient it’s a safe strategy and the way imaging the sentinel node is still something in the research phase and should not be used as a routine.
