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A Meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative neck [Elektronische Ressource] / Ayotunde James Fasunla. Betreuer: A. M. Sesterhenn

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84 Pages
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Aus der Klinik für Hals-, Nasen- und Ohrenheilkunde der Philipps-Universität Marburg Geschäftsführender Direktor: Prof. Dr. J.A. Werner in Zusammenarbeit mit dem Universitätsklinikum Gießen und Marburg GmbH, Standort Marburg A Meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative neck Inaugural–Dissertation zur Erlangung des Doktorgrades der gesamten Humanmedizin dem Fachbereich Medizin der Philipps – Universität Marburg vorgelegt von Ayotunde James Fasunla aus Benin-city, Nigeria Marburg 2011 Angenommen vom Fachbereich Humanmedizin der Philipps-Universität Marburg Am: 09.03.2011. Gedruckt mit Genehmigung des Fachbereiches Dekan: Prof. Dr. M. Rothmund Referent: Prof. Dr. A.M. Sesterhenn Korreferent: Prof. Dr. A.

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Published 01 January 2011
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Language English

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Aus der Klinik für Hals-, Nasen- und Ohrenheilkunde der Philipps-Universität Marburg Geschäftsführender Direktor: Prof. Dr. J.A. Werner in Zusammenarbeit mit dem Universitätsklinikum Gießen und Marb Standort Marburg  
 
urg GmbH,
A Meta-analysis of the randomized controlled trials o n
elective neck
dissection versus therapeutic neck
dissection in oral cavity cancers with clinically nod e-
negative neck
   Inauguralitno iDssreat zur Erlangung des Doktorgrades der gesamten Humanmedizin  
 dem Fachbereich Medizin der PhilippsUniversität Marburg vorgelegt von    Ayotunde James Fasunla aus Benin-city, Nigeria  
 Marburg 2011
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Angenommen 
Marburg 
vom
Am: 09.03.2011.
 
Fachbereich 
Humanmedizin 
Gedruckt mit Genehmigung des Fachbereiches
Dekan: Prof. Dr. M. Rothmund
Referent: Prof. Dr. A.M. Sesterhenn
Korreferent: Prof. Dr. A. Torossian
 
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Philipps-U niversität
 
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icat
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ly wif
ve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Sternocleidomastoid muscle Selective neck dissection
Spinal accessory nerve
Ultrasound 
RND
 
SAN
RT
SND
SCM
Radiotherapy 
Radical neck dissection
 
 
 
 
 
 
US
 
Meta-
analyses  
Preferred Reporting Items for Systematic reviews and
OBS
PET
PRISMA 
 
 
4
Internal jugular vein
Intensity modulated radiation therapy
International union against cancer
Magnetic resonance imaging
Modified radical neck dissection
Observation or therapeutic neck dissection
Positron emission tomography
DNA
 
EBT
 
Computerised tomography
Elective neck dissection
External beam therapy
Deoxyribonucleic acid
AJCC
American Head and Neck Society
AHNS  
American Academy of Otolaryngology-Head and Ne ck Surgery
END
CCRT  
Concurrent chemoradiotherapy
American Joint Committee on Cancer
IJV
IMRT  
 
CT
MRND 
AAO-HNS 
IUCC  
MRI
 
 
Lists of abbreviations
            
            
            
            
Contents       1 Introduction 1.1 Relevant anatomy of the oral cavity 1.2 Lymphatic drainage of the oral cavity 1.3 Statements of problem 1.4 Justification of the study 1.5 Research question 1.6 Hypothesis 2 Study objectives 3 Materials and method 3.1 Type of study 3.2 Study design 3.3 Type of participants 3.4 Topography, nomenclature and physiology of the lymp hatic system of the neck 3.5  Staging of oral squamous cell carcinoma    3.6 Diagnosing the node-negative neck 3.7 Criteria for inclusion 3.8 Exclusion criteria 3.9 Search strategy and method for identification of stud y  3.10 Validity method of assessment 3.11 Type of intervention 3.12 The development of surgical procedures for treatment of cervical lymph node metastases 3.13 Classification of neck dissection 3.14 Data extraction 3.15 Outcome measures        3.16 Statistical analyses 4 Results 5 Discussion 6 Summary 7 Zusammenfassung  5
 
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1
Introduction
Oral squamous cell carcinoma is the most prevalent of all m alignancies arising
from the oral cavity and could result in severe morbiditi es and mortality if not
promptly identified and treated. It accounted for 30% o f all head and neck
cancers [90]. The rich lymphatic drainage in this region makes these tumors to
show a high incidence of metastasis to regional cervical lym ph nodes [30].
Cancers arising in the oral cavity have been demonstrated to have a high
metastatic rate of well over 50% [140]. Neck node status i s the single most
important prognostic factor in oral cancers and other head and neck cancers
[26]. The incidence of lymph node metastases of these canc ers depends
largely on histo-pathologic factors like tumor thickness, perine ural and
microvascular invasions, lymphocytic inflammatory infiltratio n, pattern of tumor
invasion and differentiation, and molecular tumor markers [45,58,140,150].
Tumor size greater than 2cm and tumor invasion depth of more than 4mm are
known risk factors for nodal metastasis [97,135]. The degree o f histologic
differentiation and tumor staging also play a significant role in nodal
metastases. The incidence of nodal metastases is higher in poorly
differentiated and late stage diseases [140]. However, in the American Joint
Committee on Cancer (AJCC) 2010 classification system, pT1-2 N0 oral cavity
squamous cell carcinomas are considered to be the early stage can cer [41].
The staging system is similar to that of the International Union Against Cancer
(IUCC) 2009 [141].
 
A subset of oral cancer patients without clinical evidence o f regional
metastases is known to harbor occult metastases. Unfortunately , there is still
no examination method that can validly detect micro-me tastasis in
cervical lymph nodes during evaluation of these patients . Available imaging
methods such as computed tomography (CT) scan, magnetic resona nce
imaging (MRI), positron emission tomography (PET) and ultrasoun d-guided fine
needle aspiration biopsy have been shown to have sign ificant false-negative
and false-positive rates [35]. Also, there has not been accurate biomarker that
can reliably identify or predict the presence of occult ce rvical metastases.
 
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Therefore, histologic examination of the neck specimen is th e single most
important and reliable investigation to detect neck nodal metastasis.
 
The great challenges in the management of these patie nts by surgeons and
radiotherapists include the identification of the patien ts with true clinically node-
negative neck (N0 neck) and determination of the extent of appropriate therapy
that will not be regarded as over treatment. Optimal treatment for carcinomas of
the oral cavity with clinical N0 neck remained a controversia l issue. Primary
tumor control can be achieved by an appropriate surgical opera tion with or
without radiotherapy. However, controversies exist on the ma nagement of the
neck in clinically node-negative neck (N0) patients although ; the available
management policies include observation, elective neck di ssection, or
irradiation [71,99,169]. Even though there is no unive rsal consensus guideline
on the management of the neck in squamous cell carcinoma o f oral cavity with
clinical N0 necks, the predominant opinion is elective neck dissection
[117,136]. Elective neck dissection refers to dissection of cervi cal lymphatics
and fibrofatty tissues in the absence of an obvious clini cal or radiological
evidence of neck node metastasis for either staging or therape utic purposes.
Those who advocate for neck treatment stated that most of t hose patients
whose necks are observed eventually develop nodal metastasi s and are
usually detected at an advanced stage of the disease wit h poor management
outcome. The benefits of neck dissection as advocated by this group include
successful reduction of regional recurrence, pathological stagi ng of neck,
avoidance of unnecessary neck irradiation and indication of cases where
adjunct therapy should be employed [45,58,71,97,99,1 40,150,169].
Nevertheless, there is still an unresolved controversy on it s benefits in the
eventual regional control and survival compared with the p olicy of observation
[46,157]. The advocators of observation or ‘watchful wait ing’ policy after the
removal of the primary tumor have stated that elective ne ck dissection in
clinically N0 necks is just a diagnostic staging procedure rather than a
therapeutic operation hence unjustifiable [66]. They recom mended close
watching of the neck during follow-up of these patients a nd performance of
therapeutic neck dissection only if cervical metastases develo ped [116]. 8