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Auris
Nasus
Larynx
journal homepage:www.elsevier.com/locate/anl
Letter
to
Editor
Letter to “Medial linguallymph nodemetastasisin carcinoma of thetongue”
To the Editor,
We have red with interest the paper from Eguchi et al.
[1] describing lf caseof metastasis ina lingual lymph node located in the medialcompartment. The case presentation is detailed, andthe iconographyis excellent.
The reported case was properly treated with upfront surgery, and the lingual metastasis was identified and effec-tively addressed even if it disclosed as an intraoperative un-expected finding.
The definitive pathological analysis demonstrated a radi-callyresected tumorshowing minorvascularinvasion, witha lingual mass within the T-N tract confirmed as a metastasis in alingual lymph node of the medial compartment andnot anisolated secondlocalizationofthe primarytumor. Further-more, 2 adjunctive occultneck metastases were identified in the ipsilateral neck specimen.
The Authors claimed that the absence of extranodal ex-tension and the negative margins justified the omission of postoperative adjuvant treatment.
Being aware that retrospective evaluations are always bi-ased by the uncovered clinical evolution, the reader should take advantage of this peculiar case to reflect on the impor-tance of adjuvant treatment in Stage IV oral cancer, and on its indications, that are not always straightforward.
In the discussion, the authors correctly acknowledge that the presence of a lingual lymph node metastasis has to be consideredanegativeprognosticfactorwarrantingaggressive treatment, but this factor was not deemed sufficient to con-sider postoperativetreatment.
Following the 7th TNM edition [2] (the one applied in this report) the pathological staging of this tumor was pT4a becauseoftheinfiltrationoftheextrinsictonguemusculature, andN2bbecauseofthe 2lymphnodemetastasesintheneck (Stage IVA). Furthermore, additional negative elements not impacting on the pTNM were the presence of a metastasis in a lingual lymph node and the presence of minor vascular invasion.
Also following the 8th TNM edition, [3] pathological staging would have been IVA, given the pN2b nodal
sta-tus. Furthermore, the authors reported a tumor thickness of 15.9 mm and it is most likely to assume that the depth of infiltration of this tumor exceeded 10 mm, making it a pT3.
Adjuvant therapyshouldbe consideredfor head andneck squamous cellcarcinomas pathologically staged as Stage III andIV[4].However,we agreethat NCCNguidelinesdo not provide definitiveguidance inthissetting.
Followingthe TNMstagingusedbytheauthors, postoper-ative radiotherapy should have not been excludedeven for a radically resected pT4a tumor,regardless of the lymph node status,especiallywhendisplayingvascularinvasion.The pres-ence of 2 neck node metastases shouldalso be considered a significant risk factor to be taken into account when consid-ering postoperative radiotherapy. In fact, the recent ASCO ClinicalPractice Guideline[5] suggestthatadjuvant neck ra-diotherapyshouldbeadministeredtopatientswithoralcavity cancerand pathologicN2 or N3 disease.
The presence of 2 or more lymph node metastases was considered the cutoff lymph node burden for postoperative chemoradiation in the RTOG 9501 trial by Cooper et al.
[6] However, when these findings were combined with the results of the other pivotal adjuvant EORTC 22931 trial by Bernieretal,theabsence of ENEandpositivemargins justi-fied to omit postoperative chemotherapy, delivering only ad-juvantradiotherapy [7].
Finally,thepresenceofmultipleipsilateralneckmetastases isasignificantriskfactorforthepresenceofoccult contralat-eral lymph node metastasis/disease in oral cavity squamous cellcarcinomas [8,9].
Inouropinion, thetake-homemessagetobeunderlinedis that,inthe presence of an ipsilateralN2bneck andafurther lymph node metastasis in the medial lingual compartment, postoperative radiotherapy targeting the ipsilateral and con-tralateralneck should be stronglyconsidered.
Inlightof thecontralateralneckrecurrenceonly6 months afterprimary surgery, thecasereportedbyEguchi etal. sug-gests that contralateral neck dissection should be warranted after the intraoperative discovery of a suspicious medial lin-guallymph node.
In conclusion, we agree with the authors on the severity ofthereportedclinicalcondition,beingthe taskofthe multi-disciplinaryteam toanalyzeall available elements,to plana
https://doi.org/10.1016/j.anl.2020.05.023
2 Letter to Editor / Auris Nasus Larynx xxx (xxxx) xxx
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completetherapeuticprogram, evenmoreinrareoccurrences as the oneherein described.
Funding
The author(s) received no financial support for the re-search,authorship, and/orpublication of this article.
Declarationof CompetingInterest
The author(s) declared no potential conflicts of interest withrespecttoresearch,authorship,and/orpublicationofthis article.
References
[1]EguchiK,KawaiS,MukaiM,NagashimaH,ShirakuraS,SugimotoT, etal.Mediallinguallymphnodemetastasisincarcinomaofthetongue. AurisNasusLarynx2020;47:158–62.
[2]SobinL,GospodarowiczMK,WittekindC.TNMclassification of ma-lignanttumours.7thed.Hoboken,NJ,USA:JohnWiley&Sons;2009.
[3]Brierley JD, Gospodarowicz MK, Wittekind C. TNMclassification of malignant tumours. 8th ed. Hoboken,NJ, USA: John Wiley& Sons; 2017.
[4]National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Head and Neck Can-cers (Version 1.2020). https://www.nccn.org/store/login/login.aspx? ReturnURL=https://www.nccn.org/professionals/physician_gls/pdf/ head-and-neck.pdf.AccessedDate:February12,2020.
[5]KoyfmanSA,IsmailaN,CrookD,D’CruzA,RodriguezCP,SherDJ, etal.Management oftheneckinsquamouscellcarcinomaoftheoral cavityandoropharynx: ASCOclinicalpracticeguideline. JClinOncol Jul.2019;37(20):1753–74.
[6]CooperJS,PajakTF,ForastiereAA,JacobsJ,CampbellBH,SaxmanSB, etal.Postoperativeconcurrentradiotherapyandchemotherapyfor high--risksquamous-cellcarcinomaoftheheadandneck.NEnglJMedMay 2004;350(19):1937–44.
[7]BernierJ,CooperJS,PajakTF,VanGlabbekeM,BourhisJ,ForastiereA, et al. Defining risk levels in locally advanced head and neck can-cers:a comparative analysisofconcurrent postoperative radiation plus chemotherapytrialsoftheEORTC(#22931)andRTOG(#9501).Head NeckOct.2005;27(10):843–50.
[8]KowalskiLP,BagiettoR,LaraJR,SantosRL,TagawaEK,SantosIR. Factorsinfluencingcontralaterallymphnodemetastasisfromoral carci-noma.HeadNeckMar.1999;21(2):104–10.
[9]Kurita H, Koike T, Narikawa JN, Sakai H, Nakatsuka A, Uehara S, et al.Clinical predictorsfor contralateral necklymph node metastasis fromunilateral squamouscell carcinomaintheoralcavity.Oral Oncol 2004;40:898–903.
AlbertoDeganello∗,Vittorio Rampinelli, TommasoGualtieri, AlbertoPaderno
Unitof Otorhinolaryngology,Head and NeckSurgery, University ofBrescia,ASST Spedali Civili ofBrescia, Brescia,Italy
Pierluigi Bonomo
Unitof RadiationOncology, University ofFlorence, AziendaOspedaliera Universitaria Careggi, Florence,Italy
MichelaBuglione diMonaleeBastia
Unit ofRadiationOncology, University ofBrescia,ASST SpedaliCivili ofBrescia, Brescia,Italy
∗Correspondingauthor at: Unitof Otorhinolaryngology,
Head andNeckSurgery,Department of Medicaland Surgical Specialties, Radiological Sciences,and Public Health,University of Brescia,ASSTSpedali Civilidi Brescia. Brescia,25121, Italy.
