ReviewElective versus therapeutic neck dissection in node-negative oral cancer: Evidence from five randomized controlled trials
Introduction
Oral cancer is the sixth most common cancer in the world and accounts for nearly 3% of all cancer cases [1]. The most common tumor in the oral cavity is oral squamous cell carcinoma (OSCC), an aggressive cancer frequently associated with poor prognosis. Surgery is still the preferred treatment [2], [3], [4]. Neck dissection plays an important role in the treatment of OSCC and is an indispensable part of many OSCC treatments [4]. However, iatrogenic injury to the anatomically contiguous vital structures in the neck, either during surgery or that resulting from postoperative complications, is a risk. Although OSCC is a locally aggressive disease with a strong tendency for loco-regional metastasis, some patients with clinically node-negative (cN0) OSCC do not actually have cancer cells in the cervical lymphatic tissue. In such cases, elective neck dissection could potentially result in avoidable morbidity and its associated costs such as prolonged hospital stay. Conversely, cN0 patients with actual micro metastases, but, in whom, neck dissection is not included in the management plan, may experience increased mortality [5]. In other words, there is no greater controversy related to the management of oral cancers than that surrounding the choice of treatment strategy for OSCC, especially in cN0 patients [6], [7], [8], [9], [10].
Treatment of early stage cN0 OSCC has been a contentious issue since the past 50 years. Surgery is still the preferred treatment in these cN0 OSCC patients. The two main surgical strategies for addressing the neck involvement include: (1) a conservative approach consisting of observation with therapeutic neck dissection only in the event of nodal relapse; (2) Elective neck dissection at the time of the excision of the primary tumor. Proponents of elective neck dissection cite decreased relapse rates and better disease-free survival (DFS) as well as overall survival (OS) [10], [11], [12], [13], [14], [15]. However, some studies found no statistically significant difference with respect to DFS or OS between the two strategies [6], [7], [16]. Results from a few randomized controlled trials (RCTs) and retrospective studies have largely been inconclusive. Although the elective neck dissection approach may improve DFS and/or OS, the observation approach has the potential advantage of avoiding an additional surgical procedure in more than 70% of patients. Furthermore, neck dissection could increase treatment costs including that of treatment and complications. These considerations have resulted in variability in global practices.
The purpose of this research is to compare the outcomes of elective neck dissection (END) with those of a conservative surgical strategy comprising of observation followed by therapeutic neck dissection in the event of nodal relapse (OBS), in cN0 OSCC, by conducting a meta-analysis of the RCTs that have compared these two approaches.
Section snippets
Inclusion criteria
Studies were included if they met all the following inclusion criteria: (a) patients diagnosed with cN0 OSCC without any treatment before surgery; (b) patients treated with oral surgical excision of the primary tumor with or without neck dissection; (c) reported clinical outcomes of END and OBS; (d) reported outcome measures included OS or DFS; (e) randomized controlled trials without limitations on publication status; (f) something about summary data being available for the outcomes of
Search findings
A total of 827 records were retrieved on database search and 12 additional records were identified after reviewing the reference lists of retrieved articles. After deleting the duplications, 814 papers were left. 792 papers were excluded as being irrelevant to OSCC or survival, or due to the lack of prognostic data. The remaining 22 articles were further assessed for eligibility and another 17 articles were eventually excluded. 14 articles were excluded because of the retrospective study
Discussion
The proponents of the treatment strategy that includes elective neck dissection cite lower relapse rates and better prognosis as benefits of this strategy [10], [11], [12], [15]. However, some researchers disagree with this assertion [6], [16]. Retrospective studies have not been helpful in resolving the lack of consensus on this subject [10], [16], [20], [21]. Although some RCTs have sought to address this issue, the evidence backing the comparative advantage of elective neck dissection is
Conflict of interest statement
None declared.
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Co-corresponding author.