Physicians at the Henry Ford Cancer Institute report success with a minimally invasive procedure called a sentinel lymph node biopsy for patients with early stage oral cancer. The biopsy can be performed at the same time oral cancer is surgically removed, and it can determine if the cancer has spread to nearby lymph nodes.
For Henry Ford patient Marlene Calverley, the biopsy meant having three lymph nodes removed instead of 30 to 60 lymph nodes, as well as a two-inch scar instead of a five- to six-inch scar. It also meant no neck drains, no physical therapy, and a decreased risk of complications.
“We are one of the few, if not the first, medical centers in the state of Michigan to adopt this new paradigm for treating early oral cavity squamous cell cancers,” said head and neck cancer surgeon Tamer A. Ghanem, MD, PhD, director of growth, access, and service for the Department of Otolaryngology at the Henry Ford Cancer Institute.
The new approach is based on a standard treatment for breast cancer and melanoma skin cancer. Early data shows that it may improve survival rates. It also demonstrates a significant decrease in recovery time, complications, and effects attributed to treatment, says Steven Chang, MD, director of the head and neck oncology program and microvascular surgery division at the Henry Ford Cancer Institute.
Head and neck cancers are among the most common cancers in the United States and around the world, the Henry Ford Cancer Institute reports. When patients are first diagnosed with oral cancer, about 15% to 25% of them have hidden microscopic cancer cells in the lymph nodes of the neck.
During a routine dental exam, Calverley was told to watch a small spot on her tongue. Three years later, an oral surgeon discovered cancer. Knowing there was a significant chance of cancer spreading, the surgeon recommended a neck dissection to remove all lymph nodes. Henry Ford, however, offered a new and more precise treatment approach.
Typically when oral cancer is found, neck surgery is performed and all the lymph nodes are removed, whether they are known to be diseased or not. About 75% to 85% of patients do not need the surgery. After surgery, patients may require neck drains, and some will experience shoulder and lip weakness caused by exposing and manipulating the nerves. Patients also will have a large scar and longer recovery time.
In the past, patients who had early oral cavity lesions and who were at risk for hidden cancer in the lymph nodes were routinely offered extensive neck surgery to find any diseased nodes. Now, the Henry Ford Cancer Institute is offering the simple sentinel node biopsy to select patients such as Calverley to find diseased nodes, said Ghanem.
To eliminate the cancer, a quarter of Calverley’s tongue would need to be removed. When doctors at another medical center initially recommended having all of levels one to four removed, which could consist of 30 to 60 nodes in her neck, and grafting donor tissue onto her tongue, she sought a second and third opinion.
“Dr. Chang was the only one who offered to do the sentinel node biopsy and to have my tongue heal on its own,” said Calverley, a 72-year-old Rochester resident, who added that it was an easy decision once Chang explained that the procedure also is performed on women having a mastectomy.
“I went home and prayed and spent two days talking to people about my decision. Friends in the medical field agreed with me and asked, ‘Why would you have all the lymph nodes in your neck removed if they aren’t cancerous, and then deal with all the repercussions? It’s not necessary,’” she said.
“I had my surgery in November, and my tongue is healing beautifully. Only three nodes were removed, and my scar is only about two inches. It’s right in line with a wrinkle on my neck, and you can barely see it,” she said. “Within three days, I was up and making pumpkin rolls for Thanksgiving,” said Calverley, who only spent one night in the hospital after the surgery.
Compared to surgery that removes all the lymph nodes, the sentinel lymph node biopsy lowers the risk of lymphedema, which causes a buildup of fluid and swelling in the body. The biopsy also involves mapping lymph nodes in the lower neck and opposite sides of the neck, areas not typically included in the traditional approach. For cancer in the middle area of the head or neck, patients can avoid surgery on both sides of the neck.
The procedure injects a weak radioactive substance that marks white blood cells into the oral cancer site. The substance acts as a tracer and is picked up by the lymph vessels, travelling along the path most likely used by any cancer cells that might drain from the tumor to the lymph nodes. Depending on the patient, cancer cells may travel in different paths or patterns. The first lymph node the substance goes to is called the sentinel lymph node.
Imaging will find the sentinel lymph node and any other nodes where the tracer is located. The surgeon will remove the suspected lymph nodes along with the oral cancer. A pathologist will immediately examine the tissue to determine if cancer is actually present in the nodes. If it is, the surgeon will perform a neck dissection to remove the diseased lymph nodes. If the nodes are negative for cancer, the patient won’t need a full neck surgery.