Sentinel Node Biopsy in Head and Neck Cancer: Preliminary
Results of a Multicenter Trial
Gary L. Ross, MD, David S. Soutar, ChM, D. Gordon MacDonald, FRCPath,
Taimur Shoaib, FRCSEd, Ivan Camilleri, FRCS(plast), Andrew G. Roberton, PhD,
Jens A. Sorensen, PhD, Jorn Thomsen, MD, Peter Grupe, MD, Julio Alvarez, MBBS,
L. Barbier, MD, J. Santamaria, MD, Tito Poli, MD, Olindo Massarelli, MD, Enrico Sesenna, ChM,
Adorján F. Kovács, PhD, Frank Grünwald, MD, Luigi Barzan, MD, Sandro Sulfaro, MD,
and Franco Alberti, MD
Background: The aim was to determine the reliability and reproducibility of sentinel node biopsy
(SNB) as a staging tool in head and neck squamous cell carcinoma (HNSCC) for T1/2 clinically N0
patients by means of a standardized technique.
Methods: Between June 1998 and June 2002, 227 SNB procedures have been performed in HNSCC
cases at six centers. One hundred thirty-four T1/2 tumors of the oral cavity/oropharynx in clinically N0
patients were investigated with preoperative lymphoscintigraphy (LSG), intraoperative use of blue
dye/gamma probe, and pathological evaluation with step serial sectioning and immunohistochemistry,
with a follow-up of at least 12 months. In 79 cases SNB alone was used to stage the neck carcinoma, and
in 55 cases SNB was used in combination with an elective neck dissection (END).
Results: In 125/134 cases (93%) a sentinel node was identified. Of 59 positive nodes, 57 were
identified with the intraoperative gamma probe and 44 with blue dye. Upstaging of disease occurred
in 42/125 cases (34%): with hematoxylin–eosin in 32/125 (26%) and with additional pathological
staging in 10/93 (11%). The sensitivity of the technique with a mean follow-up of 24 months was
42/45 (93%). The identification of SNB for floor of mouth (FOM) tumors was 37/43 (86%),
compared with 88/91 (97%) for other tumors. The sensitivity for FOM tumors was 12/15 (80%),
compared with 30/30 (100%) for other tumor groups.
Conclusion: SNB can be successfully applied to early T1/2 tumors of the oral cavity/oropharynx
in a standardized fashion by centers worldwide. For the majority of these tumors the SNB technique
can be used alone as a staging tool.
Key Words: Cervical metastases—Elective neck dissection—Head and neck—Neoplasms—
Sentinel node biopsy.
When approaching a case of head and neck squamous
cell carcinoma (HNSCC), one of the most crucial
management decisions, for staging, treatment, and
prognosis, is determining the absence or presence of
Staging of HNSCC, via the TNM classification, is
both clinical and pathological.
Traditionally, for clinical
staging, clinical palpation has been the mainstay of de-
termining the presence of nodal metastasis. More re-
cently, because of the relative unreliability of clinical
centers have turned to imaging techniques
to locate the presence of nodal disease.
even these have been shown to be unreliable in the
identification of early nodal disease.
For pathological staging, hematoxylin and eosin
(H&E) has traditionally been used to detect metastasis.
More recently, additional pathological techniques such
as step serial sectioning and immunohistochemistry have
Received September 3, 2003; accepted March 25, 2004.
From the Plastic Surgery Unit, Canniesburn Hospital (GLR, DSS, TS, IC), Bearsden,
Glasgow, UK; Department of Oral Pathology, Glasgow Royal Infirmary (DGM), Glas-
gow, UK; Beatson Oncology Centre (AGR), Glasgow, UK; Departments of Plastic and
Reconstructive Surgery (JAS, JT) and Nuclear Medicine (PG), Odense University Hos-
pital, Odense, Denmark; Servicio de C. Maxilofacial, Hospital de Cruces (JA, LB, JS),
Cruces, Spain; Sezione di Chirurgia Maxillo-Faciale, Dipartmento di Scienze Otorino-
Odonto-Oftalmologiche e Cervico Facciali (TP, OM, ES), University Hospital of Parma,
Parma, Italy; Clinic for Maxillofacial Plastic Surgery (AFK) and Department of Nuclear
Medicine (FG), Johann Wolfgang Goethe University Medical School, Frankfurt am
Main, Germany; and Operative Units of Otolaryngology (LB), Department of Pathology
(SS), and Department of Nuclear Medicine (FA), Azienda Ospedaliera “S. Maria degli
Angeli,” Pordenone, Italy.
Address correspondence and reprint requests to: Gary Ross, MD, 14 Northern
Grove, Didsbury, Manchester, M202WL, UK; Fax: 44-1612916381; E-mail:
Published by Lippincott Williams & Wilkins © 2004 The Society of Surgical
Annals of Surgical Oncology, 11(7):690–696