Lymphoscintigraphy and sentinel node biopsy: A potential new approach in the management of the N0 neck

The management of the N0 neck in early head and neck cancer, particularly early oral cavity lesions, has been a source of great controversy. Traditionally, many surgeons favored close observation and lymphadenectomy only for palpable lymph node involvement. More recently, with the development of less morbid procedures for dissecting the neck, many surgeons have advised selective cervical lymphadenectomy for patients at risk for the development of metastases. The basic problem generating this controversy is our inability to predict accurately lymph node involvement in a noninvasive fashion. To address this problem, we have extrapolated from available data concepts regarding the use of lymphoscintigraphy in melanoma and breast cancer as a means of determining lymph node involvement. This technique provides an intraoperative confirmation of lymphatic drainage patterns and allows for a minimally invasive sampling of the first, 'sentinel' lymph node. The absence of carcinoma in such a lymph node theoretically obviates the need for more extensive neck dissection. The technique also provides the opportunity to identify aberrant patterns of lymphatic drainage. Initial attempts to use this technique in oral cavity tumors should include selective neck dissection as histologic confirmation of the validity of 'sentinel' node biopsy. We hope to validate this technique for accessible squamous cell carcinomas of the oral cavity and oropharynx.