Oral Oncology (2006) 42, 96101

http://intl.elsevierhealth.com/journals/oron/

Elective neck treatment versus observation

in patients with T1/T2 N0 squamous cell
carcinoma of oral tongue
ntti a,*, Timo Atula a, Jyrki To
rnwall b,
Harri Keski-Sa
kitie a
Petri Koivunen c, Antti Ma
a

Department
P.O. Box 220,
b
Department
c
Department

of Otorhinolaryngology Head and Neck Surgery, Helsinki University Central Hospital,

FIN 00029 HUCH, Helsinki, Finland
of Maxillofacial Surgery, Helsinki University Central Hospital, Helsinki, Finland
of Otorhinolaryngology Head and Neck Surgery, Oulu University Hospital, Oulu, Finland

Received 20 June 2005; accepted 28 June 2005

KEYWORDS

Summary A retrospective analysis of 80 patients treated for T1/T2 N0 squamous

cell carcinoma of oral tongue was performed. The patients were divided into two
groups according to the management of the neck: those without (n = 34) and those
with elective neck treatment (n = 46). The two groups were compared with respect
to overall survival (OS), disease specific survival (DSS), and recurrences. The incidence of occult nodal disease and the results of salvage treatment were analysed.
There were significantly fewer regional recurrences in patients with elective neck
treatment. Statistical differences in OS or DSS between the treatment groups were
not found. Of all the patients with locoregional recurrence, 33% were salvaged. The
incidences of occult metastasis for T1 and T2 tumours were 24% and 35%, respectively. The elective neck treatment resulted in better regional control. The results
of salvage treatment were poor. The risk for occult cervical metastasis is high in
patients with early tongue tumours and only carefully selected patients can be left
without prophylactic neck treatment.
c 2005 Elsevier Ltd. All rights reserved.

Mobile tongue tumour;

Occult metastasis;
Elective neck
dissection;
Survival

* Corresponding author. Tel.: +358 9 4711; fax: +358 9 4717 5010.

E-mail address: harri.keski-santti@hus.fi (H. Keski-Sa
ntti).

1368-8375/$ - see front matter c 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.oraloncology.2005.06.018

Elective neck treatment versus observation in patients with T1/T2 N0 squamous cell carcinoma

Introduction
The benefits of prophylactic neck treatment in patients with early tongue tumours (T1/T2 N0) have
remained obscure. The results of the few prospective randomised studies and the retrospective studies on the topic have been inconclusive. Some of
the studies have failed to reach statistically significant differences in survival between patient groups
with either electively or therapeutically treated
neck nodes14 while in other studies there has been
a significant survival benefit in favour of the elective neck treatment.57 The observed patients
tend to have markedly more regional recurrences4,7,8 and the results of the salvage treatment
of the neck are generally reported poor.3,4,7,9
In oral tongue tumours, the incidence of occult
cervical metastases is relatively high. Of the patients with T1 and T2 squamous cell carcinoma
(SCC) of the oral tongue clinically staged N0, 13
33% and 3753%, respectively, have occult metastases at the time of diagnosis.6,1012 When the
depth of invasion of the primary tumour exceeds
4 mm, 3870% of the patients will have occult
spread in cervical lymph nodes.1315 Hence, the
risk for metastatic neck nodes is remarkable in all
but the smallest and most superficial tongue
tumours.
It has been our policy to treat the neck electively, when the risk for occult metastasis is estimated to exceed 20%. The aim of this study was
to retrospectively analyse our treatment results
in patients with Stage III oral tongue SCC with
special reference to the potential effect of the
chosen neck treatment regimen on the treatment
outcome.

97

tral Hospital. The hospital records were reviewed

and data on patient characteristics, histopathology, treatment, and follow-up were collected.
The patients were divided into two groups
according to the management of the neck. The patients in the observation (OBS) group had not received any kind of neck treatment primarily. The
elective neck treatment (ELNT) group consisted
of patients who had received prophylactic neck
treatment, either operation or radiotherapy, or
both. These two groups were compared with respect to overall survival (OS), disease specific survival (DSS), and recurrences. The incidence of
occult disease was calculated and the results of
salvage treatment were analysed. In the OBS
group, occult disease was defined as a neck recurrence in the follow-up without failure at the primary site. Cervical metastases in patients with
recurrent primary tumour were not considered occult metastases, because the nodal spread may
have occurred after the initial treatment. In the
ELNT group, occult disease was defined as presence
of microscopic disease on the histopathological
examination of the neck dissection specimen. The
patients with prophylactic neck irradiation only
(n = 2) were not taken into account in the assessment of occult metastases.
The dates and causes of death were provided by
Statistics Finland. Overall survival and DSS rates
were calculated by computerized software package
(SPSS, Version 9.0, Chicago, IL) using Life-Table
analysis. Correlations between neck treatment
groups were performed using Pearsons Chi-square
analysis.

Results
Patients and methods
The Research Ethical Board at the Helsinki University Central Hospital approved the study protocol.
Clinicopathological data of 141 patients who were
diagnosed with a SCC of the oral tongue at the Helsinki University Central Hospital between 1992 and
2002 were reviewed. Only those patients with
tumours clinically defined as T1 or T2, N0 and a
clinical follow-up data with a minimum of 24
months or until death were included in the study.
Eighty patients were eligible for the inclusion. All
the patients were surgically treated with curative
intent at the Departments of Otorhinolaryngology
or Maxillofacial Surgery, Helsinki University Central
Hospital. Radiotherapy was performed at the
Department of Oncology, Helsinki University Cen-

Eighty patients met the inclusion criteria. Of the

patients included, 41 were male and 39 female
(median age 57 years, range 2396 years). The
clinical T classification was as follows: T1: n = 40
(50%), T2: n = 40 (50%). The location of the primary
tumour was as follows: lateral border: n = 66, ventral surface: n = 11, tip of tongue: n = 2, dorsum:
n = 1. All patients were staged N0 after clinical
and radiological assessment. The assessment of
the cervical lymph nodes consisted of palpation
only in five patients. For the rest of the patients,
imaging of the neck was performed as follows:
Computed Tomography: n = 24, Ultrasonography:
n = 22, Magnetic Resonance Imaging: n = 35. All
patients underwent resection of the primary tumour (66 without reconstruction and 14 with
reconstruction). In 34 patients there was no further

98
Table 1

H. Keski-Sa
ntti et al.
Descriptive statistics of study cohort
No. in group (%)
OBS

ELNT

Total

Number of patients

34

46

80

Gender
Female
Male

21 (62)
13 (38)

18 (39)
28 (61)

39 (49)
41 (51)

T Stage
I
II

28 (82)
6 (18)

12 (26)
34 (74)

40 (50)
40 (50)

34 (100)

8 (17)
38 (83)

42 (52)
38 (48)

Treatment of the primary tumour

Resection
Resection + radiotherapy
Neck Treatment
Observation
Neck dissection
Neck dissection + radiotherapy
Radiotherapy
Age (y)
Range
Median

34 (100)
9 (20)
35 (76)
2 (4)
2396
64

3079
53

2396
57

Abbreviations: OBS, patients who did not have elective neck treatment; ELNT, patients who had elective neck treatment.

treatment primarily (the OBS group). Forty-six patients received elective neck treatment (the ELNT
group). An elective neck dissection (END) was performed on 44 patients and 35 of them received
postoperative radiotherapy. The ENDs were all performed unilaterally only. Two patients received
prophylactic neck irradiation without END. All the
patients who received radiotherapy of the neck
also received postoperative irradiation of the primary site. The patient characteristics are described in Table 1.
The 3- and 5-year OS rates for the whole patient
series were 74% and 43% and the DSS rates were
82% and 79%, respectively. The 5-year DSS rates
for T1 and T2 tumours were 75% and 68%,
respectively.
The OBS group consisted of 34 patients (13
males, 21 females). Twenty-eight patients (82%)
had a T1 primary tumour, while six patients (18%)
had a T2 tumour. A total of 15 patients (44%) relapsed at the primary site and/or neck and eight
(53%) of the patients who relapsed died of disease
(Table 2). The locoregional recurrences were located as follows: primary site only: n = 3 (9%), primary site + neck: n = 4 (12%), neck only: n = 8
(24%). Three patients had a recurrence at the contralateral side of the neck (one patient with bilateral neck recurrences and two patients with a
recurrence also at the primary site). Distant metas-

tases (in the liver and in the lung) were detected in

two patients, who also had a locoregional recurrence diagnosed previously. A total of 12 patients
(35%) in this group died, of which eight patients
(24%) died of disease and four patients (12%) died
of other causes. The 3- and 5-year OS rates were
79% and 66%, respectively (Fig. 1). The 3- and 5year DSS rates for this group were 81% and 77%,
respectively (Fig. 2).
The ELNT group consisted of 46 patients (28
males, 18 females). Twelve patients (26%) had T1
primary tumour, while 34 patients (74%) had T2 tumour. The histopathologic examination of the neck
dissection specimens of 44 patients with END revealed metastatic lymph nodes in 15 (34%) patients
(pN1: n = 12, pN2b: n = 3). A total of nine patients
(20%) relapsed at the primary site and/or neck
and eight of these patients (89%) died of disease
(Table 2). The locoregional recurrences were located as follows: primary site only: n = 3 (7%), primary site + neck: n = 2 (4%), neck only: n = 4 (9%).
Five of the six patients with recurrence in cervical
lymph nodes had had pathologic lymph nodes in the
neck dissection specimen. The neck recurrences
were all ipsilateral. Distant metastases were not
encountered in this cohort. A total of 21 patients
(46%) in this group died, of which nine patients
(20%) died of disease and 12 patients (26%) died
of other causes. The 3- and 5-year OS rates for this

Elective neck treatment versus observation in patients with T1/T2 N0 squamous cell carcinoma
Table 2

99

Locoregional recurrences and salvage treatment

Site of failure

No. in group (%)

OBS
(n = 34)

ELNT
(n = 46)

Total
(n = 80)

Primary site
Ipsilateral neck
Contralateral neck
Bilateral neck
Primary site + neck
Total

3 (9)
7 (21)
0
1 (3)
4 (12)
15 (44)

3 (7)
4 (9)
0

6 (8)
12 (15)
0

2 (4)
9 (20)

6 (8)
24 (30)

Salvage treatment
Yes
No
Salvaged

10
5
7

4
5
1

14
10
8

Abbreviations: OBS, patients who did not have elective neck treatment; ELNT, patients who had elective neck treatment.

1.0

0.9
0.9

0.8

Cumulative survival

Cumulative survival

1.0

0.7
0.6
0.5
0.4

12

18

24

30

36

42

48

54

60

Follow-up, months
Figure 1 Overall survival of the observation group
(dotted line) and the elective neck treatment group
(solid line).

group were 76% and 63%, respectively (Fig. 1). The

3- and 5-year DSS rates were 82% and 82%, respectively (Fig. 2). The OS and DSS were not significantly different between the OBS group and the
ELNT group.
When the effect of the neck treatment on regional control was assessed, the patients with recurrence at the primary site were excluded, because
the nodal spread may have occurred after the initial treatment. In the OBS group there were eight
and in the ELNT group four patients with only a regional recurrence. The difference in the regional
failure rate between the study groups was statistically significant (p = 0.035).
Of the 15 patients with a locoregional recurrence in the OBS group, salvage treatment with
curative intent was offered for 10 patients with
recurrent disease, while for five patients only
palliative treatment was considered possible

0.8

0.7

0.6
0

12

18

24

30

36

42

48

54

60

Follow-up, months
Figure 2 Disease specific survival of the observation
group (dotted line) and the elective neck treatment
group (solid line).

(Table 2). Seven (47%) of the 15 failed patients

were salvaged in the OBS group. Of the nine
patients with locoregional recurrence in the ELNT
group, salvage treatment with curative intent was
offered for four patients with recurrent disease,
while for five patients only palliative treatment
was considered possible. One (11%) of the nine
failed patients was salvaged in the ELNT group.
Of all the 24 patients with locoregional recurrence,
eight (33%) were salvaged.
Of the 12 patients with failure at the primary
site, five patients had T1 tumour and seven
patients had T2 tumour. Five of these 12 patients
had got postoperative irradiation of the
primary site at the initial treatment, which did
not result in any improvement of local control
(p = 0.66).

100
The incidence of occult metastasis was 29% (23/
78). The incidences of occult metastasis in patients
with T1 and T2 tumours were 24% (9/38) and 35%
(14/40), respectively.

Discussion
We aimed to retrospectively analyse our treatment
results of patients with Stage III SCC of oral tongue with special reference to the potential effect
of the chosen neck treatment regimen (observation
vs. elective treatment) on the treatment outcome.
The elective neck treatment markedly improved
regional control. The OS and DSS were quite similar
for both treatment approaches. However, in the
OBS group, the majority of patients (82%) had their
primary tumour clinically staged T1, while in the
ELNT group the majority (76%) had stage T2
tumours (which is predictable in a retrospective
patient series). Moreover, in the OBS group fewer
patients had occult neck disease at presentation
than in the ELNT group (24% vs. 34%). Thus, one
would expect the survival in the OBS group to be
better with comparable treatment. As a matter
of fact, the survival figures in the OBS group were
not satisfactory; almost every fourth patient died
as a result of their initially early disease. The results of salvage treatment were poor. Only one
third of all the patients, who failed locoregionally,
could be salvaged. Especially in the ELNT group,
the outcome of failed patients was extremely poor:
only one out of nine failed patients could be salvaged. Poor salvage rate is also reported in many
other studies.2,3,9,10
In our series, fifteen patients with positive neck
nodes still at occult stage received neck treatment
(END+RT in 14 patients, END in one patient). Despite the aggressive treatment initially, seven
(47%) of these patients finally died of disease in
the follow-up. Twelve patients developed cervical
lymph node metastases in a previously untreated
neck (four with also local recurrence). Seven
(58%) of these patients died of disease in the follow-up. Hence, in our material, the benefit of
treating the metastatic neck nodes still at occult
stage was surprisingly small. This finding indicates,
that patients with occult cervical metastases are at
great risk of death despite elective neck treatment
and postoperative radiotherapy in conjunction with
chemotherapy should probably be offered more
often to these patients.
Even as a tiny, early, local lesion, SCC of oral tongue is potentially an aggressive and fatal disease. At
present, we do not have a reliable marker to find

H. Keski-Sa
ntti et al.
patients with subclinical neck nodes and who will
need multi-modality treatment initially. When
deciding about the treatment of patients with early
SCC of the tongue, the optimal treatment outcome
must be balanced with the morbidity caused to the
patients who may be treated unnecessarily. According to many studies including the present one, 35
53% of patients with clinically T2N0 oral tongue SCC
have occult metastasis in cervical lymph nodes at
the time of diagnosis.6,10,11 This considerable proportion of patients with occult disease entitles
elective neck treatment in this patient group. Elective neck dissection is generally preferred, because
it enables definite pathologic staging of the neck
nodes and provides important information (metastatic lymph nodes, extracapsular spread) on the
patients at greatest risk and at the need of postoperative (chemo)radiation. The morbidity related to
unilateral END is usually considered minimal.
The present results indicate, that more attention needs to be paid especially to the treatment
of the patients with T1 tumours. A 44% locoregional
failure rate in the OBS group and 75% 5-year DSS in
patients with T1 tumours warrants consideration of
new treatment strategies. Our results and the results by others46 suggest, that these patients need
prophylactic neck treatment more often than was
offered in the present series. However, it is not
sensible to give prophylactic neck treatment to
all patients with T1 tumour. Therefore, there is a
need for methods by which to select the patients
who would most likely benefit from elective neck
treatment. Tumour thickness is an option to find
the patients at greatest risk for metastatic disease
in this group. Considering the high proportion of occult metastasis (3870%) when tumour thickness
exceeds 4 mm,1315 it would seem rationale to give
prophylactic neck treatment to patients with T1 tumour more than 4 mm thick. Another option is the
sentinel node biopsy, which has been under investigation in oral SCC in recent years. It seems that
sentinel node biopsy will be validated for clinical
use in staging clinically N0 neck in oral SCC.16 We
find this method most useful in patients with small
primary tumours (T1) who, in the past, have often
been left without prophylactic neck treatment.
With the prognostic information gained by tumour
thickness and sentinel node biopsy, prophylactic
neck treatment can probably be targeted with reasonable accuracy to this patient group. Only the
patients with superficial (<4 mm) T1 tumours and
negative sentinel lymph nodes should be left without prophylactic neck treatment. In practice, this
would mean a two-phase procedure: first the excision and histopathological analysis of the primary
tumour and the sentinel lymph nodes and then, if

Elective neck treatment versus observation in patients with T1/T2 N0 squamous cell carcinoma
needed, an END. This treatment protocol will presumably lead to improved survival in patients with
T1 tongue tumours without causing significant
unnecessary morbidity. In addition, new prognostic
markers are needed to better predict lymph node
metastasis and poor survival in patients with SCC
of mobile tongue.
In conclusion, prophylactic neck treatment
markedly improved regional control of Stage III
SCC of oral tongue in our series. The results of salvage treatment were poor. Although there were no
statistical differences in OS or DSS between the
OBS group and the ELNT group in this retrospective
analysis, we conclude that only carefully selected
patients can be left without prophylactic neck
treatment.

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