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ORIGINAL ARTICLE
Year : 2013  |  Volume : 3  |  Issue : 2  |  Page : 106-111

Surgical management of the neck in oral cancers: A single-institute experience from South India


1 Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication13-Dec-2013

Correspondence Address:
Amitabh Jena
Department of Surgical Oncology, Sri Venkateswara Institute of Medical Sciences, Tirupati - 517 507,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.122928

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  Abstract 

Background: Oral cancers are not uncommon. We have analyzed the incidence of nodal metastasis in oral cancer clinically and compared it with the final histopathology examination (HPE) report, correlating the pathologically positive lymph nodes with different parameters such as tumor sites, pathological stage, differentiation, lymphovascular, perivascular extension and perineural invasion.
Materials and Methods: This retrospective study was carried out on patients who were evaluated with a histological diagnosis of oral cancer from 2008 to 2012. Lymph node positivity was established by clinical and ultrasound evaluation in 218 patients who underwent neck dissection for oral cancer. This was compared with the histopathology findings.
Results: The most common site of oral cancer was buccal mucosa. Histopathologically, majority were squamous cell carcinoma (SCC). Lymph node positivity was observed for different sites as follows: buccal mucosa (26.7%), gingivo-buccal sulcus (20.8%), retromolar trigone (40%), tongue (50%), and floor of mouth (100%). In well-differentiated SCC, node positivity was 25.4%. In moderately differentiated SCC, it was 52.3% and in poorly differentiated SCC, it was 50%. Five cases of verrucous carcinoma did not show any lymph node positivity. According to the pathological staging, the lymph node positivity was as follows: T1 (25.58%), T2 (23.59%), T3 (37%), and T4 (34.78%). Out of 218 patients, 5.5% patients showed positive resected margin, 1.8% patients showed skip metastasis, and 14.6% patients had lymphovascular or perivascular invasion. Univariate analysis showed significant correlation of lymph nodal metastasis with various clinicopathological parameters like tumor site, stage, and differentiation.
Conclusion: In our female predominant study group, mostly locally advanced tumors were encountered involving the alveobuccal subsites. Standard neck dissections play an important role in the control of neck disease.

Keywords: Lymph node metastasis, neck dissection, oral cancer, squamous cell carcinoma


How to cite this article:
Jena A, Patnayak R, Vamsi RN, Reddy SK, Banoth M. Surgical management of the neck in oral cancers: A single-institute experience from South India. Arch Int Surg 2013;3:106-11

How to cite this URL:
Jena A, Patnayak R, Vamsi RN, Reddy SK, Banoth M. Surgical management of the neck in oral cancers: A single-institute experience from South India. Arch Int Surg [serial online] 2013 [cited 2024 Mar 19];3:106-11. Available from: https://www.archintsurg.org/text.asp?2013/3/2/106/122928


  Introduction Top


Oral cancer is the most common cancer in South Asian countries. Incidence of oral cancer in India is among the highest in the world. [1],[2],[3] One of the significant lifestyle risk factors is betel quid (pan) chewing practice that is highly prevalent in India. Oral cancers are more common in men than in women. However, recent trends show that the incidence of oral cancer is increasing in women. This may be attributed to the increasing rates of drinking and smoking among women. [4] Surgery continues to play a prominent role in the management of patients with oral cancer, and neck dissection remains an integral part along with primary surgical ablation. [5]

At the time of resection of the primary tumor, it is essential that one should have a thorough knowledge of the lymph node groups and corresponding draining area. This helps to decide the type of neck dissection to be performed. Different surgeons prefer different incisions based on the site of the primary and the type of neck dissection to be done. In the early 20 th century, Crile first made attempt to describe the neck dissection in a systematic way. This forms the basis of most of the techniques today. [5],[6] There is a difference of opinion regarding the most appropriate management of a clinically node-negative neck cancer. [7],[8],[9],[10],[11]

The aim of the present study was to analyze the incidence of nodal metastasis in oral cavity cancer clinically and compare it with final histopathologic examination (HPE) report after definite surgical ablation. Also, pathologically positive lymph nodes were correlated with different parameters like tumor sites, pathological T stage, differentiation, and extranodal spread like lymphovascular extension (LVE), perivascular extension (PVE), and perineural invasion (PNI). We have also tried to justify the need of neck dissection in oral malignancy.


  Materials and Methods Top


This retrospective study was based on the review of our experience with oral cancers at a tertiary health care center in South India. The study period was from January 2008 to April 2012. All the patients with oral cancer, who were operated with neck dissection and excision of primary, were included in the study. Neck dissection was done as a part of surgery, along with excision of primary. Decision of type of neck dissection was based on tumor location, stage of the disease, and size of the lesion. The type of neck dissections done were supraomohyoid neck dissection (SOND), modified radical neck dissection (MRND) type II, and MRND type III [Figure 1], [Figure 2], [Figure 3]. MRND type II was done in patients where pectoralis major myocutaneous flap (PMMF) reconstruction was part of the reconstruction procedure after primary tumor resection along with mandible. Here, sternomastoid muscle was removed to accommodate pectoralis major muscle which traverses in the neck to oral cavity for flap reconstruction. MRND type III was done when no flap reconstruction was required. SOND was done for small lesions. In a few patients, for lesions encroaching the midline, MRND and opposite side SOND was done. After excision of primary, PMMF [12] reconstructions, skin grafting, buccal pad of fat reconstruction, or primary closure was done.

For each patient, the following data were recorded: Age, history of tobacco or betel nut chewing habit, smoking, alcohol intake history, primary tumor site, presence of clinical neck nodes, stage, surgical outcome, complications, histopathology report, and follow-up. An open punch biopsy or an incisional biopsy from the tumor was taken for the all the cases. The stage of the disease was evaluated by clinical examination assisted by radiological (Computerized Tomography or Magnetic Resolution Imaging) examination. A routine chest X-ray was done in all patients. Patients who received preoperative neoadjuvant therapy were documented.
Figure 1: Right supraomohyoid neck dissection showing lymph node clearance above the supraomohyoid muscle

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Figure 2: Left modified radical neck dissection type II showing preservation of internal jugular vein and spinal accessory nerve

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Figure 3: Left modifi ed radical neck dissection type III showing preservation of sternomastoid muscle, internal jugular vein, and spinal accessory nerve

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Data were statistically subjected to univariate analysis. The final HPE reports on pathological lymph node (pN) positivity were correlated with different characteristics like sites, pathological T stage, differentiation, extranodal spread, LVE, PVE, and PNI.


  Results Top


Overall, 218 neck dissections ware done for oral cancers. The total number of patients operated for oral cancers was 238. In 20 patients, only wide excision was done without neck dissection. In this subset of patients, decision was made based on the smaller tumor size and ultrasonography findings. Male:female ratio was 1:5. Mean age was 52.2 ± 10.5 years. The most common site was buccal mucosa [116 patients (53.2%)]. All the patients presented with either ulcer or ulceroproliferative lesion. Pain was the other common symptom. Trismus and dysphagia were rare. The duration of symptoms ranged from 1 to 24 months. Majority of the patients [137 (62.8%)] were betel nut chewers apart from those having other habits like chewing tobacco, smoking, and intake of alcohol. The lesion was biopsied, confirmed histopathologically, and staged clinically before surgery. Clinically, 6 (2.8%) patients were in stage I, 34 (15.6%) in stage II, 67 (30.7%) in stage III and 111 (50.9%) were in stage IV cancer [Table 1]. The types of neck dissection done were SOND in 36 (16.5%) patients, MRND type II in 158 (72.5%) patients, MRND type III in 22 (10.1%) patients, and combined MRND type III with opposite SOND in 2 (0.9%) patients.

Postoperative HPE report showed squamous cell carcinoma (SCC) in all. Though clinically 150 (68.8%) patients had significant cervical lymph nodes, final histopathology report showed metastatic deposits in only 66 (30.27%) patients. Histopathologically positive lymph nodes in patients were as follows: level I nodes were 50, level II 32, level III 15, level IV 2, and 2 patients had level V positive nodes. Many patients had positive lymph node at more than one level. Final histopathologic stage grouping showed stage I in 23 (10.6%) patients, stage II in 71 (32.6%) patients, stage III in 30 (13.8%) patients, and stage IV in 94 (43.1%) patients. Out of 218 patients, 12 (5.5%) patients showed positive resected margin, 4 (1.8%) patients showed skip metastasis, and 32 patients had LVE, PVE, or PNI [Table 1].
Table 1: Tumor characteristics and pathological parameters

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Node positivity was observed for different sites as follows: buccal mucosa, 31 out of 116 patients (26.7%); gingivo-buccal sulcus, 25 out of 72 patients (34.7%); retromolar trigone, 4 out of 10 patients (40%); tongue, 5 out of 10 patients (50%); and floor of mouth, 1 out of 1 patient (100%). Histopathologically, 169 patients had well-differentiated SCC (77.5%), out of whom 43 showed node positivity. Moderately differentiated SCC was shown by 42 (19.3%), and among them, 22 were node positivity. Poorly differentiated SCC was reported in 2 (0.9%) patients and one showed lymph node positivity. Verrucous carcinoma was diagnosed in 5 (2.3%) patients. However, none of them showed lymph node positivity [Table 1] and [Table 2]. Pathological stage T1 was seen in 43 patients, T2 in 89 patients, T3 in 27 patients, and T4 in 69 patients. Out of them, 11 (25.58%) patients with T1 had lymph node positivity, 21 (23.59%) patients in stage T2 had node positivity, 10 (37%) patients in stage T3 and 24 (34.78%) patients in stage T4 had node positivity [Table 1] and [Table 3].
Table 2: Comparison of clinical and histopathological lymph node
positivity


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Table 3: Correlation of metastatic lymph nodes with various parameters

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LVE, PVE, and PNI were also observed in 20 patients out of 66 positive lymph nodes cases. Among these patients, only LVE was seen in 12 out of 20 patients (60%) and only PVE in 1 out of 2 patients (50%). Combined LVE and PVE was detected in 2 out of 2 patients (100%) and LVE and PNI in 1 patient (100%). All (LVE, PVE, and PNI) positivity was present in 4 patients (100%). Univariate analysis was done for patients with positive lymph nodes and correlated with various clinicopathological parameters like tumor site, pathological T stage, differentiation, and extranodal spread like LVE, PVE and PNI. All the above were statistically significant (P value 0.001).

Postoperatively, all patients with lymph node positivity, positive resected margin, residual tumor, and stage IV were referred for radiotherapy or chemoradiation. Out of 218 patients, 103 (47.2%) patients were advised only follow-up, 97 (44.5%) patients received radiation therapy, and 4 patients (1.8%) underwent chemoradiation. However, 14 (6.4%) patients who were advised adjuvant treatment defaulted therapy.


  Discussion Top


In our study of 218 patients, the majority [184 (84.4%)] were females. Compared to the global and Indian scenario, it is diametrically opposite. [13] The reason for higher incidence of oral cancer in females can be attributed to the habit of pan or tobacco chewing, poor oral hygiene, and malnutrition among the females in this region. Most (81.7%) of our patients had presented in advanced stage (III and IV). This is high compared to the worldwide incidence which is around 40%. [13] This is mostly due to ignorance, low socioeconomic status, combined with their poverty. Most of the patients were not aware of the signs and symptoms of oral cancer and invariably tried local alternative medicine before ending up in a tertiary center with advanced disease.

Cancer of the alveobuccal complex has long been known as the "Indian oral cancer." [13] In our study, we found majority were buccal mucosa (53%) followed by gingivo-buccal sulcus (33%) lesions. Combined these two accounted for 86% of our patients with alveobuccal complex cancer. Interestingly, though our patients presented at an advanced stage, the incidence of N0 status clinically (31.1%) and especially pathologically (68.8%) was very high. Metastases to the regional lymph nodes is the single most important prognostic factor in predicting local and distant failure as well as survival. The nodal metastasis reduces the survival by 50%. [9],[14]

The Committee for American Academy of Otolaryngology - Head and Neck Surgery classified neck dissection into four categories in 1991, which was updated in 2001 and 2008. They are: 1) radical neck dissection (RND); 2) MRND types I, II, and III; 3) selective neck dissection (SND) denotes preservation of one or more group(s) of lymph nodes; and 4) extended RND denotes removal of one or more additional lymphatic and/or non-lymphatic structure(s). [15]

Majority of our patients underwent MRND type II (72.5%), followed by SOND (16.5%) and MRND type III (10.1%). MRND type II in many of our patients was facilitated by the requirement of flap reconstruction for the primary. Though the present trend is more in favor of SND in the form of SOND and superselective neck dissections (removing only submandibular nodal basin), the presence of advanced stage of the disease did not permit the same in our patients. [16] The incidence of occult metastasis in our study was 10.4%, which predominantly included buccal mucosa and alveobuccal lesions. Out of the 157 patients who underwent MRND type II in our study, 105 (66.8%) turned out to have node-negative disease pathologically. So, the question of what can be done to avoid the morbidity of extensive neck dissection in this group of patients with N0 neck still remains.

SOND is the standard of care for N0 disease in oral cavity cancers, but most of the evidence for elective neck dissection for oral cavity cancers comes from prospective studies on the carcinoma of tongue and floor of mouth which are comparatively at a higher risk for occult metastasis than the buccal mucosa or alveobuccal complex lesions. [17] Even in our study, though the number of patients of sites other than buccal mucosa and alveobucccal complex was less, the incidence of lymph node metastasis was high at retromolar trigone, tongue, and floor of mouth, which was 40%, 50%, and 100%, respectively, compared to the incidence at buccal mucosa (26.7%) and gingivo-buccal complex (20.8%). As clinical examinations and imaging studies are not very accurate, interest has been focused on the prediction of the risk of neck metastases. Many studies have been published attempting to predict this risk. However, the main difficulties encountered in these studies are related to the difficulties in the application of the results pre- or intraoperatively to perform or avoid neck dissection, since it is impossible to analyze the pathological features of the primary tumor intraoperatively and, moreover, the designed indexes are of poor discriminatory value. Most of these studies have not been widely validated in other tumor localizations, reducing their generalization. [18]

The incidence of occult metastases varies with the site, size, and thickness of the primary tumor and differentiation. Based on the site, the incidence of occult metastasis in patients with buccal mucosa lesions was 5% (2 out of 36 patients) and of gingivo-buccal sulcus was 16% (4 out of 24 patients), though majority of these patients had T3/T4 lesions. It may be suggested that at these subsites of the oral cavity, the "T" value may have less significance and other factors have to be taken into consideration for deciding on the need for elective neck dissection. Practically applicable, clinically recognizable factors have to be assessed to evaluate the predictive risk of occult metastasis, as the incidence of false positives with only clinical examination and imaging is quite high (60.4% in our study). In our study, we noticed that node positivity statistically correlated well with primary site (especially tongue, floor of mouth, retromolar trigone), differentiation (the poorer the differentiation, the higher the chance), and the presence of LVE, PVI, or PNI. "T" stage was not found to have a significant correlation with node positivity.

Another important factor that plays an important role on deciding whether to do an elective neck dissection or observe when the risk of occult metastasis is low is the compliance of the patient. In our center, the follow-up rates are quite low, and in the low socioeconomic group, the patient is usually looking for a "one hit comprehensive cure" than a continuously monitored scientific management. And when the patient does return with a recurrence, it is rarely salvageable.


  Conclusion Top


Oral cavity cancers form a heterogeneous group with subtle variations in the behavior and biology of the disease among subsites. Our study included predominantly women, with locally advanced tumors involving the alveobuccal sub sites. Standard neck dissections play the most important role in the control of disease in the neck. The option of more selective and modified neck dissections has to be explored along with preoperative predictive factors for identifying occult metastasis to decide on the elective management of the neck.


  Acknowledgment Top


The authors wish to thank Dr. Aparna Bitla for her help in the statistical analysis.

 
  References Top

1.Sunny L, Yeole BB, Hakama M, Shiri R, Sastry PS, Mathews S, et al. Oral cancers in Mumbai, India: a fifteen years perspective with respect to incidence trend and cumulative risk. Asian Pac J Cancer Prev 2004;5:294-300.  Back to cited text no. 1
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6.Crile G. Excision of cancer of the head and neck with special reference to the plan of dissection based on 132 patients. JAMA 1906;47:1780-6.  Back to cited text no. 6
    
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12.Jena A, Patnayak R, Sharan R, Reddy SK, Manilal B, Rao LM. Outcomes of Pectoralis Major Myocutaneous Flap in Female Patients for Oral Cavity Defect Reconstruction. J Oral Maxillofac Surg 2013 Aug 11. doi:pii: S0278-2391(13)00810-0.  Back to cited text no. 12
    
13.Khan Z. An overview of oral cancer in Indian Subcontinent and recommendations to decrease its incidence. Webmedcentral Cancer 2012;3:WMC003626.  Back to cited text no. 13
    
14.Johnson JT, Barnes EL, Myers EN, Schramm VL Jr, Borochovitz D, Sigler BA. The extracapsular spread oftumors in cervical node metastasis. Arch Otolaryngol 1981;107:725-9.  Back to cited text no. 14
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15.Robbins KT, Medina JE, Wolfe GT. Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg 1991;117:601-5.  Back to cited text no. 15
    
16.Yanai Y, Sugiura T, Imajyo I, Yoshihama N, Akimoto N, Kobayashi Y, et al. Retrospective study of selective submandibular neck dissection versus radical neck dissection for N0 or N1 necks in level I patients with oral squamous cell carcinoma. J Oncol 2012;63:41-83.  Back to cited text no. 16
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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