Cervical metastases of squamous cell carcinoma of the maxilla: a retrospective study of 25 years

Survival Outcomes and Patterns of Failure in Maxillary Alveolus Squamous Cell Carcinoma

Introduction  Squamous cell carcinoma (SCC) of the maxillary alveolus is a relatively rare disease. There is lack of data on this subsite as compared with other sites. The factors that affect survival in cases of maxillary alveolar SCC are tumor stage, local and cervical metastases, histological grading, and the margin status. Objectives  To evaluate the overall survival (OS), the disease free survival (DFS), and the complex interaction and effects of margin status, histological differentiation, habits (such as smoking and the use of smokeless tobacco products), and cervical and distant metastases based on clinicopathological data. Methods  We examined the electronic database at our hospital from 2003 to 2017. We included all cases with a histopathological diagnosis of SCC of the maxillary alveolus. Tumors originating primarily from the maxillary alveolus were included, while those originating from adjacent subsites, like the hard palate, the buccal mucosa or the maxillary sinus were excluded. We also excluded all the patients who were not operated on with a curative intent. Results  More than half of the patients had stage-IV tumors at the time of presentation, while only one fourth of them had nodal metastasis. The rate of recurrence increased in cases of primary tumors in advanced stages and the degree of histological differentiation. The 2-year and 5-year OS rates were of 54.5% (18 patients) and 30.3% (10 patients) respectively. Conclusion  Primary tumors in advanced stages, histological grade, and presence of nodal metastasis are poor prognostic markers in terms of long-term survival.

How is neck dissection performed in Oral and Maxillofacial Surgery? Results of a representative nationwide survey among university and non-university hospitals in Germany

Introduction

Neck dissection (ND) is a surgical procedure addressing cervical lymph nodes and metastases in patients with oral squamous cell carcinoma (OSCC). The aim of this study was to analyze clinical decisions regarding indications and variations of ND in Oral and Maxillofacial Surgery (OMFS) in Germany.

Material and methods

A nationwide survey of the German Association of Oral and Maxillofacial Surgery was performed using dynamic online questionnaires including 38 questions. Data about oncological centers, case numbers, and staging procedures were collected. Relevant aspects, such as inclusion of level IIb and levels IV and V to ND, uni- vs. bilateral ND, and the influence of extra-nodal extension (ENE) of metastases on extension of ND were evaluated.

Results

Eighty-four OMFS of university and non-university hospitals participated in the study (responding rate 21.4%). Sixty-six (78.57%) stated to work at certified cancer centers and 53.57% of the hospitals treated between 50 and 100 OSCC cases per year. CT and/or MRI of the head and neck was performed in most of the staging procedures. Level IIb was included by 71 (93.42%) of the participants in selective ND. Levels IV and V were included by 53 (69.74%) in node-positive neck. In solitary ipsilateral metastases (ENE−), 49 participants (62.82%) stated to perform exclusively an ipsilateral ND and 40 (51.95%) stated to perform only an ipsilateral ND in ENE+.

Conclusion

This study demonstrated a high rate of certified cancer centers in Germany showing differences regarding staging procedures, indications, and extension of ND, especially in increasingly complex cases.

Clinical relevance

Clinical decisions regarding ND are dependent on case-individual aspects and must be decided individually.

The localization and risk factors of squamous cell carcinoma in the oral cavity: A retrospective study of 1501 cases

Head and neck cancer is the tenth leading cause of cancer mortality. Ninety percent of tumours in the oral cavity are squamous cell carcinomas. Information about the exact localisation of OSCC is missing in the literature. In the present study, we retrospectively analysed a total of 1501 OSCC patients, who were treated between 1975 and 2009. The purpose of this study was to examine the localisation of OSCC tumours and to analyse the influence of various parameters on tumour localisation. 71.5% of these patients were male and 28.5% were female. The mean age was 60 years. The most common sites of OSCC occurrence were the floor of the mouth and the anterior base of the mouth. The hard palate was the most affected anatomical area of the maxilla. Descriptive statistical analysis, chi-square testing and a multivariate analysis using a multinomial logistical model showed a significant correlation of younger age and female gender with tumour occurrence in the maxilla and the tongue. We provide a very detailed anatomical mapping of OSCC.

Prognostic value of pathologic grade for patients with oral squamous cell carcinoma

OBJECTIVE

The purposes of this study were to explore both the prognostic value of pathologic grade and the relationships between differentiation and clinicopathological characteristics in oral squamous cell carcinoma.

METHODS

This retrospective cohort study included the records of 2036 patients with oral squamous cell carcinoma who were surgically treated from June 1999 to December 2011. Chi-square test, Kaplan-Meier analysis, and Cox proportional hazards regression model were performed for statistical analysis.

RESULTS

Many clinicopathological characteristics were associated with pathologic grade. Kaplan-Meier analysis showed that well-differentiated tumors had a better prognosis than the other two grades. Cox regression model showed that differentiation was an independent risk factor for prognosis in patients with early stage, but not with advanced stage. The predictive abilities of pathologic grade, T stage, N status, and lymph node ratio were similar, but the presence of extracapsular spread and perineural invasion were stronger prognostic factors than pathologic differentiation.

CONCLUSIONS

Pathologic grade was found to be an independent risk factor for early-stage oral squamous cell carcinoma, but not for advanced stage. Many important clinicopathological characteristics were associated with histological classification; however, its prognostic value was limited.

Outcome and cervical metastatic spread of squamous cell cancer of the buccal mucosa, a retrospective analysis of the past 25 years

OBJECTIVES

Because of the low proportion of squamous cell carcinomas (SCCs) of the buccal mucosa within the carcinomas of the oral cavity in the Western population, data concerning metastatic pattern are sparse. Therefore, this retrospective study is focusing on the occurrence of cervical metastases (CM) and the overall outcome of this tumor entity.

MATERIALS AND METHODS

From January 1988 to October 2013, 113 patients were treated in the Department of Oral and Maxillofacial Surgery, Mainz, for an oral SCC of the cheek. Metastatic pattern and clinical parameters that are possibly associated with an increased risk for CM as well as overall outcome were analyzed.

RESULTS

The average follow-up was 48 months (range: 1-248 months). A total of 55 (49%) patients were female and 58 (51%) male, with an average age of 65 ± 13 years (♀68 ± 14 years; ♂63 ± 11 years). In total, 55% of the patients either smoked and/or consumed alcohol. In total, 34% of the patients had a stage III or IV tumor, with overall 23% having CM at the time of diagnosis. During the follow-up, 50% (n = 56) of the patients developed a relapse after 12 months (median). Tumor size (P = 0.002*) and grading (P < 0.001*) are significantly associated with the occurrence of CM. Metastases (P = 0.008*) and advanced tumor size (P = 0.018) had an influence on the survival, whereas the relapse had no significant influence (P = 0.928). Five-year survival rate was 80%.

CONCLUSIONS

SCC of the buccal mucosa shows aggressive behavior with a considerably high proportion of relapse. Since overall outcome is significantly decreased by the cervical metastatic pattern, a selective, ipsilateral neck dissection for this patient group is recommended as the primary management.

Elective neck dissection in unilateral carcinomas of the tongue: Unilateral versus bilateral approach

PURPOSE

Elective neck dissection (END) is a common primary treatment strategy for oral tongue squamous cell carcinoma (OTSCC), although uncertainty remains regarding the necessary extent of END for strictly unilateral early stage OTSCC. The authors evaluated two END variations, unilateral and bilateral, to determine the optimal extent.

MATERIALS AND METHODS

A retrospective cohort study was performed on patient data from two departments of oral and maxillofacial surgery. All previously untreated patients from both clinics who were diagnosed with early-stage (pT1-2) unilateral OTSCC were included. The following variables were collected: age, gender, END type/extent, tumor localization, later nodal metastasis, and TNM status. Statistical analyses were performed (p < 0.05).

RESULTS

A total of 150 patients were identified, 105 receiving unilateral END and 45 bilateral END. The rates of postoperative positive lymph nodes were 21.9% for ipsilateral END and 26.7% for bilateral END (bilateral END: all positive nodes ipsilateral). In all, 14 patients in the ipsilateral group developed nodal metastasis during tumor aftercare (11 patients ipsilateral, 3 patients contralateral neck). In the bilateral group, nodal metastasis was later observed in 4 cases (8.9%; 3 cases ipsilateral, 1 case contralateral neck). Statistical analysis could not detect significant differences between the END procedures.

CONCLUSION

As both procedures lead to similar results in preventing or omitting possible later nodal metastasis, the two methods seem to be valuable alternatives. In conclusion, we recommend bilateral END because of advantages with regard to oncologic safety and esthetic outcome, but the decision for END should always be according to the patient's general health status, comorbidities, and individual tumor risk profile.

Cervical Metastases Behavior of T1-2 Squamous Cell Carcinoma of the Tongue

INTRODUCTION

The cervical lymph node metastasis (CM) is one of the most important prognostic factors for oral squamous cell carcinoma. Although the frequency and distribution of CM for tongue carcinoma (TC) are well documented in the literature, there is only little data on metastasis patterns depending on the location of the cancer within the tongue.

MATERIALS AND METHODS

In a retrospective study all patients with a T1-T2 TC who were treated between 1997 and 2013 were analysed regarding epidemiological data, risk factors, and tumour parameters such as exact localization, CM.

RESULTS

204 patients (59 ± 15 years; ♀37 %, ♂63 %) were included. At the initial diagnosis 23 % had an advanced tumour stage (III-IV) due to CM. The occurrence of CM was significantly higher for T2, advanced G-status and the localization in the posterior area of the tongue. The presence of CM-but not the recurrence-had a significant influence on the survival rate.

CONCLUSION

The small TC has an aggressive metastatic behaviour depending not only on the classical prognostic factors such as grading and tumour size, but is also strongly influenced by the posterior location within the tongue.

Supraclavicular Metastases from Distant Primary Solid Tumours: A Retrospective Study of 41 Years

OBJECTIVES

Approximately 1 % of all malignant solid tumours of the head and neck area are metastases from primary tumours beneath the clavicles. The aim of this study was to analyse the distribution of primary tumours since meta-analyses might have been biased due to the usually extraordinary character of case reports.

MATERIALS AND METHODS

All patient files from 1970 to 2012 from the Oral and Maxillofacial Surgery unit at a University Hospital were analysed regarding the existence of metastases to the head and neck area from distant primaries.

RESULTS

Of the seventy-three patients 18 had breast cancers (25 %), 9 melanomas (12 %), 8 tumours of the kidneys and 8 of the lungs (each 12 %), 3 colon cancers (6 %), 2 prostate cancers (3 %), 2 Ewing sarcomas (3 %), and 1 each of liposarcoma, esophagus, rectum, hepatocellular carcinoma, vulva, ovarian and testicular cancer. In 15 cases, a cancer of unknown primary was diagnosed. In 28 cases the metastasis was the initial sign of the malignant disease. Skeletal metastasis occurred in 37 cases and a soft tissue metastasis in 36 patients.

CONCLUSION

The different primaries seem to metastasize in different frequencies to the head and neck area. The relatively common prostate cancer rarely seems to produce metastases in the head and neck area compared to cancers arising in the kidneys. In case of a malignant tumour of unknown primary, osseous metastases most often are caused by breast or lung cancer or renal cell carcinoma. Soft tissue metastases are most often caused by breast cancer.

Cervical metastases behavior of T1-2 squamous cell cancer of the oral mucosa

OBJECTIVES

The clinical management of the neck of patients with early-stage oral squamous cell cancer (OSCC) is still controversially discussed in the current literature. This study analyzes histo-clinical factors influencing the occurrence of cervical lymph node metastases (CM).

MATERIALS AND METHODS

In a retrospective mono-center study, patients with a primary T1-2 OSCC between 2000 and 2014 were analyzed regarding histo-clinical parameters possibly influencing the CM rate and the outcome.

RESULTS

Two hundred eighty-five patients (66 %) were male and 146 female (44 %), with a mean age of 60 ± 12 years at the time of diagnosis. Seventy-seven percent showed a positive risk profile (nicotine/alcohol) and 69 % underlying diseases. Forty-four percent of the patients were staged as T2 (30 % with CM). Advanced tumor size (T1 vs. T2) and grading (G1-2 vs. G3) were statistically significantly (p < 0.001) associated with the occurrence of CM. The localization within the oral cavity, age, gender, risk profile, or underlying diseases had no influence on CM occurrence. During the follow-up, tumor size (p = 0.001), CM (p < 0.001), and tumor relapse (p < 0.001) were significantly associated with a worse outcome.

CONCLUSIONS

Early-stage OSCC showed aggressive lymphatic metastatic behavior that depends on the size and the grading of the tumor.

CLINICAL RELEVANCE

A watch-and-wait policy as the primary management for cN0 may likely be inferior to a selective neck dissection for this patient group and should only be considered for very small tumors with a good differentiation.

Management of the neck in maxillary sinus carcinomas

PURPOSE OF REVIEW

To discuss and review the role for elective treatment of the neck in maxillary squamous cell carcinoma. Improvements in survival have been seen because of improved local therapies and control; therefore, the treatment of the neck has become a topic of debate.

RECENT FINDINGS

The risk of occult metastases in neck nodes is higher for T3-4 tumors. The rate of nodal relapse in the N0 neck without elective treatment is 8-15%. With elective irradiation the nodal relapse rate decreases. However, most nodal relapses are accompanied by local failure or distant disease. Local failure remains the most common site of failure and cause of death in this patient population.

SUMMARY

Treatment failure occurs overall in 62% of all patients, with local recurrence by far the most common site of treatment failure, which is rarely amenable to salvage therapy. Therefore, elective neck irradiation is not routinely indicated in the clinically N0 neck; those that recur only in the neck can be surgically salvaged more than 50% of the time.