Level IIb Neck Dissection in Oral Cavity Cancers- When Should One Address it..?

Prevalence of Skip Metastases to Cervical Lymph-Nodes in Oral cavity Cancer in Eastern India-an observational study

To determine the prevalence of skip metastases in Oral-squamous-cell-carcinoma (OSCC). This prospective observational study was carried out on 100-cases of biopsy proven OSCC who underwent surgical treatment for the primary tumor along with neck dissection (ND). Data regarding depth of invasion (DOI) by primary tumor, perineural-invasion, lymphovascular-invasion, presence of metastatic-lymph-node (level, size, number and extranodal-extension) were collected from histopathology reports and were analyzed. Out of 100-cases, 73-were-male and 27-were-female. Mean age was 49.5 ± 12.3 years (range 24-4 years). Common subsites of tumor were buccal-mucosa, tongue and lower-alveolus in 40, 37 and 14% respectively. Pathological staging of tumor were stage-I, stage-II, stage-III, stage-IVa and stage-IVb in 22, 14, 25, 22 and 15% cases respectively. Preoperative neck staging was cN0 in 50 necks (47.2%) and cN+ in 56 necks (52.8%). In 100-patients 106-NDs (unilateral-94 and bilateral-6) were performed. Type of NDs were Supraomohyoid, extended-Supraomohyoid and modified radical neck-dissection in 23,07and76 cases respectively. Prevalence of cervical lymph node metastases was 36% (pN + necks). Among 36pN + patients; 25 (69.4%) cases, 20 (55.5%) cases, 9 (25%) cases, 4 (11.1%) cases, 2 (5.5%) cases had metastases to level-I, II, III, IV and V respectively. Skip-metastases was present in four-cases {level-IIb:one-case (2.78%), level-III: two-cases (5.5%) and level-V:one-case (2.78%)}. No-skip-metastasis to level-IV was noticed. All-four-cases of skip-metastases were from advance cases of squamous-cell-carcinoma of tongue with DOI > 5 mm. Skip-metastases to levels IIb, IV and V are uncommon in cases of OSCC. Most of the metastasis in our study was noted to levels I, II and III in a predictable fashion. Thus, extensive ND can be avoided in patients to prevent complications and morbidities associated with the same.

Prevalence of Positive Level IIb Lymph Nodes in Tongue Carcinoma: Experience From a Tertiary Care Center in North India

Introduction

Complications during and after dissection of level IIb lymph nodes include spinal accessory nerve (SAN) dysfunction, which results in the limitation of shoulder movements and, thus, hurts the quality of life. The current study aims to know the occurrence of level IIb lymph node positivity in tongue carcinoma.

Methods

This cross-sectional study was conducted from January 2019 to December 2019 in a tertiary care center in North India. Adult cases with primary ulcer-proliferative growth over the lateral border of the tongue were included in the study. The level IIb lymph node positivity from the postoperative histopathology report was the primary outcome measure of this study. To investigate the potential association of tumor size on level IIb lymph node positivity, we compared the maximum tumor dimensions among the level IIb lymph node-positive and -negative groups. In addition, to analyze the impact of the tumor's invasive nature on level IIb lymph node positivity, we compared the depth of invasion and proportion of cases with muscle involvement among the level IIb lymph node-positive and -negative groups. Lastly, to investigate their concurrent occurrences, we compared the number of level IIb lymph node-positive cases among the level IIa lymph node-positive and -negative groups.

Results

A total of 39 patients fulfilling the inclusion criteria were included in the study. Only six had positive level-IIb lymph nodes. No significant associations of tumor size, invasion depth, muscle invasion, or involvement of level IIa lymph nodes with the positivity of level IIb lymph nodes were found. However, only three were level IIb lymph node-positive in 28 level IIa lymph node-negative cases.

Conclusion

Considering the low risk of isolated level IIb lymph node positivity in level IIa lymph node-negative cases, the dissection of level IIb nodes could be omitted during the surgical excision of the tumor. However, radiological investigations detecting metabolic activity should be used in the preoperative period and postoperative follow-up to detect early lymph node involvement and disease recurrence.

Prevalence of Metastasis and Involvement of Level IV and V in Oral Squamous Cell Carcinoma: A Systematic Review

The occurrence of occult metastases in oral cavity squamous cell carcinoma (OSCC) to lower levels in the neck (levels IV and V) or development of skip metastases that bypass the upper neck levels (levels I to III) and go directly to level IV or V is common. This challenges the efficacy of conventional neck dissection approaches in the treatment of OSCC. Therefore, the decision to include lower levels cervical nodes during elective neck dissection of OSCC remains controversial.

This systematic review was designed to assess the prevalence of level IV and/or V involvement or skip metastases in patients with the clinically negative neck (cN0) or positive (cN+) oral squamous cell carcinoma (OSCC). We searched for studies published between December 2000 and December 2020. Potentially relevant abstracts and full-text articles were screened, and data from the studies were extracted. Quality was rated using the Newcastle Ottawa Scale (NOS) criteria.

In total, 802 abstracts and 227 full-text articles were screened, and 32 studies were included in this analysis. The prevalence of metastasis ranged from 1.8% to 66.0%. The incidence for skip metastasis to level IV or V was low, reaching 8.5%. Evidence favored elective neck dissection, including levels I to III, in selected patients with OSCC and patients with cN0 or cN+ neck. The literature was non-conclusive on the recommendation for inclusion of lower levels.

Metastatic involvement of level IIb nodal station in oral squamous cell carcinoma: A clinicopathological study

Background:

The purpose of this study was to determine the prevalence of Level IIb metastasis in patients with oral squamous cell carcinomas (OSCCs).

Materials and Methods:

A total of 110 newly diagnosed oral cavity cancer patients requiring surgery as the primary modality were included in the study. Preoperative clinical examinations were done and tumor-node-metastasis staging was noted. Intraoperatively, Level IIb nodal tissue was dissected and sent separately.

Results:

A total of 129 neck dissections (58 SOHD, 67 modified neck dissections, and 4 radical neck dissections) were carried out in 110 patients (males = 80 and females = 30), 91 patients required unilateral neck dissection, and 19 patients required bilateral neck dissection. Out of these 129 neck dissections, only 4 (3.2%) neck dissections (in a total of 3 patients out of 110 patients) had Level IIb positive (with bilateral Level IIb involvement in one patient).

Conclusions:

Dissection of the Level IIb region in patients with OSCC may be required only in cases with advanced N stage, positive Level IIa lymph nodes, and extracapsular spread. Furthermore, in tongue cancers (high propensity of isolated Level II involvement), retromolar trigone, and floor of mouth cancers, routine Level IIb clearance should be considered.

A prospective analysis of prevalence of metastasis in levels IIB and V neck nodes in patients with operable oral squamous cell carcinoma

OBJECTIVES

The present study was designed to know and analyze the prevalence of pathological involvement of level IIB and V neck nodes in operable oral cavity squamous cell carcinomas.

MATERIALS AND METHODS

All treatment naïve, willing biopsy proven patients of age group 18-70 years with oral cavity squamous cell carcinomas undergoing surgery from May 2015 to December 2016 in a single tertiary care Institute were prospectively analyzed for level IIb and V involvement.

RESULTS

A total of 199 patients met the selection criteria of the study. Most common site was buccal mucosa, majority were cT2 lesions and 90% underwent Modified neck dissection. 63% of patients had pN0 disease. The rate of involvement of level II b and V nodes was 3% and was associated with higher T size, disease burden in proximal basin and lymphovascular invasion. There was no skip metastasis to level IV. Only one patient had skip metastasis to levels V and IIB each.

CONCLUSION

To conclude our data strongly supports omission of level IIb and level V nodal dissection routinely in patients with cT1 and T2 buccal cancers. However, a randomized controlled study to evaluate the morbidity as well as recurrence pattern between the selective and super-selective approach is warranted.

Cervical level IIb metastases in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis

Purpose

The aim of this study was to clarify whether level IIb dissection should be performed or avoided in the treatment of oral squamous cell carcinoma by meta-analysis.

Materials and methods

Articles that were published before June 2017 were searched electronically in four databases (Web of Science, PubMed, Ovid and China National Knowledge Infrastructure) without any date or language restrictions by two independent reviewers. Abstracts and full-text papers which investigated the cervical metastases to level IIb from primary head and neck cancers and were deemed potentially relevant were screened. Data were analyzed using RevMan 5.3.

Results

Four hundred and fifty-five abstracts and 129 full-text papers were screened, and 22 studies were included in the analysis. Among the 2001 patients included, 112 patients had level IIb metastases, the pooled frequency of which was 6% (95% confidence interval [CI]: 4.0–7.0). Among the 400 patients with tongue squamous cell carcinoma from 12 studies, 37 patients had level IIb metastases, the pooled incidence of which was 7% (95% CI: 5.0–10.0). Metastases to level IIb always went together with level IIa, and only three patients were found to have isolated level IIb metastases without involving the other levels.

Conclusion

Due to the low frequency of level IIb nodal metastases in oral squamous cell carcinoma patients and rare occurrence of isolated level IIb, level IIb dissection could be avoided when the primary lesions were in early stages (T1 and T2), with the exception of tongue cancer. It is recommended to dissect level IIb tongue cancers without considering the stages of primary lesions and the lymph nodes status. It is also suggested that level IIb dissection should be performed in patients preoperatively or intraoperatively found with multilevel neck metastasis, especially level IIa metastasis.