Elective neck dissection versus observation for cN0 neck of squamous cell carcinoma primarily located in the maxillary gingiva and alveolar ridge: a retrospective study of 129 cases

Oncologic and functional results between sentinel lymph node biopsy and elective neck dissection in cT1/2N0 maxillary squamous cell carcinoma

OBJECTIVE

To evaluate the oncologic safety and quality of life associated with the use of sentinel lymph node biopsy (SLNB) as compared to elective neck dissection (END) in patients with cT1/2N0 maxillary squamous cell carcinoma.

METHODS

This study constituted a retrospective analysis of consecutively treated patients who underwent SLNB or END, with data collected prospectively. We analyzed the impact of the different neck procedures on regional control and disease-specific survival via the Cox model. Patients in both groups completed the University of Washington Quality of Life questionnaire.

RESULTS

We included a total of 130 patients, with 47 receiving SLNB. In all cases, the sentinel lymph node could be identified, and of these, 5 had a positive result, yielding a sensitivity of 83.3 %, a specificity of 100 %, a false negative rate of 16.7 %, and a negative predictive value of 97.6 %. The sensitivity, specificity, false negative rate, and negative predictive value of END in detecting occult metastasis were 64.3 %, 100 %, 35.7 %, and 93.2 %, respectively. In comparison to END after propensity score matching, SLNB exhibited no significant difference in its effects on regional control (p = 0.519, HR: 1.05, 95 % CI: 0.52-1.93) and disease-specific survival (p = 0.634, HR: 1.22, 95 % CI: 0.53-1.99). Patients in SLNB group showed significantly higher mean scores of shoulder and taste domains at 3 months, 6 months, and 12 months postoperatively compared to those in END group.

CONCLUSION

SLNB could act as a viable alternative to END in cT1/2N0 maxillary squamous cell carcinoma with comparable prognosis and better quality of life.

The significance of elective neck dissection for patients with T2N0M0 OSCC at different ages

BACKGROUND

The aim of this study was to determine the significance of elective neck dissection (END) for patients of different ages with T2N0M0 oral squamous cell carcinoma (OSCC) and sought to analyze the reasons behind it and its value for clinical guidance.

METHODS

This study enrolled 391 patients with T2N0M0 OSCC who were surgically treated in our hospital and were divided into young-, moderate-, and advanced-age groups according to our previous study. The Chi-square test and Kaplan-Meier analysis were performed for statistical analysis.

RESULTS

Compared with moderate- and advanced-age patients, young patients with T2N0M0 OSCC had higher lymph node metastasis rates and lymph node ratios. Therefore, END significantly improved the recurrence (p = 0.001) and survival (p = 0.001) for young patients, but not for moderate-age patients. Advanced-age patients even benefit from watchful waiting. END significantly improved recurrence and survival in young patients with smoking or alcohol consumption habits.

CONCLUSIONS

END improved the prognosis of young patients, and it was related to their higher metastasis rate. However, advanced-age patients benefited from the wait-and-see policy. END is essential for the young patients with smoking or drinking habit, it is also highly recommended for nonsmokers and nondrinkers.

Occult metastases of oral maxillary squamous cell carcinoma: Systematic review and meta-analysis

Squamous cell carcinoma (SCC) is the most common malignant neoplasm of the oral cavity. The performance of END (elective neck dissection) in cases of maxillary SCC is controversial because the literature traditionally classified maxillary tumors as having low metastatic potential. The aim of this systematic review and meta-analysis was to determine the percentage of occult cervical metastases in maxillary SCC to identify in which cases there is the need to perform an END. We searched the PubMed database to select articles dated from 2000 to 2020 that fulfilled our inclusion criteria; finally, we reviewed 27 manuscripts. We show that the overall cervical and occult metastases rate was 35% and 19%, respectively. For T1, the percentage of occult metastasis rate was 11%; for T2, it was 16%; for T3, it was 20%; and for T4, it was 32%. We suggest END (levels I-II-III) as treatment to T3/T4 cN0 patients.

Prognostic factors and related complications/sequalae of squamous cell carcinoma located in the gingivobuccal complex

Background

Gingivobuccal complex (GBC) was a relatively new concept of oral subsite that was comprises of the upper and/or lower gingiva, gingival buccal sulcus, and adjacent buccal mucosa. Squamous cell carcinoma (SCC) of the GBC had a poor prognosis, with few studies analyzing this particular entity. The objective of this study was to analyze the risk factors affecting the prognosis and complications/sequalae of gingivobuccal complex cancer.

Methods

Between December 2014 and August 2019, a total of 122 patients diagnosed with primary gingivobuccal complex cancer in Beijing Stomatological Hospital, Capital Medical University were enrolled in the study. Through outpatient reviewed and telephone followed-up for 2-5 years postoperatively, postoperative relapse and complications/sequalae were assessed. The primary outcome parameter was 2-year disease-free survival.

Results

The most common central site of the tumor was the buccal mucosa (45.1%), followed by the lower gingiva (36.9%). The most diseases were pT4a (45.1%) and there was lymph node invasion (pN+) in 41.8% of patients. Moderate differentiated squamous carcinoma (77.9%) accounted for the vast majority of the histopathological differentiation. A total of 62.3% of tumors invaded the bone, while, 5.7% invaded the skin layer. Survival analysis found that 44.3% of patients experienced relapse within two years postoperatively and the mortality rate after relapse was 75.9%. Almost 60.0% of the tumors involving the maxilla and/or mandible developed relapse. Cox proportional hazards model found that pN stage (p= 0.002) and bone invasion (p= 0.007) were significant independent predictors of 2-year disease-free survival. Importantly, 63.1% of patients had postoperative (and postradiotherapy) complications/sequalae. It was noteworthy that 18 of 43 patients (41.9%) who implanted with titanium plates had hardware-related complications/sequalae, and the most of them were titanium plate exposure (61.1%).

Conclusions

Squamous cell carcinoma of the gingivobuccal complex cancer, as a new subsite worthy of attention in oral cancer, has a high complication/sequalae rate, high relapse rate and poor prognosis.

Trial registration

Prospective, Observational, Real-world Oral Malignant Tumors Study (clinicaltrials.gov identifier: NCT02395367). The approval of the Institutional Review Board of the Beijing Stomatological Hospital of Capital Medical University (Approval number: CMUSH-IRB-KJPJ-2015-08)

Local recurrence and survival after treatment of oral squamous cell carcinoma of the maxilla: A systematic review and meta-analysis

OBJECTIVE

Oral squamous cell carcinoma involving the maxilla (MSCC) is a rare malignancy. The aim was to perform a systematic review and meta-analysis of available literature on local recurrence (LR), overall survival (OS), and associated risk factors of MSCC.

STUDY DESIGN

The Cochrane, PubMed, and EMBASE databases were searched with related keywords and synonyms. The pooled proportions of both LR and OS were subsequently calculated with 95% confidence intervals.

RESULTS

In total, 2638 articles were screened on title and abstract, 131 articles were screened on full text, and 20 were included. The pooled 5-year LR rate was 19.3%, and the 5-year OS rate was 53.7%. The subgroup analysis between surgery only and surgery with (neo)adjuvant treatment resulted in an odds ratio (OR) of .76 (95% confidence interval [CI]; .41-1.40).

CONCLUSIONS

Postoperative (chemo)radiotherapy or preoperative intra-arterial chemoradiotherapy improves survival when adverse tumor characteristics are present. Posterior tumor extension into the soft palate, pterygoid muscle, pterygoid process, and infratemporal fossa was significantly associated with decreased OS in multiple studies. More research into the risk-reduction of local recurrence is warranted.

Trans-lymphatic contrast-enhanced ultrasound with sentinel lymph node biopsy for detecting cervical skip metastasis to lymph nodes in early-stage oral tongue squamous cell carcinoma

OBJECTIVES

The purpose of this study was to assess whether trans-lymphatic contrast-enhanced ultrasound (CEUS) combined with sentinel lymph node biopsy can be used to assess the status of cervical lymph nodes and skip metastasis in patients with early squamous cell carcinoma (SCC) of the oral tongue.

METHODS

This study included 21 subjects with early oral tongue SCC who received multiple intramucosal peritumoral injections of Sonazoid. CEUS examinations were performed immediately after Sonazoid injection to identify sentinel lymph nodes (SLNs). The SLNs were excised for histological examination to determine if the lymph nodes has metastases.

RESULTS

Thirty-five SLNs were detected by CEUS after Sonazoid injection in the subjects. SLNs were identified in 20 of the total 21 subjects. Four participants had metastasis to lymph nodes, and one had skip metastasis in level Ⅲ. In one subject, SLNs were successfully detected in level Ⅳ without skip metastasis.

CONCLUSIONS

Trans-lymphatic CEUS combined with sentinel lymph node biopsy showed high accuracy for evaluating cervical lymph node status. This could be a reliable approach for detecting cervical skip metastases of lymph nodes in early-stage oral cancer patients.

Systematic review and meta-analysis of cervical metastases in oral maxillary squamous cell carcinoma

Background

Management of the node‐negative neck in oral maxillary squamous cell carcinoma (SCC), encompassing the hard palate and upper alveolar subsites of the oral cavity, is controversial, with no clear international consensus or recommendation regarding elective neck dissection in the absence of cervical metastases.

Aim

To assess the occult metastatic rate in patients with clinically node negative oral maxillary SCC; both as an overall metastatic rate, and a comparison of patients managed with an elective neck dissection at index surgery, compared to excision of the primary with clinical observation of the neck.

Methods and results

A systematic review was performed by two independent investigators for studies relating to oral maxillary SCC and analysed according to PRISMA criteria. Data were extracted from Pubmed, Ovid MEDLINE, EMBASE, and SCOPUS via relevant MeSH terms. Grey literature was searched through Google Scholar and OpenGrey. Five hundred and fifty‐three articles were identified on the initial search, 483 unique articles underwent screening against eligibility criteria, and 29 studies were identified for final data extraction. Incidence of occult metastases in patients with clinically node negative oral maxillary SCC was identified either on primary elective neck dissection or on routine follow up. Meta‐analyses were performed. Of 553 relevant articles identified on initial search, 29 were included for analysis. The pooled overall rate of occult metastases in patients initially presenting with clinically node‐negative disease was 22.2%. There is a statistically significant effect of END on decreasing regional recurrence demonstrated in this study (RR 0.36, 95% CI 0.24, 0.59).

Conclusion

The results of this systematic review and meta‐analysis suggest elective neck dissection for patients presenting with hard palate or upper alveolar SCC, even in a clinically node negative neck.

Elective Neck Dissection in T1N0M0 Oral Squamous Cell Carcinoma: When Is It Necessary?

PURPOSE

Elective neck dissection (END) versus observation remains controversial for cT1N0M0 oral cavity squamous cell carcinoma (OSCC). The aim of this study was to determine whether neck dissection is indicated for cT1N0M0 OSCC versus observation when considering oral cavity subsites and depth of invasion (DOI) as predictors.

PATIENTS AND METHODS

A multicenter, ambispective cohort study of patients with cT1N0M0 OSCC treated at the University of Michigan and Beijing Stomatological Hospital from August 1998 to July 2017 with a follow-up end date of July 2019 was performed. Patients were excluded if follow-up was less than 2 years and no neck disease had occurred or if the final pathologic analysis resulted in upstaging to T2 using American Joint Committee on Cancer criteria, eighth edition. A total of 283 patients met the criteria. The main outcome parameter was the 2-year neck metastatic rate.

RESULTS

The total 2-year lymph node metastatic rate was 11.3%. Overall neck metastatic rates escalated consistently according to DOI: less than 2 mm, 2.1%; 2 to 3 mm, 9.4%; 3 to 4 mm, 15.2%; and 4 to 5 mm, 24.6%. On univariate Cox regression analysis, DOI greater than 3 mm, tumor grade, and perineural invasion were statistically significant indicators of 2-year neck metastasis. On multivariate analysis, only DOI and tumor grade remained. On multivariate analysis of 2-year survival, no factors were independent predictors. Our proposed treatment strategy for END based both on statistically significant results for DOI and on review of the raw data using a 20% cutoff analysis showed cutoffs of 2 mm for the tongue (18.2%), 3 mm for the floor of the mouth (40.0%) and upper gingiva (20%), and 4 mm for the lower gingiva (33.3%) and no cutoff for the hard palate (0.0%).

CONCLUSIONS

The watch-and-wait approach remains a reasonable approach in selected patients with cT1N0M0 OSCC. Decision making for END in T1N0M0 patients should minimally consider tumor grade, DOI, and oral cavity subsite.

Is a "watch and wait strategy" safe to manage clinically N0 squamous cell carcinoma of the upper jaw?

PURPOSE

The main aim of the present study is to analyze the behavior of squamous cell carcinoma (SCC) of maxillary gingiva, alveolus, and hard palate and to determine the utility of selective neck dissection in clinically N0 patients at early stages.

MATERIAL AND METHOD

Twenty-nine previously untreated patients with SCC of maxillary gingiva, alveolus, and hard palate were diagnosed and treated with at least a tumorectomy and selective neck dissection at HUVN and included in the study.

RESULTS

A total of 34.4% of patients (10/29) showed nodal involvement at postoperative histopathologic exam. Several pathologic features such as N involvement, N stage, T stage, and locoregional failure all have a negative impact on overall survival.

DISCUSSION

SCC of maxillary gingiva, alveolus, and hard palate shows an aggressive behavior that is comparable with other oral cavity cancers. A more aggressive treatment is thus required for improving locoregional control and overall survival. Supraomohyoid neck dissection may be useful in cT2N0M0.

Lymph node ratio is associated with adverse clinicopathological features and is a crucial nodal parameter for oral and oropharyngeal cancer

The lymph node ratio(LNR) has been described as a novel predictor of the survival of patients with oral and oropharyngeal squamous cell carcinoma(O/OPSCC). The purpose of this study was to evaluate whether LNR is better at predicting survival and the need for adjuvant treatment than traditional tumour-nodal-metastasis(TNM) staging. Eight hundred nine patients with O/OPSCC and positive lymph node disease were retrospectively enrolled in this study. LNR equal to 0.075 is the best cut-off value for stratifying 5-year disease-free survival(DFS). High LNR is closely associated with more advanced T stage, higher N stage, more severe pathological grade, the presence of diffuse infiltration and extracapsular spread(ECS). LNR is better for evaluating prognosis than the pathological N stage. Patients with high LNR coupled with high number of positive lymph nodes who received adjuvant concurrent chemo-radiotherapy(CCRT) had a better 5-year DFS than patients who received surgery alone. Multivariate analyses revealed that T stage, ECS and LNR are independent prognostic factors of 5-year DFS and disease-specific survival(DSS). Therefore, high LNR is closely correlated with adverse parameters that markedly hinder prognosis. LNR is superior to traditional TNM staging for the evaluation of prognosis,and the combination of the LNR with the number of positive lymph nodes can predict the benefits of adjuvant CCRT.

Is elective neck dissection needed in squamous cell carcinoma of maxilla?

Objectives

To define the risk of occult cervical metastasis of maxillary squamous cell carcinoma (SCC) and the therapeutic value of elective neck dissection (END) in survival of clinically negative neck node (cN0) patients.

Materials and Methods

Sixty-seven patients with maxillary SCC and cN0 neck were analyzed retrospectively, including 35 patients with maxillary gingiva and 32 patients with maxillary sinus.

Results

Of 67 patients, 10 patients (14.9%) had occult cervical metastasis. The incidence of occult cervical metastasis of maxillary gingival SCC was higher than that of maxillary sinus SCC (17.1% and 12.5%, respectively). The 5-year overall survival rate was 51.9% for the END group and 74.0% for the non-END group. The success rate of treatment for regional recurrence was high at 71.4%, whereas that for local or locoregional recurrence was low (33.3% and 0%, respectively).

Conclusion

The incidence of occult cervical metastasis of maxillary SCC was not high enough to recommend END. For survival of cN0 patients, local control of the primary tumor is more important than modality of neck management. Observation of cN0 neck is recommended when early detection of regional recurrence is possible irrespective of the site or T stage. The key enabler of early detection is patient education with periodic follow-up.

Elective neck dissection versus observation in early stage oral squamous cell carcinoma: recurrence and survival

Objectives

To evaluate the results of elective neck dissection versus those of observation in the treatment of early stage oral squamous cell carcinoma and to identify factors related to recurrence and survival.

Materials and Methods

This was a retrospective study of 52 patients who underwent elective neck dissection and 27 who did not receive neck dissection.

Results

In survival analyses, elective neck dissection showed a benefit in overall recurrence (P=0.027), especially in stage I patients (P=0.024). With regard to survival, the benefit was statistically insignificant (P=0.990). In multivariable analysis, overall recurrence was independently related to poor histologic grade (odds ratio [OR]=9.65, P=0.006), and cancer-specific death was independently related to advanced age (OR=6.3, P=0.022), higher clinical T stage (OR=15.2, P=0.01), and poorly differentiated histologic grade (OR=6.6, P=0.025).

Conclusion

Though there was lower recurrence in the elective neck dissection group, there were no statistically significant results on survival. The characteristics of the tumor itself, such as clinical T stage and poor histologic grade, may be more important in cancer-specific survival.

Prognostic factors in mandibular gingival squamous cell carcinoma: A 10-year retrospective study

The mandibular gingiva is the second most common site of oral cavity squamous cell carcinoma. This retrospective study was designed to determine the clinicopathological features of squamous cell carcinoma of the mandibular gingiva (MGSCC) and to establish a new risk model to predict overall survival. The study included 207 patients with primary MGSCC from January 2000 to September 2009. The medical charts were reviewed and data related to clinical characteristics, treatment provided, histopathological analysis, and follow-up were recorded. All patients underwent surgery as the first-line therapy; follow-up ranged from 1 to 171 months (median 63 months). Clinical characteristics and pathological outcomes were analyzed with respect to the 5-year overall survival rate. A survival risk model was established, and patients were classified into low-, moderate-, and high-risk groups based on the prognostic index designed in this study. The 5-year overall survival rates for the low-, moderate-, and high-risk groups were 92.3%, 76.9%, and 34.2%, respectively. Pathological node metastasis, perineural invasion, and extracapsular spread were the most significant predictive factors for 5-year overall survival. MGSCC is not aggressive, and the survival outcomes of MGSCC are better than those of squamous cell carcinoma (SCC) at other sites. It is suggested that patients with T2-T4 tumours undergo elective neck dissection and those with T1 tumours be followed up without addressing the neck.

Prognostic factors of gingival-alveolar squamous cell carcinoma of the maxilla

OBJECTIVES

To determine prognostic factors in gingivo-alveolar squamous cell carcinoma of the maxilla (GA-SCC-M), and particularly the prognostic value of both vertical and antero-posterior tumor spread.

MATERIAL AND METHODS

Our retrospective study included all naïve-treatment patients treated in our center between 2006 and 2013 for GA-SCC-M. Posterior involvement was considered when the tumor extended behind the mesial side of the first maxillary molar. Spread posterior to the maxillary tuberosity was defined by the spread to at least one of the following structures: pterygomaxillary fissure, pterygoid muscles, and processes. Involvement of the maxillary sinus floor, nasal fossa, and orbital floor was assessed, concerning the vertical spread.

RESULTS

A radiological tumor spread to the nasal fossa, maxillary sinus floor, and orbital floor were prognostic factors independently of age, cervical lymph node metastasis and positive margins in multivariate analysis (p < 0.05). Radiological suggested spread tended to be noticeably more predictive of a poor prognosis than histological proven tumoral spread. The prognosis was not significantly different between clinical tumoral spread anteriorly or posteriorly to the first molar (p = 0.46). The prognosis was not worsened, even in case of radiological suggested spread posterior to the maxillary tuberosity (p = 0.09).

CONCLUSION

A vertical radiological spread of GA-SCC-M was a prognostic factor but not the extension posteriorly to the maxillary tuberosity. T4b tumors were mostly resectable, proving that a T4b stage was not predictive of unresectability in GA-SCC-M of the maxilla.

Risk factors for relapse of middle-stage squamous cell carcinoma of the submandibular region and floor of mouth: the importance of en bloc resection

Our aim was to investigate retrospectively the rate of recurrence in the intervening region for middle-stage squamous cell carcinoma (SCC) of the tongue and identify the factors that predict relapse and prognosis. A total of 204 patients were included, 96 in the en bloc group and 108 in the control group. The groups were comparable. Two patients in the en bloc group (2%) and 12 in the control group (11%) developed recurrences in the intervening region. Kaplan-Meier analysis showed a reduction in the 5-year disease-specific survival once a recurrence had developed after the primary operation (77% compared with 14%, p<0.001). The en bloc group developed significantly fewer recurrences (2%) than the control group (11%) during the five years; p=0.037), and also had better 5-year disease-specific survival (80% compared with 66%, p=0.04). Cox's multivariate regression indicated that the pathological nodal status (p=0.016) and surgical technique (p=0.037) were independent predictive factors for the 5-year recurrence rate, as well as of 5-year disease-specific survival (p=0.001 and p=0.050, respectively). Recurrence in the intervening region is a negative prognostic factor for these patients, and we recommend en bloc resection as the management of choice for middle-stage SCC of the tongue.

Supraomohyoid neck dissection and modified radical neck dissection for clinically node-negative oral squamous cell carcinoma: a prospective study of prognosis, complications and quality of life

BACKGROUND

To assess the prognosis and morbidity between supraomohyoid neck dissection (SOND) and modified radical neck dissection (MRND) for oral squamous cell carcinoma (OSCC) in patients with a clinically node-negative neck (cN0).

PATIENTS AND METHODS

This prospective randomized study began in June 1999, and patient accrual concluded in May 2010. The cN0 neck was confirmed on clinical palpation by senior doctors. Ultimately, there were 322 patients recruited into the study.

RESULTS

Patient demographics were well balanced between the two groups. There were 10 patients in the SOND group and 21 patients in the MRND group who developed nodal recurrence without associated local recurrence or distant metastasis. The 3-year neck control rate (NCR) rate was 92.6% for the SOND group and 87.5% for the MRND group (in favor of SOND, P = 0.108). There was no significant difference between the SOND group and the MRND group in the 3-year disease-specific survival (DSS) rate (79.0% vs. 76.9%, P = 0.659). Importantly, there were significantly fewer complications in the SOND group compared with the MRND group (13.0% vs. 21.9%, P = 0.040). The disease-free survivors in the SOND group also reported better pain relief (P = 0.013) and shoulder function (P < 0.001) than those in the MRND group one year after treatment.

CONCLUSIONS

We recommend SOND as a priority treatment for cN0 OSCC patients.

Supraomohyoid neck dissection in the management of oral squamous cell carcinoma: special consideration for skip metastases at level IV or V

PURPOSE

The aim of this study was to evaluate the therapeutic safety and prognosis of supraomohyoid neck dissections for oral squamous cell carcinoma, with a special focus on the risk of skip metastases in level IV or V.

MATERIALS AND METHODS

A retrospective study was conducted of 637 patients with oral squamous cell carcinoma who were admitted to the department of oral and maxillofacial surgery from September 1995 through July 2010. After completing a diagnostic evaluation, all patients underwent surgery (wide primary excision with supraomohyoid neck dissection, extended supraomohyoid neck dissection, or modified radical or radical neck dissection) and were followed periodically.

RESULTS

Levels I, II, and III were the most common sites of occult metastasis. Skip metastases alone at level IV or V and any neck recurrence at level IV or V were not found. Three-year neck recurrence-free survival and disease-specific survival were not significantly different among the patients who underwent supraomohyoid neck dissection, extended supraomohyoid neck dissection, or modified radical or radical neck dissection owing to cN0 to cN(+) disease.

CONCLUSIONS

The rate of skip metastasis at level IV or V is very rare and is very difficult to diagnose accurately. The results of this retrospective study show that supraomohyoid neck dissection for oral squamous cell carcinoma is an appropriate treatment.