Is it oncologically safe to leave the ipsilateral submandibular gland during neck dissection for head and neck squamous cell carcinoma?

Functional reconstruction of tissue defects after total parotidectomy using a modified submandibular gland flap

OBJECTIVE

Reconstruction of soft tissue defects after total parotidectomy requires a feasible and effective pedicled flap with sufficient volume. In this study, we introduce a modified submandibular gland flap (SMGF) for functional reconstruction of soft tissue defects resulting from total parotidectomy.

MATERIALS AND METHODS

This study included 12 patients diagnosed with parotid gland carcinoma undergoing total parotidectomy and ipsilateral selective neck dissection. The modified SMGF was harvested and transferred to the parotid bed. This procedure was coupled with anastomosis between the parotid gland duct and Wharton's duct. The feasibility of the surgery, postoperative complications, facial profile restoration, and salivary secretion were assessed.

RESULTS

All SMGFs pedicled only over the proximal facial artery survived without major complications. Facial profiles were well-restored, and salivary secretion was partially reserved. During the postoperative follow-up, no tumor recurrence was observed in any of the cases, and the volume of the SMGFs did not show obvious atrophy.

CONCLUSIONS

The modified SMGF is a viable solution for volume restoration and functional reconstruction after total parotidectomy.

CLINICAL RELEVANCE

This modified technique is simple and feasible for the functional reconstruction of soft tissue defects after total parotidectomy compared to other flaps and is worthy of clinical promotion.

Involvement of submandibular gland in oral squamous cell carcinoma

BACKGROUND

The submandibular gland (SMG) is sacrificed during neck dissection in patients undergoing curative surgery for oral squamous cell carcinoma (OSCC). This may cause a decrease in the production of saliva and result in xerostomia.

PURPOSE

This study aimed to determine the incidence, invasion patterns, risk factors, and prognosis of SMG involvement in OSCC.

METHODS

The primary predictor variable in this study was SMG involvement, and the secondary predictor was prognosis.

MAIN FINDINGS

The primary outcome variables were patient characteristics and pathological results for extranodal extension (ENE), perineural invasion (PNI), and pN stage. Four out of 173 patients (2.23 %) showed SMG involvement. Of these cases, one (25 %) was from the primary lesion and three (75 %) were from the metastatic neck lymph nodes (LNs). The primary lesion was located on the lower gingiva, and the other three were from level-Ib LNs with ENE. The pathological PNI was observed in three of the four patients, and ENE was observed in three of the four patients. Preoperative CT and MR revealed SMG invasion and contact in two patients. There were significant differences in the ENE and pN stages between patients with and without SMG involvement (P<0.05). There was a significant difference in the overall survival between patients with (25.0 %) and without (71.5 %) SMG involvement (P = 0.011).

CONCLUSIONS

SMG involvement was associated with ENE, pN stage, and poor prognosis.

Risk stratification of submandibular salivary gland involvement in oral squamous cell carcinoma based on histopathological parameters: A 15-year retrospective study

Objective

Squamous cell carcinoma (SCC) represents about 90% of all oral malignancies. The study aimed to assess the involvement of the submandibular salivary gland (SMG) in oral SCC (OSCC) patients and the need for SMG excision.

Materials and Methods

Demographics, clinical information and staging of the 210 patients undergoing surgery for OSCC were obtained from the department records. The histopathological slides were retrospectively reviewed. The nodal status was also verified with the histopathology reports. Frequency distribution, Chi-square association, ordinal logistic regression analysis and Kaplan-Meier analysis were performed.

Results

SMG was excised in 171 patients. Five patients had SMG involvement. Buccal mucosa (BM) and gingivobuccal sulcus had a greater risk of level IB metastases (P < 0.01). Pattern 3 and pattern 4 of invasion had a higher risk of level IB metastases (P = 0.04). Depth of invasion (DOI) >4 mm was associated with level IB lymph node (LN) involvement (P = 0.0001). DOI >4 mm to 8 mm had 3.7 times the risk and a DOI >8 mm to 12 mm had 5 times the risk of level IB metastases. Pattern of invasion (POI), tumour budding and DOI >4 mm were significant prognosticators for patient survival.

Conclusion

Histologically, patients may be categorised as 'high risk': those with an increased risk of level IB LN involvement and 'low risk': those at low risk for level IB involvement with the help of POI, tumour budding and DOI as risk factors. In low-risk patients, SMG may be spared and the level IB LNs are dissected. High-risk patients may be chosen as candidates for SMG transfer or excision based on the extent of LN involvement.

Submandibular gland involvement in oral cavity squamous cell carcinoma: a retrospective multicenter study

BACKGROUND

The submandibular gland (SMG) is routinely excised during neck dissection. Given the importance of the SMG in saliva production, it is important to understand its involvement rate by cancer tissue and the feasibility of its preservation.

METHODS

Retrospective data were collected from five academic centers in Europe. The study involved adult patients affected by primary oral cavity carcinoma (OCC) undergoing tumor excision and neck dissection. The main outcome analyzed was the SMG involvement rate. A systematic review and a meta-analysis were also conducted to provide an updated synthesis of the topic.

RESULTS

A total of 642 patients were enrolled. The SMG involvement rate was 12/642 (1.9%; 95% CI 1.0-3.2) when considered per patient, and 12/852 (1.4%; 95% CI 0.6-2.1) when considered per gland. All the glands involved were ipsilateral to the tumor. Statistical analysis showed that predictive factors for gland invasion were: advanced pT status, advanced nodal involvement, presence of extracapsular spread and perivascular invasion. The involvement of level I lymph nodes was associated with gland invasion in 9 out of 12 cases. pN0 cases were correlated with a reduced risk of SMG involvement. The review of the literature and the meta-analysis confirmed the rare involvement of the SMG: on the 4458 patients and 5037 glands analyzed, the involvement rate was 1.8% (99% CI 1.1-2.7) and 1.6% (99% CI 1.0-2.4), respectively.

CONCLUSIONS

The incidence of SMG involvement in primary OCC is rare. Therefore, exploring gland preservation as an option in selected cases would be reasonable. Future prospective studies are needed to investigate the oncological safety and the real impact on quality of life of SMG preservation.

Gland-sparing neck dissection: oncological and functional outcomes in oral cancer patients

This study was performed to evaluate the subjective and objective functional outcomes of patients who had undergone submandibular gland-sparing neck dissection. All data were obtained from patients treated in a single hospital. Seventy-seven patients who had undergone complete submandibular gland sparing (CSGS) were included in the study. Cancer prognosis items were recorded. The subjective outcomes included patient self-evaluation of mouth dryness and the evaluation of the presence of saliva secretion following the application of digital pressure. Saliva scintigraphy served as the objective test. Self-reported xerostomia was compared between the CSGS patients and a control group of patients who had undergone unilateral submandibular gland removal (USGR; n = 74). In the CSGS group, local recurrence occurred in 3.8% of the 80 cancer sites, and neck recurrence occurred in 5.9% of neck dissection sites. Regarding the subjective measurements, 7.0% of the CSGS patients reported xerostomia and 91.9% demonstrated saliva secretion by digital pressure. Scintigraphy revealed actively secreting glands, with 42.9% of them showing normal gland function; none of the patients had severe xerostomia. The relative risk of dry mouth was significantly higher in the USGR patients than in the CSGS patients (P < 0.001). Submandibular gland sparing during neck dissection was found to result in satisfactory saliva secretion, with a relatively small risk of local or neck recurrence.

Can Submandibular Gland be Preserved During Neck Disscetion in Oral Cavity Squamous Cell Carcinoma?

Submandibular gland is commonly removed as an integral part of level I neck dissection for oral cavity squamous cell carcinoma. However, it is unclear whether lymph nodes are present within the submandibular gland which may form the basis of lymphatic spread and gland removal. So, this study investigated the incidence of submandibular gland involvement in oral cavity squamous cell carcinoma to determine the possible feasibility of submandibular gland sparing neck dissection. The medical records of 83 patients diagnosed with oral cavity squamous cell carcinoma were reviewed retrospectively to determine frequency of intraglandular lymph nodes in submandibular gland [submandibular gland metastasis] and incidence and mechanism of submandibular gland involvement by oral cavity squamous cell carcinoma. The overall incidence of cervical metastasis was 56.4%, of whom majority had level I metastasis. Submandibular gland involvement via direct invasion from the anatomical proximity of T4a tumors or extra nodal extension from level 1b node was evident in 6 patients. Despite the high incidence of level I metastasis, lymphatic metastases to submandibular gland itself are unlikely based on absence of intraglandular lymph nodes. The results suggest the feasibility of preserving the submandibular gland in early-stage oral cavity carcinoma unless the tumor extends level 1b with extra nodal extension.

Prevalence of submandibular gland involvement in neck dissection specimens of patients with oral cavity carcinoma

INTRODUCTION

The submandibular gland is commonly removed during neck dissection in patients with head and neck cancer. The patient experiences various complications due to the removal of the submandibular gland. Therefore, the necessity of submandibular gland removal should be evaluated. This study aimed to was to determine the frequency of submandibular gland (SMG) involvement in patients with oral cavity squamous cell carcinoma (SCC).

METHODS

In this retrospective study, medical records of patients with oral cavity cancer who were referred to Amir Alam Hospital between 2015 and 2020 were reviewed. Patient data includes surgical report, histopathology report (tumor size, number of lymph nodes involved, and SMG tumor involvement), Tumor Location, History of Smoking, History of Opium, and Alcohol consumption was extracted from patients' medical records and statistically analyzed using SPSS software version 20.

RESULTS

Of the total 60 patients, 24 (40%) were female and 36 (60%) were male. Smoking was reported in 55% of patients with a mean of 4.11 pack-year. Alcohol and opium use was observed in 18.3% and 26% of patients. The majority of patients (78.3%) had tongue cancer. More than half of the patients (53.3%) reported tumors of 2 cm or smaller, and 16.7% of patients had tumors larger than 4 cm. The majority of patients (80.3%) did not have cervical lymph node metastasis, 13.1% had 1-2 involved lymph nodes and 4.9% had 3 to 6 involved lymph nodes and there were no cases of metastasis to more than 6 lymph nodes. Finally, no individual had submandibular gland involvement, ie 100% of patients had no submandibular gland metastasis.

CONCLUSION

The results confirmed that SMG involvement is very rare in patients with oral SCC and therefore it is not necessary to remove the gland as part of treatment. Preservation of the submandibular gland prevents complications related to the removal of this gland and reduces morbidity and increases the quality of life of patients after surgery.

Rare Metastasis to the Submandibular Gland in Oral Squamous Cell Carcinoma

Purpose

In the current recommendation of neck dissection in oral squamous cell carcinoma (OSCC), the submandibular gland (SMG) should also be removed. This study aimed to investigate the incidence and the patterns of SMG involvement in OSCC patients.

Methods

Patients initially diagnosed with OSCC between January 2018 and October 2020 were included. The distribution of lymph nodes metastasis in level IB was analyzed.

Results

We included 145 patients who underwent primary surgery and neck dissection in this study. All patients had level IB lymph node dissection and simultaneous removal of the SMG. Of these patients, only one patient (0.7%) had involvement in SMG by directly infiltrating from the primary tumor. A total of 18 positive lymph nodes were found in level IB in 16 patients, and no positive lymph nodes were located in the SMG. There were 6 lymph nodes located in the lateral part of the SMG and 12 lymph nodes located in the anterior of the SMG. Patients with tumors located in the buccal mucosa and N3 stage were the independent predictive factors associated with level IB nodal metastasis.

Conclusion

Involvement of SMG in OSCC is quite rare. Preservation of the SMG during neck dissection in selected patients with OSCC seems to be feasible and oncologically safe.

Functional outcomes after submandibular gland-sparing neck dissection in patients with oral squamous cell carcinoma

The feasibility of submandibular gland (SMG) preservation during neck dissection has been described. The aim of this study was to analyse the functional outcomes in patients undergoing SMG preservation during neck dissection for cT1-2N0 oral squamous cell carcinoma. Consecutive patients were divided into two groups based on the management of the SMG, and underwent a saliva flow test before surgery, 7 days after surgery, and at 3, 6, 9, and 12 months after surgery. All enrolled patients completed the fourth version of the University of Washington Quality of Life (UWQOL) questionnaire at 12 months after surgery. In patients who underwent SMG preservation during neck dissection, the flow rate at 7 days after surgery was significantly lower than that preoperative; however, it gradually returned to baseline at 9 months after surgery. The saliva flow rate at 9 months after surgery was similar to that at 12 months after surgery. Further, patients with SMG preservation had higher scores for the activity, swallowing, chewing, and saliva domains than patients without SMG preservation. The results of the study suggest that saliva secretion ability can be preserved following SMG-sparing neck dissection, and that SMG preservation improves postoperative quality of life.

Impact of submandibular gland preservation in neck management of early-stage buccal squamous cell carcinoma on locoregional control and disease-specific survival

Background

The feasibility of submandibular gland (SMG) preservation in oral squamous cell carcinoma (SCC) has occasionally been analyzed, but the differences in survival associated with the presence or absence of SMG preservation remain unknown. We aimed to prospectively evaluate the oncologic results of SMG preservation in cT1-2 N0 buccal SCC.

Methods

This was a prospective, non-randomized cohort study. Patients with surgically treated cT1-2 N0 buccal SCC were prospectively enrolled and divided into two groups based on the management of the SMG. Level 1b lymph nodes were categorized into six groups based on the positional relationship between the lymph node and the SMG. The main study endpoints were locoregional control (LRC) and disease-specific survival (DSS).

Results

A total of 31 of the 137 included patients underwent SMG-sparing neck dissection. Patients with SMG preservation were likely to be young persons. Superior metastasis occurred in 11 patients with a prevalence of 8.0%, followed by an anterior metastasis rate of 5.1%, and no metastases developed deeply or within the SMG. The 5-year LRC rates in the SMG-sparing and SMG-excision groups were 74 and 75%, respectively, and the difference was not significant (p = 0.970). The 5-year DSS rates in the SMG-sparing and SMG-excision groups were 74 and 69%, respectively, and the difference was not significant (p = 0.709).

Conclusions

SMG involvement was rare, and the superior group carried the highest risk for lymph node metastasis. SMG-sparing neck dissection is selectively suggested in cT1-2 N0 buccal SCC patients, and could avoid postoperative asymmetric appearance and dry mouth.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12885-020-07534-5.

Level I Nodal Positivity as a Factor for Involvement of the Submandibular Gland in Oral Cavity Carcinoma: A Case Series Report

Introduction  The routine practice of neck dissection in the surgical management of oral carcinoma has evolved into a more functionally conservative approach. Over time, the rationale for removal of the submandibular gland has been questioned. Routine extirpation of the submandibular gland can aggravate the xerostomia experienced by many patients, significantly affecting their quality of life. Objective  The objective of the present study was to determine the incidence of submandibular gland metastases in oral cavity carcinoma and to identify possible factors that may affect their involvement. Methods  A total of 149 cases of oral carcinoma presenting at a private tertiary care hospital in Karachi, Pakistan, over the course of 1 year were reviewed retrospectively. Results  Histopathological data showed that the submandibular gland was involved in 7 (4.7%) cases. Involvement of level I lymph nodes was found in all of the cases. Direct extension of primary tumor was noted in two cases when the primary tumor was in the floor of the mouth. Conclusion  The results suggest that preservation of the submandibular gland during neck dissection for oral carcinoma can be practiced safely when there is no evidence of direct extension of the primary tumor toward the submandibular gland or when there is no clinical or radiological evidence of neck disease in level I. Presence of pathological lymph nodes in level I requires caution when contemplating preservation of the submandibular gland.

Feasibility of Submandibular Gland Preservation in cT1-2N0 Squamous Cell Carcinoma in the Floor of the Mouth

Purpose: Our goal was to analyze the feasibility of submandibular gland (SMG) preservation in cT1-2N0 floor of the mouth (FOM) squamous cell carcinoma (SCC) patients. Methods: Patients with cT1-2N0 FOM SCC were retrospectively enrolled and divided into two groups according to the management of the SMG. Level 1b tissues were divided into six groups according to their location with respect to the SMG. The Kaplan-Meier method was used to calculate the locoregional control (LRC) and disease-specific survival (DSS) rates. A Cox model was used to determine the independent risk factors. Results: Twenty-nine patients underwent SMG-preserving neck dissection, and lymph node metastasis occurred in the superior group in 3 of the 37 dissections with a prevalence of 8.1% and in the anterior group in 2 of the 37 dissections with a prevalence of 5.4%. In patients without SMG preservation, lymph node metastasis occurred in the superior group in 7 of the 137 dissections with a prevalence of 5.1% and in the anterior group in 6 of the 137 dissections with a prevalence of 4.4%. The only pattern of SMG involvement was invasion by positive lymph nodes. The 5-year LRC rates for patients with SMG preservation and patients with SMG excision were 84 and 73%, respectively, and the difference was not significant (p = 0.239). The 5-year DSS rates for patients with SMG preservation and patients with SMG excision were 88 and 84%, respectively, and the difference was not significant (p = 0.524). Conclusions: In early-stage FOM SCC patients, SMG involvement is rare, the most common metastatic site in level 1b is the superior group, and SMG preservation does not decrease the LRC or DSS rates. Therefore, the findings suggest that there might be high feasibility of SMG-preserving neck dissection in cT1-2N0 FOM SCC.

The preservation and application of the submandibular gland in oral squamous cell carcinoma (STROBE)

This prospective study aimed to investigate metastases of oral squamous cell carcinoma (OSCC) to cervical lymph nodes and submandibular glands and to analyze the safety and feasibility of preserving and using submandibular glandular flaps to repair postoperative OSCC defects.Overall, 330 patients with OSCC who met the inclusion criteria were enrolled in the study from January 2014 to July 2018. OSCC metastasis to cervical lymph nodes and submandibular glands was investigated using intraoperative frozen section and postoperative pathological observation. Fifteen patients who underwent repair of postoperative OSCC defects with submandibular glandular flaps were monitored for postoperative wound healing, complications, pathology, and appearance satisfaction and were followed up long term.Among the 330 patients with OSCC, the most common type was tongue cancer (138/330); 204 patients were node negative and 126 were node positive. Of 363 samples of the submandibular gland, 7 were metastatic with stage IV lesion, 5 were directly invaded by the primary tumor, and 2 were metastatic with extranodal extension in level Ib. None of the submandibular gland samples showed intraglandular hematogenous and nodal metastases. The repair of OSCC defects with submandibular glandular flaps was successful in all 15 patients, including 11 males and 4 females, with an age range of 19-74 years and a mean of 51 years. Of 15 patients, some had complications with heart and cerebrovascular diseases, diabetes, or chronic respiratory disease. All the submandibular glandular flaps survived postoperatively without any complications, and the mucosification on the surface was adequate. Follow-ups (median duration: 14 months) revealed the satisfactory recovery of shape and function without any local recurrences or distant metastases.Direct invasion is the main form of OSCC metastasis to the submandibular gland, while hematogenous and nodal metastases are uncommon. Preservation of the submandibular gland is oncologically safe. Thus, repair of postoperative OSCC defects with submandibular gland flaps is a feasible and promising procedure.

Submandibular Gland Invasion by Oral Cavity Cancers: A Systematic Review

OBJECTIVE

The submandibular gland (SMG) is typically included in level I neck dissection specimens despite limited data demonstrating SMG invasion. The main objective of this article is to determine the rate and pathways of SMG invasion by squamous cell carcinoma of the oral cavity and oropharynx.

DATA SOURCES

A systematic review of relevant studies was performed, evaluating articles identified via the PubMed, Cochrane, and Medline databases.

REVIEW METHODS

Descriptive features of primary tumors, primary treatment modalities, the rate and pathway of SMG invasion, and survival outcomes, if present, were reported following the PRISMA guidelines.

RESULTS

The initial literature search yielded 273 articles, of which 17 met inclusion criteria. A total of 2306 patients with 2792 SMG resections were analyzed. Fifty-eight resections (2.0%) were revealed to have tumor involvement. Among patients with SMG tumor involvement, the most common invasion pathway was direct SMG invasion by primary tumor (43 of 58, 74.1%). The second-most common mode of SMG invasion was from involved adjacent lymph nodes (10 of 58, 17.2%). Only 3 SMG resections out of 2792 (0.1%) had isolated metastatic parenchyma without evidence of direct tumor invasion or invasion by involved lymph nodes.

CONCLUSION

Given this rarity of SMG involvement, preservation of SMG might be feasible in selected patient population. However, additional studies need to examine the functionality of preserved SMGs among patients who receive postoperative adjuvant radiation therapy.

Selectively sparing the submandibular gland when level Ib lymph nodes are included in the radiation target volume: An initial safety analysis of a novel planning objective

BACKGROUND

Submandibular gland (SMG) metastases are extremely rare in head and neck cancer, even in the presence of level Ib lymph node (LN) involvement. In recent years, we have contoured the SMG and specifically attempted to limit its dose exposure even in patients in whom the level Ib LN station is targeted. This study reports our preliminary feasibility and safety experience with selective submandibular gland sparing.

METHODS

Patients with squamous cell cancer (SCC) of the oral cavity or oropharynx with T1-2, N0-3, M0 disease in whom at least a single level Ib lymph node region was included in the target volume were identified. All patients were treated from 2009 to 2014 with definitive or postoperative IMRT with or without chemotherapy. Patients with recurrent disease, previous radiation or treated palliatively were excluded.

RESULTS

A total of 174 patients met criteria for inclusion. Among the 185 level Ib LN stations that were deliberately targeted in the clinical treatment volume, 32 submandibular glands were contoured, excluded from the target volume and avoided during treatment planning. Mean dose to the spared SMG were reduced by 12% (66.6 Gy vs. 58.9 Gy, p < .001). None of these patients experienced any level 1b LN failures.

CONCLUSION

Selective sparing of the submandibular gland when targeting the level 1b nodes in oral cavity and oropharynx cancer is feasible, reduces the mean dose to submandibular glands and does not result in increased level 1b nodal failure rates. Additional studies with larger cohorts are needed to validate this preliminary observation.

Determinants of level Ib involvement in oral squamous cell carcinoma and implications for submandibular gland-sparing neck dissection

Traditional neck dissection for oral squamous cell carcinoma (OSCC) involves removal of the submandibular salivary gland. Several studies have cited the low incidence of direct gland invasion by tumours and have recommended gland-sparing neck dissection. In this study, a detailed audit of level Ib involvement in OSCC was performed in order to assess the feasibility of submandibular gland-sparing in neck dissection; the rate of direct involvement by the primary tumours, the involvement of periglandular level Ib nodes, and their determinants were investigated. A total of 586 neck dissection specimens obtained between 2005 and 2014 from patients operated on at the study institution for floor of mouth, tongue, and buccal primaries, were evaluated for direct invasion of the gland and periglandular lymphadenopathy. Of 226 node-positive patients, 21 (9.3%) had direct gland invasion by tumour. Risk factors were tumour diameter >4cm (P=0.002) and depth of invasion >10mm (P=0.003). Determinants of periglandular lymphadenopathy were depth of invasion >10mm (P<0.001), perineural invasion (P=0.02), lymphovascular invasion (P=0.014), and moderate/poor differentiation (P<0.0001). Gland-sparing neck dissection is safe in early tumours (pT1pN0-1), with a good chance of minimizing xerostomia without radiotherapy. Larger tumours without clear evidence of submandibular gland invasion or suspicious level Ib lymphadenopathy may be considered for gland preservation, however the oncological safety is unclear.

Submandibular gland invasion and feasibility of gland-sparing neck dissection in oral cavity carcinoma

OBJECTIVE

This study investigated the incidence and routes of submandibular gland involvement in oral cavity carcinoma to determine the feasibility of submandibular gland sparing neck dissection.

METHODS

The records of 155 patients diagnosed with oral cavity squamous cell carcinoma, with a total of 183 neck specimens, including those involving level I, were reviewed retrospectively.

RESULTS

Submandibular gland involvement, via direct invasion from the anatomical proximity of T4a tumours, was evident in two patients. The floor of mouth location, either primarily or as an extension of the primary tumour, was the only risk factor for submandibular gland involvement in oral cavity carcinoma (p = 0.042). Tumour location, clinical and pathological tumour (T) and nodal (N) stages, and radiological suspicion of mandible invasion, were not found to be statistically relevant (p > 0.05).

CONCLUSION

The results suggest the feasibility of preserving the submandibular gland in early stage oral cavity carcinoma unless the tumour is located in, or extends to, the floor of mouth.

The effect of submandibular gland preservation during level 1B neck dissection on postoperative xerostomia

OBJECTIVE

Compare the presence and degree of postoperative xerostomia following preservation or excision of the submandibular gland (SMG) during level IB neck dissection (ND) without adjuvant radiation.

METHODS

Retrospective review with patient questionnaire administered to patients with pT1-2N0 oral squamous cell carcinoma (SCC) who underwent resection and ND with SMG preservation or SMG excision without postoperative radiation from 2011 to 2015. We analyzed an additional control group that was age and gender-matched and had not undergone oral resection or SMG excision. We compared the scores reported by the three groups from three questionnaires: University of Michigan Xerostomia Quality of Life (XeQoL), Short Form-8 (SF-8), and a xerostomia severity scale (XSS). Dry mouth severity (DMS) was calculated based on XSS scores among those complaining of any xerostomia.

RESULTS

Eleven SMG preservation group, 14 SMG excision group and 15 control group patients completed the survey. Complication and recurrence rates were comparable among experimental groups. No differences were identified between the two experimental groups for the XeQoL, SF-8, and XSS questionnaires (p=0.96, 0.87, 0.7). Control patients reported less xerostomia on XeQoL (p=0.046) and XSS (p=0.01) compared to the experimental groups combined with no statistical difference in SF-8 scores (p=0.25). No patients in either group developed regional recurrence in level IB.

CONCLUSION

SMG preservation, though technically and oncologically sound, does not appear in this study to reduce xerostomia. Oral resection with ND may result in some degree of xerostomia perception.

Questionable Necessity for Removing Submandibular Gland in Neck Dissection in Squamous Cell Carcinoma of Oral Cavity

To assess whether submandibular gland is involved by metastasis in cases of oral cavity squamous cell carcinomas. It was a retrospective study, where we reviewed the records of the patients who underwent neck dissections for Squamous Cell Carcinoma of the oral cavity. It included 112 patients who had undergone 115 neck dissections (three patients had undergone bilateral neck dissection), either therapeutic or prophylactic. No pathologic evidence of metastasis to submandibular gland was seen in any of the case. Preservation of submandibular glands can be a good technique for reducing future complications in a patient undergoing Neck Dissection wherever feasible. Therefore, if there is no need to expose large oral cavity tumors through the submandibular triangle, or when there is no direct extension of the primary and/or regional lymph nodes into the submandibular gland, it may be safe to preserve the submandibular gland.

Prospective study of the pattern of lymphatic metastasis in relation to the submandibular gland in patients with carcinoma of the oral cavity

BACKGROUND

The submandibular gland is responsible for 70% to 90% of unstimulated saliva production. Its excision causes a decrease in basal salivary flow resulting in increased symptoms of subjective xerostomia and decreased quality of life. In this study, we have tried to assess the pattern of nodal metastasis in relation to the submandibular gland. With this study, we have tried to find out whether submandibular gland preservation is a viable option in patients with carcinoma of the oral cavity.

METHODS

This was a prospective study conducted in a tertiary care cancer center. The fibrofatty tissue surrounding the submandibular gland was divided into 6 parts depending upon its location with the submandibular gland. All these 6 parts along with the submandibular gland were separately sent for histopathological analysis. Metastasis pattern in level Ib region was noted.

RESULT

The study included 137 patients with carcinoma of the oral cavity who underwent neck dissections. Eighty-five patients had clinic-radiologically N0 neck, 52 patients had cN+ (clinically node positive) neck. Level Ib was involved in 8.2% of the cases with cN0 (clinically node negative neck). In patients with cN+ neck, level Ib metastasis was seen in 40% of the cases. Metastasis in N0 necks in the area deep to the submandibular gland was seen in only 1 case (9% of all pathologically node-positive patients) with cN0 neck. This was the only case in which submandibular gland mobilization would have been required to take out the metastatic node. Even in cases with N+ neck, deep metastasis was seen in 4 cases only (14.8%). None of them had a primary tumor in the tongue. Therefore, there is a possibility of preserving the submandibular gland in cases of carcinoma of the tongue.

CONCLUSION

Involvement of level Ib in early tongue cancers is not very common and direct metastases to the submandibular glands are rare. Even when metastasis is present in level Ib, it can be excised without affecting the submandibular gland. In early tongue lesions, submandibular gland mobilization for dissection at level Ib is not required as no metastases deep to the submandibular glands were seen in these patients. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Oropharyngeal reconstruction with a pedicled submandibular gland flap

Locoregional flaps are widely used for reconstruction of small and medium defects in the oral cavity. The submandibular gland flap is a pedicled flap, which derives its blood supply from the facial artery, based on the submandibular gland. We describe the use of the flap in 20 patients who required oropharyngeal reconstruction with a pedicled submandibular gland flap after resection of a tumour between July 2012 and October 2014. Patients with squamous cell carcinoma were excluded. All flaps were pedicled on the facial vessels (inferiorly in 17 patients and superiorly in 3). The indications were: reconstruction of intraoral mucosal defects (n=13), filling the parapharyngeal dead space (n=6), and obliteration of the mastoid (n=1). All the flaps atrophied, but with no clinical effect. One patient developed partial loss of the flap, and one early leakage. There were no cases of xerostomia, and no signs of recurrence during the postoperative follow-up period of 3-26 months. The flap is useful, as it is simple and reliable for reconstruction of small to medium oropharyngeal defects in carefully selected cases, and gives good cosmetic and functional results.

Metastasis to submandibular glands in oral cavity cancers: Can we preserve the gland safely?

OBJECTIVE

To analyze submandibular gland (SMG) involvement in cases of oral cavity cancers and decide whether to remove submandibular glands while performing neck dissections for oral cavity cancers to decrease the incidence of xerostomia, a common issue post-operatively.

METHODS

Retrospective analysis of 157 neck dissections out of 204 neck dissections performed for oral cavity carcinomas in the Department of Otolaryngology and Head and Neck Surgery from 2008 to 2013 was done. SMG was bilaterally removed in 6 dissections, hence a total of 163 glands were analyzed. Those involved by tumor in histopathology were further studied for the pattern of involvement.

RESULTS

3.68% (6/163) glands showed involvement by the tumor. 9.20% (15/163) showed chronic sialo-adenitic changes. Four of the six involved glands showed direct contiguous spread from primary lesion, one showed extra-capsular spread from level IB lymph nodes and evidence of both modes of spread was seen in one. Evidence of metastasis was not seen in any of the glands (0%). Literature review showed a metastasis rate of 0.096% (2/2074).

CONCLUSION

Metastatic involvement of submandibular gland is extremely rare. Submandibular gland preservation, in the absence of evidence of gross contiguous involvement, does not affect survival. Hence, SMG can be safely spared during neck dissections for oral cavity squamous cell cancers except in certain situations such as close proximity of the primary lesion to gland, presence of intra-capsular lymph nodes in radiology, gross intraoperative evidence of invasion of the SMG and in salvage surgeries performed in post-irradiated and recurrent cases.

Combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers

Background

The growth of aging populations in an increasing number of countries has led to a concomitant increase in the incidence of chronic diseases. Accordingly, the proportion of older aged patients with oral cavity and oropharyngeal cancers and comorbidities has also increased. Thus, improvements must be made in the tolerance and safety of surgical procedures for these patients with complex medical conditions. In this study, we investigated combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers in terms of surgical methods, safety, and clinical outcome.

Methods

Between January 2011 and May 2012, 8 patients over the age of 65 years (7 men, 1 woman; aged 66 to 75 years (median, 69.6)) with oral cavity and oropharyngeal cancers underwent combined submandibular gland and sternocleidomastoid myocutaneous flaps for postoperative reconstruction at Ganzhou Tumor Hospital. All eight patients had comorbid cardiovascular, cerebrovascular, or chronic respiratory disease or diabetes. Clinical outcomes, complications, and tolerance to surgical treatment were observed.

Results

Surgical treatment was successful in all eight patients. All submandibular gland flaps survived with well-mucosalized surfaces and with no complications. During the postoperative follow-up period of 12 to 28 months, no patient developed local recurrence or distant metastasis, and all had good recovery of function and local contour.

Conclusions

This combined reconstruction technique enables appropriate restoration of oral function, facial aesthetics and improved quality of life. Further, this technique has several advantages: it is easier to perform, reduces operation time and surgical risk, causes less surgical injury, and has minor impact on contour. The technique provides a new and safe reconstruction option for older aged patients with oral cavity and oropharyngeal cancers.

Submandibular Gland Preservation during Concurrent Neck Dissection and Transoral Surgery for Oropharyngeal Squamous Cell Carcinoma

Objectives

Analyze the effect of ipsilateral submandibular gland preservation on patients undergoing concurrent neck dissection and transoral surgery for oropharyngeal squamous cell carcinoma. Evaluate for (1) intraoperative and postoperative communications between the oropharynx and neck and (2) oncologic outcomes.

Study Design

Retrospective chart review of prospectively collected data.

Setting

Tertiary academic referral center.

Methods and Subjects

Retrospective chart review of patients undergoing transoral laser resection of oropharyngeal squamous cell carcinoma with simultaneous neck dissection(s) for primary, persistent, recurrent, and second primary disease between January 1999 and February 2013. Data analyzed for operative technique, pathologic diagnosis, postoperative course, complications, and oncologic outcomes.

Results

Overall 253 patients were identified. Of these, 96 patients underwent ipsilateral submandibular gland preservation and 157 underwent ipsilateral submandibular gland removal at the time of neck dissection. The prevalence of intraoperative communication between the neck and oropharynx was significantly lower in cases with submandibular gland preservation (2/96, 2.08%) compared to those with submandibular gland removal (22/157, 14.13%). No postoperative leaks occurred in the gland preservation group (0/96, 0%) compared to a leak prevalence of 8.92% (14/157) when the gland was removed ( P = .0041). There was no difference in local, regional, or distant disease recurrence between submandibular gland preservation and gland removal. Similarly, Kaplan-Meier analysis showed no difference in disease free survival, disease specific survival, or overall survival.

Conclusions

Submandibular gland preservation during neck dissection in patients undergoing transoral surgery for oropharyngeal squamous cell carcinoma significantly reduces the risk of intraoperative and postoperative salivary leaks without compromising oncologic outcomes.