Oral Maxillary Squamous Cell Carcinoma: Management of the Clinically Negative Neck

doi:10.1016/j.joms.2007.12.017

Journal of Oral and Maxillofacial Surgery

Volume 66, Issue 4, April 2008, Pages 762-766

https://doi.org/10.1016/j.joms.2007.12.017 Get rights and content

Purpose

Squamous cell carcinomas of the hard palate, maxillary gingiva, and maxillary alveolus occur at relatively low rates compared with squamous cell carcinomas in other oral sites. There is little within the surgical literature to guide treatment for maxillary squamous cell carcinoma. To date, only 1 other group has addressed neck management in the oral maxillary squamous cell carcinoma patient presenting with a clinically negative neck. Adequate characterization of maxillary gingival carcinoma behavior with respect to regional cervical metastasis is wanting.

Patients and Methods

We present a retrospective review of our own clinical experience as well as a review of the existing literature.

Results

In our University of California San Francisco patient group, cervical disease was detected in 20% of those individuals with maxillary squamous cell carcinoma presenting for initial consultation. After ablative surgery, those individuals who presented with clinically negative necks had a 21.4% rate of regional node metastasis. Ultimately, 50% of our patients with squamous cell carcinomas of the palate, maxillary gingiva, and maxillary alveolus developed regional or metastatic distant disease; 42.9% of the patients manifested disease to the cervical lymph nodes alone.

Conclusions

The cases of oral maxillary squamous cell carcinomas reviewed herein exhibit aggressive regional metastatic behavior comparable to that of such carcinomas of the tongue, floor of the mouth, and mandibular gingiva. Based on the findings presented herein, we recommend selective neck dissection in the setting of a clinically negative neck as a primary management strategy for patients with oral maxillary squamous cell carcinomas involving the palate, maxillary gingiva, and maxillary alveolus.

Section snippets

Patients and Methods

A retrospective chart review of patients treated at the Oral and Maxillofacial Surgery Service, University of California San Francisco (UCSF) identified all patients treated for maxillary oral malignancies between 2003 and 2007. All of these patients received a complete clinical head and neck examination, as well as either magnetic resonance imaging or computed tomography scanning of the primary tumor site and neck. Radiographic findings were reviewed by both the treating surgeon and an

Results

Table 1 presents data on disease location, staging, primary neck management, and recurrence patterns for the series of patients treated at UCSF’s Oral and Maxillofacial Oncology Service. The study group comprised 5 men and 9 women ranging in age from 53 to 90 years. Postsurgical follow-up ranged from 7 to 45 months (mean, 16.58 ± 4.23 months). The mean postsurgical follow up for the N0 patients in the UCSF series was 26.43 ± 5.40 months. At presentation, 20% of the patients with maxillary

Discussion

We have shown that in our series of patients, maxillary squamous cell carcinoma involving the palate, gingival, and alveolus demonstrates a high rate of occult cervical metastasis as well as regional failure. A review of the current literature combined with our findings show that at initial presentation, maxillary palatal, gingival, and alveolar squamous cell carcinomas manifest clinically detectable cervical metastasis at rates ranging from 11.5% to 28.5% (Table 2).19, 20, 21 In addition, in

References (31)

M. Yao et al.
Current surgical treatment of squamous cell carcinoma of the head and neck
Oral Oncol
(2007)
L. Tao et al.
Reappraisal of metastatic lymph node topography in head and neck squamous cell carcinomas
Otolaryngol Head Neck Surg
(2006)
J.A. Woolgar
Histological distribution of cervical lymph node metastases from intraoral/oropharyngeal squamous cell carcinomas
Br J Oral Maxillofac Surg
(1999)
G.I. Smith et al.
Management of the neck in patients with T1 and T2 cancer in the mouth
Br J Oral Maxillofac Surg
(2004)
J. Kligerman et al.
Supraomohyoid neck dissection in the treatment of T1/T2 squamous cell carcinoma of the oral cavity
Am J Surg
(1994)
M. Umeda et al.
En bloc resection of the primary tumour and cervical lymph nodes through the parapharyngeal space in patients with squamous cell carcinoma of the maxilla: A preliminary study
Br J Oral Maxillofac Surg
(2005)
M. Umeda et al.
Metastasis of maxillary carcinoma to the parapharyngeal space: Rationale and technique for concomitant en bloc parapharyngeal dissection
J Oral Maxillofac Surg
(2002)
A. Yorozu et al.
Carcinoma of the hard palate treated with radiotherapy: A retrospective review of 31 cases
Oral Oncol
(2001)
A.P. Yuen et al.
Clinicopathological analysis of elective neck dissection for N0 neck of early oral tongue carcinoma
Am J Surg
(1999)
P. Zbaren et al.
Elective neck dissection for carcinomas of the oral cavity: Occult metastases, neck recurrences, and adjuvant treatment of pathologically positive necks
Am J Surg
(2006)

J.A. Woolgar et al.

A histopathological appraisal of surgical margins in oral and oropharyngeal cancer resection specimens

Oral Oncol

(2005)

B.L. Schmidt

Molecular biology and clinical behavior of oral cancer

Oral Maxillofac Surg Clin North Am

(2006)

R.A. Ord et al.

Surgical salvage for local and regional recurrence in oral cancer

J Oral Maxillofac Surg

(2006)

Y.C. Lin et al.

Salvage surgery as the primary treatment for recurrent oral squamous cell carcinoma

Oral Oncol

(2004)

C.T. Brennan et al.

Surgical pathology of cancer of the oral cavity and oropharynx

Laryngoscope

(1991)

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Patterns of recurrence in patients undergoing curative treatment for maxillary alveolus squamous cell carcinoma
2023, British Journal of Oral and Maxillofacial Surgery
The aim of this paper was to examine patterns of recurrence in patients undergoing curative treatment for maxillary alveolus squamous cell carcinoma (MASCC). Clinicopathological data on 41 patients undergoing curative resection for MASCC between February 2006 and May 2020 were retrospectively gathered. Outcomes included local, regional, or distant failure as first site of treatment recurrence. Univariate analysis identified significant clinicopathological variables for type of recurrence. Multivariate regression analysis generated predictive models. Ten of 41 patients developed regional recurrence, and nine manifested contralateral recurrence following ipsilateral neck dissection. In three patients the ipsilateral neck was pN0. Nodal metastasis was predictive of regional recurrence, particularly with extranodal tumour extension (ENE). Multivariate analysis with regional recurrence confirmed that ENE was independently predictive. Nodal disease and ENE in patients with MASCC was found to be predictive of contralateral regional recurrence. Management of the neck in MASCC that extends to the palatal aspect should therefore be considered as midline disease.
Distribution pattern and pathologic analysis of metastatic sentinel and non-sentinel lymph nodes in lymphatic basin dissection for clinical T2/T3 oral cancer with clinical N0 status
2022, Auris Nasus Larynx
The localization pattern of metastatic sentinel lymph node (SN) and non-SNs and pathologic analysis of metastatic lymph nodes in SN lymphatic basin dissection (SLBD) were investigated in patients with cT2/T3cN0 oral squamous cell carcinoma (OSCC).
This prospective multicenter trial involved 10 institutions nationwide in Japan. A total of 57 patients were enrolled. The lateral neck was divided into 5 lymphatic basins. The lymphatic basin containing SNs was defined as the SN lymphatic basin.
All patients underwent SLBD with backup selective neck dissection (I-III) combined with primary tumor removal. When SNs were found outside of levels I-III, including in the contralateral neck, SLBD was performed by removing the compartments containing SNs separately. SN metastasis was classified as isolated tumor cells (ITCs), micrometastasis, or macrometastasis. ITCs are defined as a lesion no larger than 0.2 mm in largest dimension and are classified as pN0.
SN metastasis was observed in 22 cases. All metastatic lymph nodes, including false-negative cases, were detected in the SN lymphatic basin. Isolated tumor cells in the SNs did not affect prognosis, whereas micrometastasis tended to have poor prognosis.
After adjusting for other risk factors, a positive SN remained a significant predictor of poor 5-year overall survival in pT2-4 OSCC.
SLBD for intraoperative SN biopsy is a sufficient therapeutic procedure and is valuable for determining pathologic nodal stage in OSCC. SN positivity was demonstrated to be an independent predictor of poor prognosis in patients with pT2-4 disease undergoing SLBD with backup selective neck dissection (I-III).
Pattern of cervical lymph node metastases in squamous cell carcinoma of the upper oral cavity – How to manage the neck
2022, Oral Oncology
Oral squamous cell carcinoma (OSCC) arising from the upper oral cavity is rare compared to other localizations. While cervical lymph node metastasis (CLNM) can be predicted to some extent, the probability of occult CLNM remains high. The aim of this study is to determine risk factors affecting clinical decision making.
A retrospective analysis of patients surgically treated between 2012 and 2017 for OSCC of the upper oral cavity was performed.
A total of 66 patients were included. Of these, 25 patients (37.9%) presented with CLNM after histopathological examination (pN+/cN0: 10/44 (22.7%); pN+/cN+: 15/22 (68.2%)). Lymph vessel infiltration (p = 0.03) and grade of differentiation (p = 0.03) were associated with an increased probability for CLNM. Patients with positive nodal disease at the time of primary surgery showed higher tumor depth of invasion (DOI) than patients without CLNM (mean 10.3 mm ± 6.9 versus mean 6.1 mm ± 4.9; p = 0.02). The optimal DOI cutoff value for the prediction of CLNM was 4.5 mm. The OS was significantly higher in patients with a tumor DOI ≤ 4.5 mm (p = 0.01).
Elective neck dissection should be preferably performed for OSCC of the upper oral cavity. For early-stage and clinically node-negative patients, sentinel-lymph node biopsy can be an alternative, especially in patients with a DOI ≤ 4.5 mm. Since this group had no occult CLNM below this DOI cutoff value, watch and wait might be an alternative for selected patients.
Diagnostic value of magnetic resonance imaging in cervical lymph node metastasis of oral squamous cell carcinoma
2022, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Citation Excerpt :
For DSS, the cutoff was 4.1 mm, with sensitivity of 63.5%, specificity of 62.3%, and area under the ROC curve of 0.767 (P < .001). High cervical LNM rates and poor salvage rates are associated with OSCC.12 It is essential to assess preoperative cervical lymph node status accurately and provide effective treatment as an initial therapy option.
The objective of this study was to investigate the correlation between magnetic resonance imaging (MRI) characteristics of cervical lymph nodes and the pathologically confirmed status of cervical lymph node metastasis (LNM) in oral squamous cell carcinoma (OSCC) and to provide imaging evaluation parameters for the clinical diagnosis of cervical lymph node status in OSCC.
In a retrospective analysis, 79 patients who were first pathologically diagnosed with OSCC were included. The MRI-derived imaging parameters of the cervical lymph nodes were evaluated and the pathological status of lymph nodes in neck dissection specimens was reviewed. The relationship between the imaging parameters and cervical LNM was analyzed.
The MRI-derived imaging parameters of 4419 lymph nodes were evaluated, and the pathological status of 2463 lymph nodes was reviewed. The MRI-derived shortest axial diameter (SAD) and unclear boundary of the cervical lymph node were significantly related to LNM. The cutoff value of SAD that enabled identification of LNM was 3.6 mm, and it was 4.2 and 4.1 mm for the prediction of overall survival and disease-specific survival, respectively.
The MRI-derived parameters SAD and unclear boundary of the cervical lymph node correlated with LNM in OSCC. MRI-derived SAD larger than 3 mm warrants simultaneous neck dissection at initial surgery.
History of dysplasia and primary site associated with recurrence in T1N0 oral squamous cell carcinoma
2021, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Recurrent disease occurs in a significant proportion of early-stage oral squamous cell carcinoma (OSCC) despite removal of the entire tumor with clear surgical margins. Our study sought to identify clinicopathologic factors that increase the risk of locoregional recurrence in T1N0 OSCC.
We conducted an observational retrospective analysis of 65 cases of T1N0 OSCC over a period of 13 years. For each case, we examined the clinical presentation, histopathologic appearance, and treatment characteristics of interest to evaluate the association between these variables and locoregional recurrence.
The 5-year and 10-year locoregional recurrence rates were 29.2% and 33.8%, respectively. Individuals with prior oral dysplasia had significantly higher odds for locoregional recurrence (P < .01) and reduced 5-year disease-free survival rates (P < .01). OSCC of the tongue and floor of the mouth had lower recurrence odds than carcinomas of the gingiva, buccal mucosa, and palate (P < .05). Histologic grade (P = .80), depth of invasion (P = .82), and elective neck dissection (P = .80) did not appear to influence locoregional recurrence for T1N0 tumors.
Given the morbidity and mortality associated with OSCC, understanding of the clinicopathologic factors associated with recurrent disease may lead to improved treatment and follow-up protocols for a subset of early-stage patients.
Clinical course and survival in patients with squamous cell carcinoma of the maxillary alveolus and hard palate: Results from a single-center prospective cohort
2020, Journal of Cranio-Maxillofacial Surgery
Operative management of squamous cell carcinoma of the maxillary alveolus and hard palate (MHSCC) is still a controversial issue, especially for cN0 cases. We report the survival outcomes in patients with MHSCC, including the rate of cervical occult metastasis for UICC stages I/II and survival after elective neck dissection (END).
77 patients with primary MHSCC were followed-up from 2 months to 14.6 years within a prospectively obtained patient cohort. Factors influencing overall survival (OS), oral cancer-specific survival (OCSS) and disease-free survival (DFS) were assessed. We estimated survival probabilities using Kaplan–Meier survival analysis by histology and stage. We used Cox's proportional hazard regression model to estimate adjusted hazard ratios for OS, OCSS and DFS.
Initially, 22 patients presented with stage I, 13 with stage 2, 11 patients with stage 3 and 31 with stage 4 tumors. The presence of nodal disease rose with increased tumor size. 66.2% were treated with surgery only, 26.0% received adjuvant radiotherapy, and 7.8% received primary radiotherapy. Median overall survival was 10.9 years, and survival probabilities at 2, 5 and 10 years were 68.2%, 61.1% and 61.1%, respectively. Five-year overall survival was 72.4% in the END group and 88.9% in the non-END group. Factors influencing OS, OCSS and DFS were tumor size, the presence of metastatic disease and positive resection margins.
MHSCC seems to show a better overall survival compared to OSCC of other locations and is less likely to develop regional and distant metastasis; END might not be necessary in early stage tumors.

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Basic and patient-oriented researchOral Maxillary Squamous Cell Carcinoma: Management of the Clinically Negative Neck

Purpose

Patients and Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Discussion

Oral Oncol

Otolaryngol Head Neck Surg

Br J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Am J Surg

Br J Oral Maxillofac Surg

J Oral Maxillofac Surg

Oral Oncol

Am J Surg

Am J Surg

Oral Oncol

Oral Maxillofac Surg Clin North Am

J Oral Maxillofac Surg

Oral Oncol

Surgical pathology of cancer of the oral cavity and oropharynx

Laryngoscope

Basic and patient-oriented research
Oral Maxillary Squamous Cell Carcinoma: Management of the Clinically Negative Neck