Occurrence of cervical lymph node metastasis of maxillary squamous cell carcinoma – A monocentric study of 171 patients

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Abstract

Introduction

Fewer than 5% of oral squamous cell carcinomas (SCC) are presented in the maxilla. The absence of cervical lymph node metastasis (LNM) is one of the main positive prognostic factors. This single-centre study analysed the cervical lymph node metastasis behaviour in patients with oral SCC of the upper jaw and serves as a basis for a cervical lymph node treatment suggestion.

Material and methods

The retrospective study includes 171 patients with isolated SCC of the maxilla. In addition to tumour resection, 83% of the patients underwent a selective neck dissection (ND). The data of cervical metastasis, TNM-status, tumour grade, tumour location as well as nicotine and alcohol behaviour were statistically analysed.

Results

The average rate of cervical metastasis was 44% in total. Tumour stage significantly affected risk for cervical metastasis (T1 = 6%, T2 = 41%, T3 = 60% and T4 = 60%) (p < 0.01). Development of cervical LNM was seemingly influenced by male gender.

Discussion

This study postulates a high rate of cervical metastasis of maxillary SCC. Risk for metastasis is mainly determined by the tumour stage. Alcohol and nicotine abuse have a negative impact on cervical LNM.

Conclusion

Reviewing recent literature underlined by the illustrated data, we put up for discussion the treatment of SCC of the maxilla as similar to therapy protocols for SCC of the oral cavity. This would include an ipsilateral ND even in low tumour stage and in T4 staged tumours on both sides. However, prospective multicentre studies are needed to verify and recommend these therapy assumptions.

Introduction

Head and neck cancers are among the ten most common cancers globally (Warnakulasuriya, 2009, Siegel et al., 2014). Thus, SCC, at more than 90%, are the most common type of all malignant tumours in the oral cavity (Johnson et al., 2011, McDowell, 2006, Lambert et al., 2011). Compared to other intraoral locations, SCC of the maxilla are relatively rare (Montes and Schmidt, 2008). Only about 0,5–5% of oral SCC are in the upper jaw (Sagheb et al., 2014), where it is known that oral SCC have unique clinical behaviour relative to those in other head and neck regions (Montes and Schmidt, 2008, Brennan et al., 1991). Nevertheless, it has long been believed that SCC of hard palate and maxillary alveolus have a low nodal metastatic risk (Yang et al., 2014). In contrast to that, recent studies assume a higher risk for lymphatic metastasis of maxillary oral SCC, equal to the rest of the oral cavity (Mourouzis et al., 2010, Morris et al., 2011, Sagheb et al., 2014, Kruse and Gratz, 2009). However, there is uncertainty and controversy involving the management of the neck in patients with maxillary alveolus and hard palate SCC.

It is well-known that the presence of cervical lymph node metastasis (LNM) is crucial for prognostic relevance for patients with SCC (Capote et al., 2007, Kohler and Kowalski, 2011). Furthermore, it is proven that selective neck dissection is beneficial for patients with SCC of the tongue and mouth floor (Yuen et al., 1997, Nouraei et al., 2013). However, clinical N0 necks are monitored closely in many head-neck centres without surgical intervention (Beltramini et al., 2012). Still, it is known that there are over 20% of occult neck LNM in patients with oral SCC reported in the international literature (Psychogios et al., 2013, Sparano et al., 2004). The outcome data of a “watch and wait” strategy for patients with clinical N0 necks are comparable with data of those who underwent a selective ND (Rodrigo et al., 2011).

Either way there are no binding treatment recommendations or guidelines for this kind of tumour entity of the maxilla, especially not in terms of the lymph node treatment justified by the low case numbers. In particular, there is no evidence to support treatment of the clinical N0 neck by SCC of the maxilla (Kim et al., 1999).

Therefore, this retrospective, single-centre study with a large number of patients – compared to other, previously published studies' data – evaluates the incidence of cervical metastasis in SCC of the maxilla and their possible influential factors.

Section snippets

Materials and methods

The present study retrospectively included a total 171 patients with an isolated SCC of the upper jaw treated from 1975 to 2009 at the Department of Oral and Maxillofacial Surgery, University of Heidelberg. All patients included underwent a tumour resection, 83% (n = 142) a selective ND. Of all patients evaluated, neck dissection was refused by 17 %. Indication for an ipsilateral neck dissection was given when the staging score was cT ≥ 2. For patients with cT1 and cN- Tumours, an ipsilateral

Results

A total 171 patients were retrospectively evaluated. 102 male and 69 female patients with a mean age of 63.6 years (range 28–93 years) underwent total or partial maxillectomy, and 83% of them had a selective neck dissection. Table 1 describes the distribution of cN status stratified for the different T-categories. Therefore combinations of only ultrasound, ultrasound and CT, ultrasound and MRI, CT and MRI, respectively with and without contrast medium could be found. In this period 23 different

Discussion

Data for the risk of cervical lymph node metastasis in patients with maxillary SCC are spare due to its clinical rarity compared to SCC of the tongue or the floor of the mouth (Philip and James, 2014). Currently there are no explicit treatment recommendations for ND in patients with maxillary SCC.

Still, applicable therapeutic approaches for SCC of the oral cavity include a neck dissection on both sides in advanced T-stages. The recent literature defines the risk of LNM in patients with

Conclusion

Reviewing recent literature underlined by the illustrated data, we put up for discussion the treatment of squamous cell carcinoma of the maxilla as similar to therapy protocols for SCC of the oral cavity. This would include an ipsilateral ND even in low tumour stage and in T4 staged tumours on both sides. However, prospective multicentre studies are needed to verify and recommend these therapy assumptions.

Conflict-of-interest statement

All authors disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work. We disclose no conflicts of interests.

Acknowledgements

The shown data are part of the doctoral thesis of Eva Grau. Many thanks to Don Naden for his thorough linguistic revision of the manuscript.

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