Is neck dissection needed in squamous-cell carcinoma of the maxillary gingiva, alveolus, and hard palate? A multicentre Italian study of 65 cases and literature review

doi:10.1016/j.oraloncology.2011.08.012

Oral Oncology

Volume 48, Issue 2, February 2012, Pages 97-101

https://doi.org/10.1016/j.oraloncology.2011.08.012 Get rights and content

Summary

The occurrence of occult cervical metastases due to squamous-cell carcinoma of the hard palate and maxillary alveolar ridge has not been studied systematically. We have observed that many patients return with a delayed cervical metastasis following resection of a primary cancer at these sites. Some of these patients have died as a result of a regional or distant metastasis, despite control of the primary cancer. The literature contains few recommendations to guide the treatment of maxillary squamous-cell carcinoma; prospective studies are difficult due to the rarity of such tumours. The aim of this study is to define the incidence of cervical metastasis and to investigate whether elective neck dissection is justified.

We present a retrospective multicentre study of 65 patients with squamous-cell carcinomas of the maxillary alveolar ridge and hard palate and review of the existing literature.

The overall incidence of cervical metastases was 21%. We evaluated the significance of primary-site tumours as indicator of regional disease.

The maxillary squamous-cell carcinoma cases in our multicentre study and in the literature review exhibited aggressive regional metastatic behaviour, comparable with that of carcinomas of the tongue, mouth floor, and mandibular gingiva. Based on our findings, we recommend selective neck dissection in clinically negative necks as a primary management strategy for patients with maxillary squamous-cell carcinomas involving the palate, maxillary gingiva, or maxillary alveolus.

Introduction

The involvement of regional lymph nodes in head and neck cancers depends on various factors, including site, size, depth, and other histological features of the primary tumour.¹ Elective treatment of the cervical nodes is widely accepted in such patients when the risk of occult metastases exceeds 15–20%.[2], [3], [4], [5] Many studies have evaluated the need for elective neck dissection at common sites of oral primary tumours in patients with no sign of metastasis in the neck. In a randomised prospective study, Kligerman et al.⁶ found significantly improved survival rates after selective neck dissection in the management of clinically negative neck in patients with stage 1 oral SCC of the tongue. The current management of patients with palatal, maxillary gingival, or maxillary alveolar SCC in the absence of palpable or radiographically suspicious lymph nodes, is usually to ‘watch and wait’, based on the low risk of occult cervical metastases. This regional subset of oral SCCs occurs more rarely than other oral cancer locations and we lack prospective, evidence-based studies.

Some recent studies have recommended elective neck dissection for patients with SCC of the hard palate and alveolar ridge with N0 neck.[7], [8], [9], [10], [11], [12], [13], [14] In this retrospective study, we defined the risk of cervical metastasis in patients with palatal SCCs and make recommendations for treatment based on that risk.

Section snippets

Patients and methods

A retrospective multicentre study included patients treated for maxillary SCC from 2000 to 2010 at four Italian Maxillofacial Surgery Departments (Istituto Ortopedico Galeazzi, Milano; Azienda Ospedaliero-Universitaria of Parma, Parma; Policlinico Umberto I, Roma; Azienda Ospedaliero-Universitaria of Sassari, Sassari). All patients were staged using the International Union Against Cancer (UICC) TNM classification, based on clinical head and neck examinations and magnetic resonance imaging or

Results

The study group consisted of 65 patients: 31 men (47.6%) and 34 women (52.3%), ranging in age from 34 to 95 (mean: 68.5) years at presentation. The primary SCCs of all patients were resected. In our series, 57 (87.3%) patients were cN0 at presentation; 31 (54.4%) of them received no adjuvant treatment and 15 (26.3%) underwent a neck dissection that confirmed the clinical diagnosis (pN0). Eight (12.3%) patients presented with cervical node disease, as evidenced by clinical examination or

Discussion

Clinicopathological factors associated with the development of cervical lymph-node metastasis have been extensively studied in several oral locations, such as the tongue, mouth floor, and cheek. These studies have examined tumour size (⩾3 mm in tongue carcinoma), tumour depth (⩾4 mm in tongue carcinoma), differentiation, microvascular invasion, and histological grade of malignancy.¹⁵ The presence or absence of lymph-node metastasis is a major prognostic factor for survival in patients with

Conclusions

Based on our review of the recent literature and our clinical experience, we are able to make some recommendations for the surgical treatment of the cervical lymph nodes in maxillary SCC cases. Elective neck dissection should be considered for patients with SCC of the maxillary alveolus and the hard palate with the following indications: (1) all T3- and T4-stage carcinomas of the maxillary alveolus or ⩽5 mm from the hard–soft palate transition, (2) when cervicotomy is required for reconstruction

Conflict of interest statement

None declared.

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Cited by (52)

Primary and recurrent regional metastases for lateralized oral cavity squamous cell carcinoma
2022, Surgical Oncology
Map regional lymph node metastases for lateralized oral cavity squamous cell carcinoma (OCSCC) and evaluate factors associated with regional metastases and recurrence.
Retrospective cohort study of 715 patients with lateralized OCSCC surgically treated in 1997–2011. Analysis was performed using log-rank, Kaplan-Meier, and multivariable logistic and Cox regression.
Regional metastases were identified in ipsilateral levels IIA (24%), IB (18%), III (13%), V (9%), IV (7%), IA (2%) and IIB (1%) and the contralateral neck (3%). Lymphovascular invasion (LVI) (Hazard Ratio [HR] 2.2, 95% Confidence Interval [CI] 1.2–3.9) and T category (T3 vs. T1: HR 4.1, 95% CI 1.9–9.3; T4 vs. T1: HR 2.3, 95% CI 1.2–4.3) were associated with regional metastases. Most (71%) isolated regional metastatic recurrences were in undissected levels of the neck, including 58% in levels IV and V. Tumors of the hard palate (HR 4.3, 95% CI 1.2–16.1), upper alveolus (HR 3.2, 95% CI 1.0–4.7) or with LVI (HR 2.0, 95% CI 1.0–3.9) were associated with isolated regional recurrence. For upper alveolar/hard palate tumors, depth of invasion (DOI) ≥4 mm (P = .003) and LVI (P = .04) were associated with regional metastases.
For lateralized OCSCC, elective neck dissection of level IIB or the contralateral neck may rarely be needed, but additional surgical or radiation treatment of levels IV and V may be considered based on patient risk factors, including T category 3–4 or LVI. For upper alveolar/hard palate tumors, DOI ≥4 mm is an appropriate threshold for elective neck dissection.
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.
Is a “watch and wait strategy” safe to manage clinically N0 squamous cell carcinoma of the upper jaw?
2019, Current Problems in Cancer
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.
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.
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.
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.
Oral Cavity Cancer
2019, Oral and Maxillofacial Surgery Clinics of North America
Citation Excerpt :
Recent investigations, however, have found higher than expected rates of occult nodal metastasis ranging from 20% to 36.1% for advanced-stage maxillary alveolar and palatal OSCC, calling into question the validity of deferring END.21,53,55,56 Although some investigators have suggested END for OSCC of the maxillary ridge and palate staged T2 or greater,53 the breadth of available literature supports END only for patients with T3 and T4 primary tumors.21,55,56 Clarity is lacking on the role of T-stage alone in the decision for END or the consideration for DOI at the primary site in the maxillary ridge or palate.
Impact of reconstructive microsurgery on patients with cancer of the head and neck: a prospective study of quality of life, particularly in older patients
2018, British Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The main treatment is resection, sometimes followed by adjuvant radiotherapy or chemotherapy, or both. This, together with free margins (and neck dissection when indicated)3 has increased disease-specific survival, but cervicofacial resection for cancer may have several detrimental outcomes.4 Over the last 20 years, morbidity associated with operation has decreased (for example, neck dissection has become selective) reconstruction techniques have improved, and free flap transfer combined with microvascular reconstruction optimises functional recovery of the head and neck.5
Treatment of cancer of the head and neck often requires extended resection and major reconstructive surgery, both of which can have great functional and emotional impact. It is fundamental to evaluate the outcome with respect not only to the clinical aspects but also to the quality of life (QoL) perceived by the patients. In the light of the reported increasing incidence of oral cancer in older patients, we decided to see if there was an association between QoL and age. Between June 2015 and December 2016 we submitted the Italian version of the 36-item Short Form Health Survey (SF-36) to 30 patients (mean (range) age 65.5 (23–87) years) who had had resection and microsurgical reconstruction at the Ospedale Maggiore Policlinico of Milan. The questionnaires were completed before operation, and 12 months afterwards, and clinical and personal data were also collected. From the results of SF-36 we obtained the Short Form 12 (SF-12), Physical Health Composite Score (PCS), and Mental Health Composite Score (MCS) and looked at how age influences the variation in QoL scores. The variation between SF-36 and SF-12 results (preoperatively and postoperatively) did not seem to correlate with age. Our study confirmed that reconstructive microsurgery can be realistically proposed to older as well as younger patients because, according to the QoL index, older patients are able to manage (and therefore take advantage of) this complex surgical technique.
Squamous cell carcinoma of the maxilla: Analysis of clinicopathological predictors for disease recurrence and metastatic behavior
2018, Journal of Cranio-Maxillofacial Surgery
Squamous cell carcinoma of the maxilla only constitutes a small fraction of Head and Neck Cancers. There is thereby a lack of information about frequent tumor staging and localization and their effect on patients' outcome. The main factors that influence longterm survival in HNSCC are the extent of the primary disease and recurrence rate, including local neck metastases.
In this study, clinical outcome and rates of disease recurrence in 68 surgically treated patients with maxillary SCC were evaluated in terms of primary tumor staging and localization.
It could be demonstrated that maxillary cancer is mostly located in the posterior region of the upper jaw (70%). The rate of neck node metastasis was 35.3%, which is equivalent to the rest of the oral cavity and supports the role of elective neck dissection for patients with clinically negative neck node status. Staging, tumor differentiation, and infiltration of lymphatic structures correlated significantly with the development of local neck node metastases (r = 0.321, p = 0.01; r = 0.348, p < 0.01; r = 0.64; p < 0.01).
Maxillary carcinomas exhibit similar rates of locoregional disease recurrence as the rest of the oral cavity. The existence of cervical metastases even in patients with T1 tumors supports the concept of elective neck dissection in early tumors with clinically negative neck status.

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ReviewIs neck dissection needed in squamous-cell carcinoma of the maxillary gingiva, alveolus, and hard palate? A multicentre Italian study of 65 cases and literature review

Summary

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusions

Conflict of interest statement

Am J Otolaryngol

Oral Oncol

Am J Surg

Oral Oncol

J Oral Maxillofac Surg

Br J Oral Maxillofac Surg

Otolaryngol Head Neck Surg

Prediction of cervical lymph node metastasis in squamous cell carcinoma of the tongue/floor of mouth

Head Neck

Head and Neck Surgery and Oncology

Improved survival for patients with clinically T1/T2 N0 tongue tumors undergoing a prophylactic neck dissection

Head Neck

Maxillary bone invasion by gingival carcinoma as an indicator of cervical metastasis

Dentomaxillofac Radiol

Review
Is neck dissection needed in squamous-cell carcinoma of the maxillary gingiva, alveolus, and hard palate? A multicentre Italian study of 65 cases and literature review