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DENTAL SCIENCE - SHORT COMMUNICATION
Year : 2012  |  Volume : 4  |  Issue : 6  |  Page : 341-343  

The need for early detection of neck nodal metastasis in squamous cell carcinoma of oral cavity


1 Department of Oral and Maxillofacial Surgery, Annaswamy Mudaliar General Hospital, Bangalore, India
2 Department of OMFS, JJKN Dental College and Hospital, Komarapalayam, Tamil Nadu, India
3 HOSMAT Hospital, Bangalore, India

Date of Submission01-Dec-2011
Date of Decision02-Jan-2012
Date of Acceptance26-Jan-2012
Date of Web Publication28-Aug-2012

Correspondence Address:
P Satish Kumaran
Department of Oral and Maxillofacial Surgery, Annaswamy Mudaliar General Hospital, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-7406.100300

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   Abstract 

In the Indian subcontinent, the incidence of squamous cell carcinoma of the oral cavity has been constantly increasing despite the improvement in the awareness about squamous cell carcinoma. The patients generally report to us in the period in which the tumor would have undergone metastasis. This article highlights about the grading, staging, and decision-making regarding the surgical management of squamous cell carcinoma of the oral cavity. The article also stresses upon the early detection of the lesion by the practitioner for a definitive successful surgical treatment of the patient.

Keywords: Oral carcinoma, nodal metastasis, functional neck dissection


How to cite this article:
Kumaran P S, Thangaswamy S V, Navaneetham A. The need for early detection of neck nodal metastasis in squamous cell carcinoma of oral cavity. J Pharm Bioall Sci 2012;4, Suppl S2:341-3

How to cite this URL:
Kumaran P S, Thangaswamy S V, Navaneetham A. The need for early detection of neck nodal metastasis in squamous cell carcinoma of oral cavity. J Pharm Bioall Sci [serial online] 2012 [cited 2020 Oct 22];4, Suppl S2:341-3. Available from: https://www.jpbsonline.org/text.asp?2012/4/6/341/100300

In the Indian subcontinent, carcinoma of the head and neck represents a treatment challenge due to the difficulties in patient management as well as in formulating a differential diagnosis. Also, the myriad carcinogenic stimuli and various habits of our populace make it difficult, if not impossible, to determine a standard treatment protocol. The treatment protocol also suffers due to poor patient compliance with respect to follow-up and poor understanding of the disease with respect to the patient. Tumor grading and staging are the gold standard for predicting treatment modalities, tumor response, and curative success of the protocol.


   Grading of the Tumor Top


Squamous cell carcinoma may arise from dysplastic epithelium or may be entirely independent of it. In the Indian population, field cancerization (Slaughter's theory) is found to be extremely prevalent, thereby throwing up fresh challenges for the surgeon. Squamous cell carcinoma primarily spreads via direct invasion and lymphatic routes. [1],[2],[3]

Invasive carcinoma is histologically graded and specified as well-differentiated, moderately well-differentiated, or poorly differentiated types. The grading of the tumor serves as an important aid to the overall biologic behavior of the tumor. Tumors which more closely resemble their native tissue are considered to be well differentiated (low grade). This is in contrast to the tumors exhibiting significant cytomorphologic atypia and demonstrating little or no resemblance to native squamous epithelium. These lesions are considered to be poorly differentiated (high grade) and have an increased propensity for regional metastasis and a poorer prognosis.

Perineural spread, lymphatic invasion, and tumor extension beyond the lymph node capsule usually point to a poorer prognosis overall. [2],[3]


   Metastasis Top


The size and thickness of the primary tumor most often determines metastasis. Generally, metastasis from oral squamous cell carcinoma most frequently develops in the ipsilateral cervical lymph nodes. Tumors of the lower lip and floor of mouth may initially involve the submental lymph nodes, but this is relatively rare. [2],[3],[4] Contralateral or bilateral cervical metastases canal occur especially in tumors of the base of the tongue, in advanced tumors, and in tumors that occur near the midline. [4]

Nodes are usually enlarged, firm, and nontender to palpation. If a tumor perforates the nodal capsule and invades into the surrounding connective tissue, the node will feel fixed and immobile. As many as 30% of oral cancers have cervical metastases, either palpable or occult, at the time of initial evaluation. [5]

Distant metastases are most common in the lungs, prostrate, liver, and bones, but any part of the body may be affected. [1],[3],[4]

In all cases of suspected oral carcinoma, the neck should be staged prior to biopsy of the primary tumor; otherwise, regional reactive lymphadenopathy develops subsequent to biopsy, thus hindering the appropriate staging of disease. Unfortunately, some patients may have microscopic lymph node disease which may not be detected clinically, and as such, elective neck dissections are sometimes performed to eliminate this eventuality, though the role of positron emission tomography (PET) scans has been debated.


   Staging Top


The most important indicator of prognosis which serves to establish appropriate treatment modalities is the staging of oral cancer. Staging protocol depends on quantifying three basic clinical features: size of primary tumor, status of regional lymph nodes, and the presence or absence of metastasis. The American Joint Committee on Cancer (AJCC) utilizes the tumor, lymph node, and metastases (TNM) classification system for their staging protocol. [6]

At our center, we also incorporate the guidelines for treatment of oral cancer, as determined by Tata Memorial Cancer Centre in Mumbai.


   Treatment Top


Although surgery is the primary mode of treating squamous cell carcinoma of the head and neck, radiotherapy and chemotherapy, either alone or in combination, play important roles.

The ablation of oral squamous cell carcinoma involves both local and regional techniques. The goal of surgery is to eradicate all visibly gross disease and at the same time provide adequate disease free margins to counter the risk of microscopic metastasis [Figure 1] and [Figure 2]. [2],[3]

In our center, the neck is cleared as per the Regional Cancer Centre, Thiruvanthapuram protocol, where the continuity of the specimen may be sacrificed to preserve all the vital structures, similar to functional neck dissection, but all the gross disease with margins of a minimum of 2 cm are carefully removed. Dissections are performed for patients who have positive lymph node involvement at the initial workup stage and entails complete removal of all lymphatic tissue from the neck (levels I-IV), though elective dissections are performed for all patients with tumor size more than 1.5 cm regardless of neck node involvement due to the poor patient compliance regarding follow-up in our center. [5],[7]
Figure 1: Resected primary with free margins to limit microscopic disease spread

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Figure 2: The disease (gross) free neck with preservation of Internal Jugular Vein,Sternocleidomastoid Muscle and Spinal Accessory Nerve

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The classic radical neck dissection includes comprehensive node dissection with removal of the sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. Modified radical (functional) neck dissection was developed to diminish the morbidity by removing all cervical nodes but preserving important anatomical structures. Selective neck dissections involve the removal of lymph node groups at highest risk of containing metastasis from a primary tumor. [2],[3]

Radiotherapy is primarily used as postoperative treatment for cases in which resection margins are not free of tumor, or there is surgical inaccessibility, or there has been perineural growth and bone invasion. [3] All cases in our center are sent for a radiotherapy reference prior to and after surgery.

Chemotherapy may also be given as palliative treatment to patients with locally recurrent disease, which cannot be cured with surgery or radiotherapy, or to patients with distant metastases. [1],[2],[3]


   Conclusion Top


Successive treatment of squamous cell carcinoma of the oral cavity involves a combination of addressing the anatomic site of the primary cancer, status of the neck, anticipated functional and cosmetic results, anticipated patient compliance, and the overall medical status of the patient. We feel that the ability to control oral cancer depends upon two principles: prevention and early detection. Therefore, with squamous cell carcinoma being the most common head and neck malignancy, it is mandatory that all dental professionals and facio-maxillary surgeons examine all patients with precancerous disease and early disease, with an emphasis on maximum patient education.

 
   References Top

1.Neville BW, editor. Oral and maxillofacial pathology, 2 nd ed. 843. Philadelphia: WB Saunders; 2002. p. 15.  Back to cited text no. 1
    
2.Barnes L, editor. Surgical pathology of the head and neck. v. (xi, 1866). New York: Dekker; 1985. p. 2.  Back to cited text no. 2
    
3.Gnepp DR, editor. Diagnostic surgical pathology of the head and neck. 888. Philadelphia: Saunders; 2001. p. 11.  Back to cited text no. 3
    
4.Neville BW, Day TA. Oral cancer and precancerous lesions. CA Cancer J Clin. 2002;52:195-215.  Back to cited text no. 4
    
5.Shah JP, Candela FC, Poddar AK. The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity. Cancer 1990;66:109-13.  Back to cited text no. 5
    
6.Greene FL. American Joint Committee on Cancer, and American Cancer Society. American Joint Committee on Cancer staging manual, 6th ed., 421 ill. New York: Springer-Verlag; 2002. p. xiv.  Back to cited text no. 6
    
7.Ho CM, Lam KH, Wei WI, Lau SK, Lam LK. Occult lymph node metastasis in small oral tongue cancers. Head Neck 1992;14:359-63.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Usefulness of 3T diffusion-weighted MRI for discrimination of reactive and metastatic cervical lymph nodes in patients with oral squamous cell carcinoma: a pilot study
J Si,S Huang,H Shi,Z Liu,Q Hu,G Wang,G Shen,D Zhang
Dentomaxillofacial Radiology. 2014; 43(3): 20130202
[Pubmed] | [DOI]



 

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    Abstract
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   Metastasis
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