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Predictors of Occult Neck Metastasis and Extra Capsular Spread in Early Oral Cancers

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To investigate the incidence of occult neck metastasis and to determine the prognostic factors related to the occurrence of the cervical lymph nodal metastasis and extra capsular extension (ECE) in early oral cavity cancer patients. A retrospective review performed on 100 patients with node negative squamous cell carcinoma of oral cavity who underwent primary treatment between Jan 2015 and Dec 2018. Incidence of occult neck metastasis after the elective neck dissection in our study was 35%. Independent correlates of positive occult neck metastasis were lymphovascular Invasion (P—0.000)[CI 0.004–0.326] and depth of invasion(P—0.009)[CI 0.509–13.428] on univariate analysis and statistically significant factors associated with the incidence of the extracapsular extension were age(P—0.044), lymphovascular invasion(P—0.018)[CI 0.004–0.603] and lymph node ratio(P—0.000)[CI 4.570–158.45] on univariate analysis. Lymphovascular invasion and depth of invasion correlated significantly with occurrence of neck metastasis. Age and LVI were the prognostic factors for extra capsular spread.
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1 23
Indian Journal of Otolaryngology and
Head & Neck Surgery
ISSN 2231-3796
Indian J Otolaryngol Head Neck Surg
DOI 10.1007/s12070-020-02020-7
Predictors of Occult Neck Metastasis and
Extra Capsular Spread in Early Oral
Cancers
Waseem Abbas, Saurabh Gupta, Vineeta
Goel & Anjali Aggarwal
1 23
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ORIGINAL ARTICLE
Predictors of Occult Neck Metastasis and Extra Capsular Spread
in Early Oral Cancers
Waseem Abbas
1
Saurabh Gupta
1
Vineeta Goel
1
Anjali Aggarwal
1
Received: 23 May 2020 / Accepted: 27 July 2020
ÓAssociation of Otolaryngologists of India 2020
Abstract To investigate the incidence of occult neck
metastasis and to determine the prognostic factors related
to the occurrence of the cervical lymph nodal metastasis
and extra capsular extension (ECE) in early oral cavity
cancer patients. A retrospective review performed on 100
patients with node negative squamous cell carcinoma of
oral cavity who underwent primary treatment between Jan
2015 and Dec 2018. Incidence of occult neck metastasis
after the elective neck dissection in our study was 35%.
Independent correlates of positive occult neck metastasis
were lymphovascular Invasion (P—0.000)[CI
0.004–0.326] and depth of invasion(P—0.009)[CI
0.509–13.428] on univariate analysis and statistically sig-
nificant factors associated with the incidence of the extra-
capsular extension were age(P—0.044), lymphovascular
invasion(P—0.018)[CI 0.004–0.603] and lymph node
ratio(P—0.000)[CI 4.570–158.45] on univariate analysis.
Lymphovascular invasion and depth of invasion correlated
significantly with occurrence of neck metastasis. Age and
LVI were the prognostic factors for extra capsular spread.
Keywords Occult neck metastasis Extra capsular spread
Early oral cancers Lymphnodal metastasis
Introduction
Cancer of Lip and Oral cavity is the second most common
cancer in India, with 119,992 new cases diagnosed in the
year 2018 contributing to 11.42% of all malignancies. It is
the second most common cancer-causing death, leading to
72,616 (10.09%) deaths per year [1]. Oral cavity cancer is
the most common cancer of head and neck, which includes
various subsites such as lip, oral tongue, floor of mouth,
retromolar trigone, buccal mucosa (BM), alveolar ridge,
and hard palate. The most important factor for survival and
recurrence in squamous cell carcinoma of head and neck
cancer is presence or absence of neck nodes, and lymph
node presence decreases the five-year survival by about
50% [2]. Incidence of extracapsular spread (ECS) for
clinically node negative (c N0) oral cancer is about
15–35% [3]. ECS, if present, may adversely affect the
prognosis of such patients [4]. For cN0(Clinically node
negative) oral cancer patients, elective neck dissection is
the preferred modality of treatment [5]. Apart from ECS,
other pathological features associated with poor prognosis
are perineural invasion (PNI) [6] and lymphovascular
invasion (LVI) [7]. Patients having PNI, LVI, and ECS
simultaneously carry the worse prognosis [7]. Experience
in routine clinical practice may differ from that seen in a
controlled clinical trial.
&Waseem Abbas
drabbasdoc@gmail.com
Saurabh Gupta
drsaurabh172001@gmail.com
Vineeta Goel
vineeta.goel11@maxhealthcare.com
Anjali Aggarwal
anjaliagg412@gmail.com
1
Max Institute of Cancer Care, Shalimar Bagh, Max Super
Speciality Hospital Shalimar Bagh, FC-50 C & D Block,
Shalimar Bagh, New Delhi 110008, India
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Indian J Otolaryngol Head Neck Surg
https://doi.org/10.1007/s12070-020-02020-7
Author's personal copy
Study Objectives
This is a retrospective study with the main aim to analyze
the prognostic factors for ECS, Occult neck metastasis and
incidence of occult neck metastasis in node negative oral
cavity cancer. Secondary objective of this study was to
analyse the survival on the basis of clinic-pathological
factors and treatment received.
Material and Methods
Hundred eligible patients with early stage, clinically and
radiologically node negative squamous cell carcinoma of
head and neck, diagnosed between January 2015 till
December 2018 with no previous history of any malig-
nancy, who have undergone surgery and elective neck
dissection were retrospectively analyzed. Primary treat-
ment given to all patients was wide local excision plus neck
dissection. Adjuvant Radiotherapy (RT) or Concurrent
Chemo-Radiotherapy (CCRT) was offered as per standard
guidelines. Clinical and demographic details of the patients
were obtained from the electronic medical records. Tumor
response was assessed using RECIST (Response Evalua-
tion Criteria in Solid Tumors) version 1.1. The study was
approved by the research ethics committee and review
board.
Statistical Analysis
Data was analyzed using Chi Square for univariate analy-
sis, and binary logistic regression for multivariate analysis.
Disease free survival (DFS) was calculated using Kaplan
meir curves on SPSS (Statistical Package for the Social
Sciences) version 21.0. (Copyright IBM Corporation and
its licensors 1989, 2011 Armonk, NY). DFS was calculated
from the date of surgery until local or systemic relapse, or
death of the patient.
Results
Study Subject Demographics and Clinical-
Pathological Features
In our retrospective review, 100 patients met the inclusion
criteria. The average age for all subjects was 52 years
ranging from 30 to 84 years. Most patients were males, and
the male to female ratio was 11:39. Most common subsite
involved was tongue (55%), followed by buccal mucosa
(30%). Most common pathological stage after surgery was
pT2 (63%), followed by pT1 (29%) and pT3 (8%). Sixty-
seven percent (67%) of the tumors were moderately dif-
ferentiated, twenty-six (26%) were well differentiated and
rest were poorly differentiated (7%). Unilateral and bilat-
eral neck dissection was done in 84% and 16% patients
respectively. The incidence of occult metastasis was thirty-
five percent (31%). ECS was reported in 54%, out of which
11% were found positive for ECS, and data for the rest
46% of patients was not available. LVI was seen in 9%,
and PNI in 39% of the patients. Mean lymph nodal yield
dissected in our study was 33.9. Contralateral nodal
Table 1 Depicting clinicopathological factors
Clinicopathological factors N
Age
Median (range)-years 52.19 (30–84)
Gender
Male 22
Female 78
Site of tumor
Tongue 55 (55)
Buccal mucosa 30 (30)
Non tongue and buccal mucosa 15 (15)
Pathological stage
PT1 29 (29)
PT2 63 (63)
PT3 8 (8)
Grade
Well differentiated 26 (26)
Moderately differentiated 67 (67)
Poorly differentiated 7 (7)
Neck node status
PN0 69 (69)
PN1 13 (13)
PN2a 3 (3)
PN2b 13 (13)
PN2c 3 (3)
Extracapsular spread
Yes 11 (11)
No 46 (46)
Not available 43 (43)
Lymphovascular invasion
Yes 9 (9)
No 91 (91)
Perineural invasion
Yes 39 (39)
No 61 (61)
No. of nodes dissected
Mean 33.90
Median 32.00
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metastasis was found in 16% of the patients in our study.
Bilateral neck dissection was performed in 16 patients, out
of which 5 (31.2%) had contralateral occult neck metastasis
(Table 1).
Survival Analysis
Three-year DFS in this retrospective review was study was
80% and the incidence of occult neck metastasis after the
elective neck dissection in our study was 35%. Factors
associated with the worse prognosis were, margin positiv-
ity {three-year DFS of 33.4% in margin positive versus
81.4% in margin negative patients (P—0.009) and LVI
(Three-year DFS of 33.3% in LVI negative versus 81.4% in
node negative patients (P—0.011)[CI 0.004–0.326]). Other
prognostic factors including age, sex, tumor site, tumor
grade was not predictive of poor DFS in this study
(Table 2).
Prognostic Factors and Occult Neck Metastasis
Median time of recurrence in patients with occult neck
metastasis, after surgery was 7.5 months. Occurrence of
occult metastasis was correlated with the prognostic factors
such as age, sex, LVI, tumor grade, tumor site and margin
positivity, by using univariate and multivariate analysis. In
Table 2 Prognostic factors in correlation with the disease free survival
Factors DFS Pvalue 95% Confidence intervals
Age 0.423 0.534–4.241
20–50 48
51–90 52
Sex 0.14 0.137–1.231
Male 22
Female 78
LVI 0.17 0.004–0.326
Yes 9 (9)
No 91 (91)
Grade 0.132 0.537–3.356
Well differentiated 26 (26)
Moderately differentiated 67 (67)
Poorly differentiated 7 (7)
Site 0.747 0.321–1.365
Tongue 55 (55)
Buccal mucosa 30 (30)
Non tongue and buccal mucosa 15 (15)
Margin positive 0.009
Yes 3 (3)
No 97 (97)
Table 3 Prognostic factors associated with neck metastasis
Factors neck metastasis Univariate analysis Multivariate 95% Confidence intervals
Age 0.416 0.439 0.534–4.241
Sex 0.097 0.097 0.137–1.231
LVI 0.000 0.000 0.004–0.326
Grade 0.457 0.113 0.537–3.356
Site 0.141 0.264 0.321–1.365
Margin positive 0.323 0.323
Depth of invasion 0.009 0.250 0.509–13.428
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this study, LVI (P—0.000)[CI 0.004–0.326] significant
correlated with occurrence of nodal metastasis (Table 3).
Prognostic Factors and ECS Spread
Potential predictors for occurrence of ECS such as age, sex,
LVI, tumor grade, tumor site and margin positivity were
correlated using univariate and multivariate analysis in this
study. Analysis of the ECS using prognostic factors was
done in 54 patients as per the availability of data. Age (P—
0.04) CI [1.053, 101.82] and LVI (P—0.018)[CI
0.004–0.603] were pathological factors that significantly
correlated with occurrence of ECS (Fig. 1) on univariate
analysis, whereas on multivariate analysis only LVI (P—
0.018) [CI 0.004–0.603] significantly correlated with
Fig. 1 Three-year DFS and correlation with prognostic factors
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occurrence of ECS in patients with early oral cavity cancer.
(Table 4).
Nodal Status Versus ECS Spread
In this study, three-year DFS for node negative patients
was 92.3% versus 60% for patients with nodal metastasis.
Worst prognosis, with the three-year DFS of 54.5%, was
seen in patients with nodal metastasis with ECS, which
states that nodal status, with ECS versus without ECS, had
a significant effect on DFS (P—0.010) (Fig. 2).
Discussion
The management of patients, with occult neck metastasis
and cN0 neck in early squamous cell carcinoma of oral
cavity, is evolving. With this study we contribute to liter-
ature about prognostic and predictive factors for occult
neck metastasis in early oral cancer patients. Many factors
influence the prognosis of patients with early head and
neck cancer. There is a disparity in the management and
data is evolving about the prognostic and predictive factors
of such patients. There is paucity of data regarding factors
that predict ECS, node positivity, and survival, especially
in node negative early oral cavity cancer. The occult neck
metastasis is very common after elective nodal neck dis-
section. The incidence of occult neck metastasis in our
study was 31% in agreement with other publications. Zeiad
et al. also reported 35% incidence of occult neck metastasis
[8]. ECS was reported in only 54% of the patients, 11% of
which were positive for ECS, which is less as compared to
other studies. ECS varies from 19 to 49%, but it was not
reported in 46% of the patients in our study, which was the
reason for such a low incidence for ECS (Tables 3,4).
On evaluating the association between pathological
factors and ECS, depth of invasion was a factor affecting
the occult neck metastasis. In this study the cut off length
of 5 mm was significantly associated with the occurrence
of occult neck metastasis (P—0.009). Significant associa-
tion between the occult neck metastasis and tumor thick-
ness of various cut off lengths (3 mm, 4 mm) was seen by
many authors [911]. PNI was also considered as an
independent factor associated with the occurrence of occult
cervical neck metastasis [12]. Statistically significant
association was also seen between PNI and occurrence of
occult neck metastasis in our study (P value 0.0).
LVI was seen in 9% of the patients and statistically
correlated with lymph nodal metastasis. Of 23 node posi-
tive patients, 8 (34.7%) had positive LVI which was sta-
tistically significant on univariate and multivariate
analysis. Other studies have also reported statistically sig-
nificant correlation between LVI and lymph nodal metas-
tasis [11].
In our study, three-year DFS for ECS positive and
negative patients was 45% & 78% respectively, which was
statistically significant.
Three-year DFS was 33.4% in LVI positive and 81.4%
in LVI negative patients, therefore LVI was a poor prog-
nostic factor (P—0.011). Three-year DFS for node positive
patients with ECS was 45% and without ECS was 60%
(P—0.010), therefore ECS proved to be a poor prognostic
factor for DFS.
Elective neck dissection is recommended in cN0
patients if the rate of occult neck metastasis is C20%
[12,13]. The occult metastasis often goes undetected
during clinical staging. Methods for careful detection of
neck metastasis should be studied further. Few studies
[13,14] showed ultrasound to be the most sensitive tool for
the detection of neck metastasis as compared to CT
(Computed Tomography), MRI (Magnetic Resonance
Imaging). The sites prone to occult metastasis are floor of
mouth and tongue [1518]. Detection of neck metastasis
can be explored by Sentinel Lymph Node biopsy which is
recommended for most of the early head and neck metas-
tases but still not recommended for tumors in floor of
mouth [19].
Some of the limitations of this study include its retro-
spective nature which is associated with inherent biases,
small sample size and ECS was not reported in 46% of
patients.
Conclusion
The incidence of occult neck metastasis after elective neck
dissection was 35%. Lymphovascular invasion and depth
of invasion significantly correlated with occult neck
metastasis. Age and lymphovascular invasion were the
prognostic factors for presence of ECS. Patient with ECS
had poor prognosis as compared to patients with nodal
Table 4 Prognostic factors associated with ECS (extra capsular
spread)
Factors ECS (Extra
capsular spread)
Univariate
analysis
Multivariate 95% Confidence
intervals
Age 0.044 0.045 1.053–101.812
Sex 0.694 0.772 0.109–5.178
LVI 0.018 0.018 0.004–0.603
Grade 0.352 0.338 0.476–8.662
Site 0.070 0.426 0.506–5.008
Margin positive 0.263 0.648 0.025–10.000
LNR 0.000 0.000 4.570–158.45
DOI 0.119 0.360 0.270–36.797
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metastasis without ECS. LVI and margin positivity were
the factors depicting the worse disease-free survival.
Acknowledgements Work should be attributed to Max Institute of
Cancer Care, Shalimar Bagh, Delhi.
Author Contributions The manuscript has been read and approved
by all the authors, the requirements for authorship as stated have been
met, and each author believes that the manuscript represents honest
work.
Funding No funding required.
Data Availability Data from the database of the Max Hospitals.
Compliance with Ethical Standards
Conflict of interest No disclosure or conflict of interest for the
author and the co-authors.
Ethical Approval Ethics approval was obtained from the Institution.
Consent for Publication The manuscript has been read and
approved by all the authors, the requirements for authorship as stated
have been met, and each author believes that the manuscript repre-
sents honest work.
Fig. 2 Three-year DFS with prognostic factors
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How to properly manage clinically negative neck of head and neck cancer patients is a controversial topic. Research is now directed toward finding a method sensitive enough to bring the risk of occult metastases below 20%. The aim of this review was to compare the diagnostic accuracy of different imaging modalities, including CT, MRI, PET and US, in clinically N0 head and neck cancer patients. For this systematic review and meta-analysis, PubMed and the Cochrane Database were searched for relevant original articles published up to May 2011. Inclusion criteria were as follows: articles were reported in English; CT, MRI, PET or US were performed to identify cervical metastases in clinically N0 head and neck squamous cell carcinoma; and data were sufficient for the calculation of true-positive or false-negative values. A bivariate random effect model was used to obtain pooled sensitivity and specificity. The positive and negative test probability of neck metastasis was generated based on Bayesian theory and collected data for different pre-test possibilities. Of the 168 identified relevant articles, 7 studies fulfilled all inclusion criteria for CT, 6 studies for MRI, 11 studies for PET and 8 studies for US. There was no difference in sensitivity and specificity among these imaging modalities, except CT was superior to US in specificity. The pooled estimates for sensitivity were 52% (95% confidence interval [CI], 39% ~ 65%), 65% (34 ~ 87%) 66% (47 ~ 80%), and 66% (45 ~ 77%), on a per-neck basis for CT, MRI, PET and US, respectively. The pooled estimates for specificity were 93% (87% ~ 97%), 81% (64 ~ 91%), 87% (77 ~ 93%), and 78% (71 ~ 83%) for CT, MRI, PET and US, respectively. With pre-examination nodal metastasis probabilities set at 10%, 20% and 30%, the post-exam probabilities of positive nodal metastasis rates were 47%, 66% and 77% for CT; 27%, 46% and 59% for MRI; 36%, 56% and 69% for PET; and 25%, 42% and 56% for US, respectively. Negative nodal metastasis probabilities were 95%, 89% and 82% for CT; 95%, 90% and 84% for MRI; 96%, 91% and 86% for PET; and 95%, 90% and 84% for US, respectively. Modern imaging modalities offer similar diagnostic accuracy to define and diagnose clinically N0 neck. Minimizing morbidity and avoiding elective neck dissection is acceptable in some select cases.
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This article provides a status report on the global burden of cancer worldwide using the GLOBOCAN 2018 estimates of cancer incidence and mortality produced by the International Agency for Research on Cancer, with a focus on geographic variability across 20 world regions. There will be an estimated 18.1 million new cancer cases (17.0 million excluding nonmelanoma skin cancer) and 9.6 million cancer deaths (9.5 million excluding nonmelanoma skin cancer) in 2018. In both sexes combined, lung cancer is the most commonly diagnosed cancer (11.6% of the total cases) and the leading cause of cancer death (18.4% of the total cancer deaths), closely followed by female breast cancer (11.6%), prostate cancer (7.1%), and colorectal cancer (6.1%) for incidence and colorectal cancer (9.2%), stomach cancer (8.2%), and liver cancer (8.2%) for mortality. Lung cancer is the most frequent cancer and the leading cause of cancer death among males, followed by prostate and colorectal cancer (for incidence) and liver and stomach cancer (for mortality). Among females, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death, followed by colorectal and lung cancer (for incidence), and vice versa (for mortality); cervical cancer ranks fourth for both incidence and mortality. The most frequently diagnosed cancer and the leading cause of cancer death, however, substantially vary across countries and within each country depending on the degree of economic development and associated social and life style factors. It is noteworthy that high‐quality cancer registry data, the basis for planning and implementing evidence‐based cancer control programs, are not available in most low‐ and middle‐income countries. The Global Initiative for Cancer Registry Development is an international partnership that supports better estimation, as well as the collection and use of local data, to prioritize and evaluate national cancer control efforts. CA: A Cancer Journal for Clinicians 2018;0:1‐31. © 2018 American Cancer Society
Article
Objective Patients with oral cavity squamous cell carcinoma (OCSCC) undergo adjuvant radiation for pathologically high-risk features including positive nodal disease and extracapsular spread (ECS). In the absence of these high-risk features, our objective was to determine if perineural invasion (PNI) is an independent risk factor and if adjuvant radiation (XRT) improves disease control rates.Study DesignHistorical cohort analysis.SettingTertiary university hospital.Methods Eighty-eight OCSCC patients (46 males, 42 females; mean age = 56.7 years; median follow-up = 4.6 years) treated surgically with pathologically N0 (pN0) necks were studied. Overall, 23% (20/88) were pN0/PNI+ and of those with PNI, 70% (14/20) underwent XRT. Survival analysis using Kaplan-Meier followed by multivariable Cox models was performed.ResultsMultivariate analysis verified PNI to be associated with worse disease-free interval (DFI) (P = .012) and local-regional control (LRC) (P = .005) and perivascular invasion (PVI) associated with worse DFI (P = .05). Among pN0/PNI+ patients, those who received XRT demonstrated significantly improved DFI (mean = 6.5 years vs 1.7 years; P = .014) and LRC (mean 6.7 years vs 1.9 years; P = .047). There was no improvement in overall survival (P = .68) or disease-specific survival (P = .8) in those receiving XRT.ConclusionsPNI is an independent adverse risk factor in the absence of nodal metastasis and extracapsular spread. We observed a statistically significantly longer DFI and LRC when patients were treated with adjuvant radiation.
Article
Observation or elective neck dissection (END) for cN0 neck remains controversial for the treatment of T1-2 oral squamous cell carcinoma (OSCC). Perineural invasion (PNI) has been recognized as a poor prognostic factor for OSCC. However, its significance in T1 OSCC remains unclear. A detailed histologic reevaluation of PNI was carried out in 307 patients with T1-2 OSCC who received surgical treatment between June 2001 and January 2009. We found that the presence of PNI correlated with cervical lymph node metastasis in both T1 and T2 OSCC, with a lower PNI-positive rate in T1 (17.1% vs. 36.6%; P<0.001). Importantly, observation for cN0 neck was used twice as often in T1 than in T2 patients (47.4% vs. 22.8%; P<0.001). Although patients with T1 OSCC achieved significantly better outcomes, PNI correlated with neck recurrence and poor disease-specific survival (DSS) only in T1 (P<0.001 and P<0.0001) but not in T2 patients (P=0.399 and 0.1478). Of the 146 patients with T1 OSCC, PNI independently predicted cervical lymph node metastasis, neck recurrence, and poor DSS. END significantly reduced neck recurrence of T1 OSCC in PNI-positive (P=0.001) but not in PNI-negative (P=0.114) patients. In addition, END improved the 5-year DSS of T1 OSCC more in PNI-positive than in PNI-negative patients (16.2% vs. 5.4%). Our results indicate that PNI independently predicts a poor prognosis in T1 OSCC patients who are potentially curable but tend to be treated conservatively. For its efficacy in improving treatment outcomes, aggressive END is indicated for T1 OSCC patients at the presence of PNI.
Article
PurposeThis study aims at evaluation of the different prognostic models, including stage, tumor thickness, shape, malignancy grading of tumor invasive front, Martinez-Gimeno score, and pathologic features in the prediction of subclinical nodal metastasis, local recurrence, and survival of early T1 and T2 oral tongue squamous cell carcinoma. The results will have important implication for the management of patients.Patients and Methods Seventy-two clinically T1 and T2 glossectomy specimens of oral tongue carcinoma were serially sectioned in 3-mm thickness for the evaluation of various pathologic features. The prognostic value in the prediction of subclinical nodal metastasis, local recurrence, and survival of different models were compared.ResultsAmong all the tumor parameters and predictive models being evaluated, tumor thickness was the only significant factor that had significant predictive value for subclinical nodal metastasis, local recurrence, and survival. With the use of 3-mm and 9-mm division, tumor of up to 3-mm thickness has 8% subclinical nodal metastasis, 0% local recurrence, and 100% 5-year actuarial disease-free survival; tumor thickness of more than 3 mm and up to 9 mm had 44% subclinical nodal metastasis, 7% local recurrence, and 76% 5-year actuarial disease-free survival; tumor of more than 9 mm had 53% subclinical nodal metastasis, 24% local recurrence, and 66% 5-year actuarial disease-free survival.Conclusions Tumor thickness should be considered in the management planning of patients with early oral tongue carcinoma. © 2002 Wiley Periodicals, Inc. Head Neck 24: 513–520, 2002
Article
In head and neck cancer, the most important prognostic factor is the presence or absence of neck metastasis. Although still debated in the published data regarding the "wait and see" policy for Stage T1-T2 oral cancer, a large number of clinicians support the necessity of neck dissection, especially in cases of oral tongue carcinoma, because of the poor prognosis and high risk of recurrence. The aim of the present study was to summarize and quantify the incidence of occult metastasis in oral cancer treatment at the oral and maxillofacial surgery department, Rambam Medical Center, in the past 10 years. A total of 142 neck dissections performed at our department in the past 10 years (1998 to 2009) and a series of 68 patients (44 men and 22 women) treated for Stage T1N0 or T2N0 oral cancer were included in the present retrospective study. All patients underwent surgical resection of the oral cancer and selective neck dissection of the ipsilateral side. Occult lymph node metastases were detected in 11 patients (16% overall, 9 in the tongue, 1 in the buccal mucosa, and 1 in the gingiva of the mandible). The frequency of occult metastasis from tongue carcinoma was 34% (9 of 26 cases). The 5-year survival rate in the present study was 78.9%. In patients who underwent chemotherapy, radiotherapy, brachytherapy, or a combination of the 3 after surgical management, the overall survival rate decreased significantly to 22.5% (P = .006, log-rank test). The incidence of occult metastasis in patients with oral cancer in the present study was 16% overall. In those with tongue carcinoma, a much greater incidence (34%) of occult metastasis was detected. Furthermore, the need for chemoradiotherapy after initial surgical management, mainly because of occult metastasis, was a significant negative predictor of patient outcome. The results of the present study emphasize the need for prophylactic neck dissection in patients with oral cancer diagnosed with Stage T1N0 or T2N0 disease, especially when the primary lesion is localized in the tongue.