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 Table of Contents  
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 46-49

Pattern of cervical lymph node metastasis for therapeutic decision-making in squamous cell carcinoma of buccal mucosa

1 Additional Professor, Dept. of Pathology, IGIMS, India
2 Assistant Professor, Dept. of Surgical Oncology, IGIMS, India
3 Senior Resident, Dept. of Pathology, IGIMS, India
4 Senior Resident, Dept. of Physiology, IGIMS, India

Date of Submission23-Nov-2019
Date of Acceptance26-Dec-2019
Date of Web Publication12-Feb-2020

Correspondence Address:
Manish Kumar
Assistant Professor, Dept. of Surgical Oncology, IGIMS, Patna, Bihar- 800014
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Source of Support: None, Conflict of Interest: None

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A retrospective review of the records of previously treated patients squamous cell carcinoma of buccal mucosa, oral cavity was undertaken from May, 2017 through April, 2018. The cases were studied to ascertain the pattern of lymph node metastases (NM) in neck level. The patients were grouped into three categories, by clinical neck status at the time of neck dissection: elective dissection (ED) in the NO neck, immediate therapeutic dissection (ITD) in the N+ neck, and subsequent therapeutic dissection (STD) in the neck observed which converted clinically to N+.
The data support the trend toward selective limited neck dissection in both NO and N+ patients. Further, they provide the foundation for planning of future prospective trials to assess the efficacy of modifications in the extent of neck dissection.

Keywords: Carcinoma Buccal mucosa, Nodal metastasis, Limited Neck dissection, Prognostic factors, Therapeutic decision making.

How to cite this article:
Singh SK, Kumar M, Pawar SS, Singh AR, Kumari A. Pattern of cervical lymph node metastasis for therapeutic decision-making in squamous cell carcinoma of buccal mucosa. J Indira Gandhi Inst Med Sci 2020;6:46-9

How to cite this URL:
Singh SK, Kumar M, Pawar SS, Singh AR, Kumari A. Pattern of cervical lymph node metastasis for therapeutic decision-making in squamous cell carcinoma of buccal mucosa. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2022 Oct 1];6:46-9. Available from: http://www.jigims.co.in/text.asp?2020/6/1/46/300739

  Introduction Top

The incidence of oral carcinoma is much high in Asia. In Southeast Asia, the squamous cell carcinoma of buccal mucosa is the most common form of oral cancer. The higher rate of buccal carcinoma is related to the widespread practice of pan, pan masala, betel nut, gutkha, and khaini (tobacco leaves).[1],[2] Multimodal management of buccal carcinoma include surgery, radiotherapy, chemotherapy, and the combination of the above three. It depends upon tumor factors such as site, size, location, multiplicity, proximity to bone, pathological features, histology grade, depth of invasion, and status of cervical lymph nodes.[3] Approximately 300 lymph nodes are located in the head and neck region and they comprise 30% of the total 800 lymph nodes in our body. A considerable number of patients had to be upstaged after elective neck dissection due to occult lymph node metastasis. The anatomical distribution of metastasis from various intra-oral sites can readily be determined by examining the lymph nodes in pathological resected specimens. This provides data base for logical surgical approach to the neck nodes. The number of lymph node metastasis turned out to be of prognostic value. Only a few investigations have been done into the metastasis of squamous cell carcinoma of the oral cavity and buccal mucosa. But it is striking that the incidence of cervical lymph node metastasis from squamous cell carcinoma is significant.

The aim of our study is to analyze our data on the pattern of nodal metastasis in patients presenting with clinically operable oral (Buccal mucosa) squamous cell carcinoma, their topographic distribution in different levels of cervical lymph nodes to provide grounds for appropriate and optimal type of neck dissection required for therapeutic decision-making.

  Materials and Methods Top

This study was conducted in the Department of Surgical Oncology and Pathology, Indira Gandhi Institute of Medical Sciences, Patna, from May 2017 to April 2018. A retrospective analysis of the histopathological reports of 25 patients who underwent surgical resection for primary cancer of buccal mucosa were undertaken to ascertain the pattern of lymph node metastases in neck.

Only the cases of squamous cell carcinoma variants were included in this study. Radical neck dissections synchronous with the surgical excision of the primary, and those done for subsequent neck metastases were analyzed. Patients with primary lesion in lip, tongue, floor of mouth and with inadequate neck dissection, multiple primaries, preoperative chemotherapy, or preoperative radiation therapy were excluded.

There were 26 radical neck dissections in the 25 patients. In one patient (4%), simultaneous bilateral neck dissections were performed. Average number of lymph nodes retrieved on gross examination followed by microscopic examination were 18 in number. Patients were considered to have nodal disease when one or more nodes were reported to contain the tumor cells.

The primary site of oral lesion as recorded and its staging was done as per TNM staging. Nodal stations were grouped from level I to V as per standard definition.

  Results: Top

Of the total of 25 patients, 20(80%) were male and 5(20%) were female. Maximum incidence was found in 3rd decade (28%), followed by 4th decade (24%) and 20% each in 5th and 6th decade. The youngest patient was of 28 yrs and the oldest was of 73 yrs.

23(92%) patients had history of addiction and only 2 (8%) were non addict. Squamous cell carcinoma was the histopathological tissue diagnosis.

According to tumor size, most of the cases were of T4, 18(72%), while T3 (>4 cm) lesions were 4(16%) on second number, and only 3(12%) cases were with T2-sized lesions in our case series.

Level I LN were involved in all of the cases followed by level II in 7(28%), level III in 4(16%), level IV in 2(8%) and level V in one (4%) cases.

  Discussion Top

SCC in oral region can involve any of the oral subsites and each primary site has its own significance regarding the behavior of the tumor and its growth pattern as well as metastasis to cervical lymph nodes. Buccal mucosa is a common presenting site of oral SCC in our part, the higher rates being related to the widespread practice of betel nut, Khaini, pan masala and pan chewing.

Buccal carcinoma usually presents as a slow-growing mass. The smaller lesions are asymptomatic and are often noted surprisingly on dental examination. Pain and ulceration develops commonly as the lesion enlarges. Oral ingestion worsens the pain. Hence gradually these patients develop malnutrition and dehydration. The most common associated symptoms include bleeding, poor denture fit, facial weakness or sensory changes, dysphagia, odynophagia, and trismus.[4]

Predictive factors of cervical metastasis from oral carcinoma are primary site, primary tumor size, degree of differentiation of tumor, perineural and or perivascular invasion, inflammatory response, and tumor DNA content (ploidy).[5] It is described that nearly 49% occult metastasis in cervical lymph nodes in patients presenting with squamous cell carcinoma of buccal mucosa.6 Level I was the most common site for nodal metastases (100%), followed by level II (32%), level III (16%), and level IV (8%).[4]

The traditional approach for surgical treatment of neck node metastases from primary squamous cell carcinoma of the oral cavity has been a classical radical neck dissection. Since its description by Crile in 1906,[7] it has become the mainstay of surgical treatment for decades.[8] Although this procedure provides comprehensive clearance of lymph nodes at all neck levels, it results in significant functional and aesthetic morbidity. Hence, modifications of the classical radical neck dissection were proposed to avoid its attendant morbidity.[9]

There is controversy in treatment of neck in cases of oral cavity carcinoma as to whether to perform radical, modified, or selective neck dissection. Radical neck dissection produced significant long-term morbidity and deformity secondary to sacrifice of the spinal accessory nerve, sternocleidomastoid muscle, internal jugular vein (particularly if bilateral), and to large incisions, skin flaps, and extent of resection. Shoulder dysfunction, paraesthesia, and chronic neck and shoulder pain were, sequelae of the radical neck dissection.[10]

As the world is moving towards more and more conservative and less invasive approaches in treatment of oral cavity carcinomas, selective supraomohyoid neck dissection with the removal of level I, II, and III lymph nodes is advocated by many surgeons. Supraomohyoid neck dissection has been quite satisfactory regarding clearance of metastatic nodes, in context to 5-year survival and recurrence rates.[9]

The previous studies support our finding that tumor size is a predictor of lymph node metastasis though they propose that tumor thickness is a more reliable factor.[11],[12] However, tumor thickness is a radiological or histological parameter, and it can’t be assessed preoperatively by clinical examination or biopsy.

Though we have found that level V involvement in one patient in our study, we still recommend conservative neck dissection, but with T3 lesions and with high grade tumors modified radical neck dissection should be done with removal of all levels of lymph nodes.

We believe that our retrospective study is unique in that it represents patients with primary squamous cell carcinoma of the buccal mucosa, all of whom underwent modified radical neck dissection. Thus, detailed pathologic analysis of all cervical lymph node levels was available in all patients. It is important to stress that our study deals with the prevalence and patterns of nodal metastases only.

  Conclusion: Top

Lymphatic spread from carcinoma of the buccal mucosa is low and is dependent on the size and grade of tumor. The most common region with cervical lymph node metastasis is levels I ipsilateral neck nodes. Involvement of level V node was seen in only one patient. Thus, a more conservative approach to the neck in patients with carcinoma of the buccal mucosa is recommended. This study provides modern treatment strategies for the management of squamous cell carcinoma of buccal mucosa.
Table 1: Basic Characteristics of Patients

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Table 2: Metastatic lymph node levels

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Figure 1: A patient with a squamous cell carcinoma of buccal mucosa T4

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Figure 2: Histopathological sections of tumor proper from buccal mucosa showing Invasive Squamous cell carcinoma (H&E 40x)

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Figure 3: Histopathological sections of tumor proper from buccal mucosa showing Invasive Squamous cell carcinoma (H&E 40x)

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Figure 4: Classical Reactive Lymph Node showing typical germinal center follicles (H&E 40x)

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  References Top

Hart AE, Karakla DW, Pitman KT, Adams JF: Oral and oropharyngeal squamous cell carcinoma in young adults: a report on 13 cases and review of the literature. Otolaryngol Head Neck Surg 1999, 120:828833.  Back to cited text no. 1
Zini A, Nasser N, Vered Y: Oral and pharyngeal cancer among the Arab population in Israel from 1970 to 2006. Asian Pac J Cancer Prev 2012, 13:585-589.  Back to cited text no. 2
Lin TC, Tsou YA, Lin MH, Hua CH, Tseng HC, Bau DT, Tsai MH: Impact of neck dissection in early tongue and buccal cancer without neck extension. B-ENT 2011, 7:97-102.  Back to cited text no. 3
Shah JP, Patel GP: Head and neck surgery and oncology. NewYork, NY: Mosby; 2003.  Back to cited text no. 4
Chaturvedi P: Neck, Cervical metastases, Surgery, emedicine Otolaryngology and Facial Plastic Surgery. 2008. http://emedicine.medscape.com/article/ 849611.  Back to cited text no. 5
Chan SC, Ng SH, Tzu-Chen Y, Chang JT, Chen TM: False-positive findings on F-18 fluoro-2-deoxy-D-glucose positron emission tomography in a patient with nasopharyngeal carcinoma and extensive sinusitis. Clin Nucl Med 2005, 30:62-63.  Back to cited text no. 6
Cnle GW. Excision of cancer of the head and neck. JAMA 1906; 47: 1780- 1786  Back to cited text no. 7
Martin H, Del Valle B, Ehrlich H, Cahan WG. Neck dissectíon. Cuncer 1951; 4:441-499.  Back to cited text no. 8
Majoufrec C, Faucher A, Larcoche C, De Bonofils C, Siberchiocot F, Renauds-Salis JL, Pinsolle J: Supraomohyoid neck dissectíon in cancer of the oral cavity. Am J Surg 1999, 178:73-77.  Back to cited text no. 9
Essig H, Warraich R, Zulfiqar G, Rana M, Eckardt AM, Gellrich NC,Rana M: Assessment of cervical lymph node metastasis for therapeutic decision-making in squamous cell carcinoma of buccal mucosa: a prospective clinical analysis. World Journal of Surgical Oncology 2012, 10:253-58.  Back to cited text no. 10
Macfarlane GJ, Boyle P, Scully C: Rising mortality from cancer of the tongue in young Scottish males [letter]. Lancet 1987, 2:912.  Back to cited text no. 11
Macfarlane GJ, Boyle P, Scully C: Oral cancer in Scotland: changing incidence and mortality. BMJ 1992, 305:1121-1123.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2]


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