British Journal of Oral and Maxillofacial Surgery (1999) 37, 320–323 © 1999 The British Association of Oral and Maxillofacial Surgeons
BRITISH JOURNAL OF ORAL
& M A X I L L O FA C I A L S U R G E RY
Surgical management of the neck in squamous cell carcinoma of the tongue L. Califano, A. Zupi, G.M. Mangone, F. Longo, G. Coscia, P. Piombino School of Medicine and Surgery, Department of Maxillofacial Surgery, ‘Federico II’ University of Naples, Naples, Italy (Chief: Professor C. Giardino) SUMMARY. If the nodes are involved, survival of patients with squamous cell carcinoma of the tongue is considerably reduced. Surgery remains the treatment of choice and, to define its role, we have reviewed 82 consecutive cases. Sixty-two cases (76%) were T1–2, and 46 patients (56%) had involved nodes. The cervical region II was the most often involved (n=26). Occult nodal metastases were present in 12 cases. The extent of nodal spread and prognosis varies according to whether the body or the base of the tongue is involved. Lesions of the base with involved node should be treated by a selective posterolateral neck dissection, whilst in the case of a lesion of the body of the tongue, the dissection should be selective anterolateral. In lesions of the base, when there are no nodes involved, a prophylactic selective posterolateral neck dissection is recommended, whilst in the case of the lesions of the body, selective supraomohyoid neck dissection in T2–4 lesions is recommended.
Each patient had a radical resection. A margin of 1 cm of uninvolved tissue was considered to be safe. If nodes were involved unilaterally, we did an ipsilateral modified radical and a contralateral prophylactic selective neck dissection. If they were involved bilaterally, we did a bilateral modified radical neck dissection. A ‘wait-and-see’ policy was adopted if no nodes were involved in T1 lesions while T2–3 lesions were treated by an ipsilateral prophylactic selective neck dissection (with the exception of median lesions, which were treated by bilateral prophylactic neck dissection). We had no T4 lesions. All patients were followed up for five years or more. The terms used for neck dissection are those used in the classification by Robbins et al.8
INTRODUCTION Squamous cell carcinoma (SCC) of the tongue has the most nodal metastases of any oral cancer and nodal involvement considerably lowers survival.1 Mitchell and Crighton2 reported a difference in five-year survival of 83% and 33% in T1, and of 63% and 33% in T2 lesions. The extent of nodal spread and prognosis varies depending on whether the body or base of the tongue is affected, and this depends largely on lymphatic drainage.3–5 The position of the base is such that it is directly drained by the deep cervical chain and, rarely, by posterior cervical lymph nodes. The tip of the body of the tongue is drained by submental lymph nodes while the rest of the body and margins are drained by submandibular lymph nodes. Submental and submandibular lymph nodes are drained by the deep cervical chain. Surgical treatment of the neck is therefore essential in the management of these patients. At present, however, despite the high incidence, poor prognosis, and abundance of reports, the correct management still does not seem to have been adequately established. To help to shed light on this problem, we reviewed the records of 82 consecutive cases of SCC of the tongue that had been operated on.
RESULTS Results are shown in Table 1. The male:female ratio was 1.6:1 (50:32 cases), and the peak incidence was in the age group 41–60 years (n=38, 46%). On initial investigation most cases (n=62, 76%), were T1–2, 14 (17%) were T3, and six (7%) were Table 1 – Squamous cell carcinoma of the tongue according to TN classification
MATERIALS AND METHODS
The records of 82 consecutive patients with SCC of the tongue treated surgically at the Department of Maxillofacial Surgery of the School of Medicine and Surgery of the ‘Federico II’ University of Naples (Naples, Italy) were reviewed retrospectively. Site and size of the tumour and nodal status were assessed according to the TNM classification.6 The classification suggested by Shah et al. was used to evaluate lymph nodes.7
T1 T2 T3 T4
1 11 10 5
7 9 2 1
8 20 12 6
16 2 (1) 0 0
7 (1) 9 (8) 2 (2) 0
23 (1) 11 (9) 2 (2) 0
*Numbers in parentheses are those with occult metastases. 320
Surgical management of the neck in SCC of the tongue
Fig. 1 – (A) Neck involvement in N+ SCC of the body of the tongue; (B) hidden metastases in SCC of the body of the tongue.
Fig. 2 – (A) Neck involvement in N+ SCC of the base of the tongue; (B) hidden metastases in SCC of the base of the tongue.
T4. Forty-six patients (56%) had involved nodes and the cervical region II was most commonly involved (n=43, 52%). Regions III and IV were involved in 40 cases (49%); region I was involved in 27 cases (33%); and region V was involved in three cases (4%). Thirtysix patients did not have involved nodes but 12 were found to have occult nodal metastases (15% of the total). Among the 46 patients with involved nodes, four were diagnosed as bilateral before operation, the reminder being unilateral. Histological examination of the operative specimen by the pathologist showed occult metastases on the other side in nine.
Twenty-seven patients with SCC of the body of the tongue, had involved nodes mainly in cervical region I (n=27). Regions II, III, and IV were involved in 24, 22, and 22 cases, respectively; region V was not involved (Fig. 1A). Among those with no nodes involved (n=18), one case of occult nodal metastases was found involving regions I, II, and III (Fig. 1B). Of the 27 with involved nodes, one was diagnosed preoperatively as bilateral and 26 unilateral. The five-year survival was 56%. In SCC of the base of the tongue, 19 had involved nodes; cervical region II was involved in all 19 (51%).
British Journal of Oral and Maxillofacial Surgery
Regions III and IV were involved in 18 cases (49%); and region V in three. Region I was not involved (Fig. 2A). Of the 18 with no nodes involved, 11 had occult nodal metastases (30%) (Fig. 2B). Of the patients with involved nodes, three were diagnosed preoperatively as bilateral and 16 as unilateral. Histological examination of the operative specimen by pathologist showed occult metastases on the other side in nine. The fiveyear survival was 38%.
DISCUSSION SCC of the tongue has a higher incidence of nodal metastases than any other oral cancer1 and this considerably reduces survival rate. The extent and route of nodal spread and prognosis differ depending on whether the body of the tongue or the base is the site of the SCC.3,5,7,9 Nyman et al.9 report cervical metastases in 30% of 230 patients with SCC of the body, whereas we found 56%; this difference is probably because a third of ours were T3–4. Shah et al. and Shah and Andersen reported that nodal involvement had a strong prognostic influence.7,10 Takagi et al.11 reported that half their patients treated with a prophylactic neck dissection had nodal metastases; this value has been reported as varying from 20%–66%12–14 and in our experience it was very low (2%), probably because we had so many T1–2 lesions (67%). Byers et al.15 reported that the distribution in regions I–V was 18%, 73%, 18%, 0 and 0, respectively; in our experience these rates were 2%, 2%, 2%, 0 and 0, respectively. For tumours of the body of the tongue with involved nodes, an anterolateral neck dissection should be done, as region V is rarely involved; if there is clear extracapsular diffusion, a radical neck dissection is advised, sacrificing all involved structures. The neck dissection should be ipsilateral in the case of a marginal lesion, because only rarely is there occult involvement on the other side. When the lesion occurs in the body or at the tip where lymphatic drainage can include a contralateral lymph node, a prophylactic anterolateral neck dissection on that side is recommended. Occult metastases are rare in SCC of the body of the tongue, but Foote et al.5 suggest prophylactic neck dissection for all. In our experience, T1 lesions are not associated with occult metastases and we suggest a ‘wait-and-see’ policy. In T2 lesions, occult lymphatic involvement is more common (50%) and we suggest a prophylactic neck dissection including region I (involved in all cases) and regions II and III; regions IV and V can be preserved because they are involved only rarely.15 Other variables that should be considered are site, size, and grade. In median lesions, particularly in the anterior portion, Byers et al.15 suggested bilateral neck dissection, and in posterior lesions, which arise in the area between the body of the tongue and the base, the treatment should be the same as in SCC of the base. Great attention should be paid to the true size of the lesion,16,17 which could be deeper than it looks. It is not clinically practical to evaluate the exact thickness
before excision of the tumour, but thickness graded by palpation is a reasonably good indicator of a deeply invasive lesion.17 In T1 lesions of more than 4 mm thick the dissection should be ipsilateral in the case of marginal lesions and bilateral in the case of a lesion of the tip or body of the tongue. Histological grade generally reflects the aggressiveness of the tumour.17 Poorly differentiated and undifferentiated lesions are predictably more aggressive than moderately differentiated and well-differentiated lesions, so T1 lesions with a high grade (such as 3) should be treated in the same way as T2–4 lesions.16 SCC of the base of the tongue is more likely to have nodal involvement; Hinerman et al.18 reported cervical metastases in 82% of their cases. Our overall rate of nodal involvement was only 51%, but SCC of the base of the tongue is often associated with occult metastases (30%). Consequently, regional metastases have a role in prognosis. Nodal involvement usually occurs in regions II, III, and IV similarly (51%, 49%, and 49%, respectively); region V is less commonly involved (8%), whilst region I is never involved. Bilateral metastases are common (8%). Clearly, these lesions require a neck dissection; but just which dissection depends on the characteristics of the lesion. With a lesion of the base, the dissection should be selective posterolateral, and include region V. If there is extra-capsular spread or tumoral diffusion a radical neck dissection is necessary, and the structures involved should be sacrificed. Management of node-negative lesions is controversial. There is a considerable difference between cN grade (51%) and pN grade (81%) because of the high rate of occult metastases (30%). Small lesions (T1–2) are also associated with a high rate of occult metastases (28%), so there is agreement that prophylaxis is necessary.10 The small size of the base of the tongue causes frequent and early contralateral involvement (24%), which suggests that bilateral prophylactic neck dissection is necessary. As to the choice of neck dissection, we emphasize that occult metastases of the SCC of the base behave similarly to clinical metastases. Byers et al.15 reported occult metastases in regions I–V in 0, 67%, 33%, 33% and 17%, respectively; in our experience, these rates were 0, 30%, 11%, 8% and 3%, respectively. There is a high rate of involvement of those nodes that are usually preserved. In our experience, lower jugular lymph nodes and posterior triangle lymph nodes were involved in 8% and 3%, respectively. These observations suggest that prophylactic posterolateral neck dissection is indicated. In conclusion, it is essential that the different anatomy, physiology, and histopathology of each portion of the tongue is considered if SCC is to be managed successfully.
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16. Fakih AR, Rao RS, Borges AM, Patel AR. Elective versus therapeutic neck dissection in early carcinoma of the oral tongue. Am J Surg 1989; 158: 309–313. 17. Shah JP. Oral cavity and oropharynx. In: Shah JP, ed. Head and Neck Surgery, 2nd edn. New York: Mosby-Wolfe, 1996: 167–234. 18. Hinerman RW, Parsons JT, Mendenhall WM et al. External beam irradiation alone or combined with neck dissection for base of tongue carcinoma: an alternative to primary surgery. Laryngoscope 1994; 104: 1466–1470.
The Authors Luigi Califano MD Assistant Professor Department of Maxillofacial Surgery School of Medicine and Surgery Federico II University of Naples, Naples Giuseppe Coscia MD DDS, Francesco Longo MD, Giuseppe M. Mangone MD, Aldo Zupi MD DDS Senior Residents Department of Maxillofacial Surgery School of Medicine and Surgery Federico II University of Naples, Naples Pasquale Piombino MD Resident Department of Maxillofacial Surgery School of Medicine and Surgery Federico II University of Naples, Naples, Italy Correspondence and requests for offprints to: Luigi Califano MD, Via Posillipo 55, I-80123 Naples, Italy. Fax: +39 81 5453491 E-mail: email@example.com Manuscript received 28 July 1997 Accepted 5 March 1999