Ebook Oral cancer – Diagnosis and therapy: Part 2

Part 2 book “Oral cancer – Diagnosis and therapy” has contents: Management of the neck, oral and maxillofacial reconstruction, prosthetic reconstruction for oral cancer patients using dental implants, radiotherapy, systemic chemotherapy, chemotherapy, complication of oral cancer treatment, prevention, and management,… and other contents.

8 Management of the Neck Ken Omura Abstract Regional nodal status is one of the most significant prognostic factors in patients with oral squamous cell carcinoma; therefore, diagnosis and treatment of cervical nodal disease is one of the most highly debated topics among head and neck surgeons Imaging modalities currently available in clinical practice include ultrasonography, computed tomography, magnetic resonance imaging, and positron emission tomography However, none of these methods can independently confirm occult metastasis A patient’s risk of regional metastasis is determined through clinicopathological evaluation of the primary tumor Elective management of the neck is warranted when the risk of occult metastasis is >20 % In these situations, the modality of elective treatment is influenced by that selected to treat the primary tumor When surgery is indicated, selective neck dissection (SND [I–III)] is generally required; however, SND (I–IV) is recommended for patients with tongue squamous cell carcinoma Modified radical neck dissection is the gold standard for the N-positive neck; however, SND is applicable in selected patients For patients with multiple node metastases or extracapsular spread, postoperative radiotherapy or chemoradiotherapy is recommended as soon as possible after surgery Keywords Extracapsular spread of tumor • Level • Neck dissection • Occult node metastasis • Postoperative radiotherapy/chemoradiotherapy 8.1 Introduction Oral squamous cell carcinomas (OSCCs) that are localized to the primary tumor site without regional metastatic disease have excellent cure rates with either surgery or radiation therapy The presence of regional metastatic disease decreases the cure rate by approximately 50 % [1, 2] The status of the cervical lymph nodes is one of the most significant prognostic factors for patients with OSCC; therefore, K Omura, D.D.S., Ph.D (*) Tokyo Medical and Dental University, Tokyo, Japan Oral Cancer Center, Tokyo General Hospital, Tokyo, Japan e-mail: omura.osur@tmd.ac.jp T Kirita and K Omura (eds.), Oral Cancer: Diagnosis and Therapy, DOI 10.1007/978-4-431-54938-3_8, © Springer Japan 2015 diagnosis and treatment of cervical nodal disease is one of the most highly debated topics among head and neck surgeons This chapter examines various approaches used to evaluate and treat patients with regional nodal disease 8.2 Regional Lymph Nodes The cervical lymphatic system is a rich network of lymphatic channels that drain into numerous lymph nodes scattered throughout the face and neck There are approximately 300 lymph nodes in the face and neck region [3] Cervical lymph nodes are categorized into six nodal groups or levels from I through VI; levels I, II, and V are further divided into sublevels A and B [4, 5] (Table 8.1) This classification does not 221 Submandibular nodes Upper jugular nodes, anterior to XI nerve Upper jugular nodes, posterior to XI nerve (submuscular recess) Middle jugular nodes Lower jugular nodes Posterior triangle nodes (spinal accessory group) Posterior triangle nodes (transverse cervical artery group, supraclavicular group) Central (anterior) compartment lymph nodes (paratracheal, perithyroidal, Delphian) IB IIA IIB IV VA VB VI III Submental nodes Level IA Lymph node group Table 8.1 Cervical lymph node levels Hyoid bone Horizontal plane defined by the inferior border of the cricoid cartilage Apex of the convergence of the sternocleidomastoid and trapezius muscles Horizontal plane defined by the inferior border of the cricoid cartilage Horizontal plane defined by the inferior border of the hyoid bone Skull base Skull base Body of mandible Superior Symphysis of mandible Boundary Superior edge of the manubrium sternum bone Clavicle Horizontal plane defined by the inferior border of the cricoid cartilage Clavicle Horizontal plane defined by the inferior border of the hyoid bone Horizontal plane defined by the inferior border of the hyoid bone Horizontal plane defined by the inferior border of the cricoid cartilage Body of hyoid bone Inferior Lateral border of the sternocleidomastoid muscle or sensory branches of the cervical plexus Lateral border of the sternocleidomastoid muscle or sensory branches of the cervical plexus Common carotid artery Lateral border of the sternohyoid muscle Lateral border of the sternohyoid muscle Vertical plane defined by the spinal accessory nerve Anterior belly of the contralateral digastric muscle Anterior belly of the digastric muscle Stylohyoid muscle Anterior (medial) Common carotid artery Anterior border of the trapezius muscle Lateral border of the sternocleidomastoid muscle Lateral border of the sternocleidomastoid muscle or sensory branches of the cervical plexus Lateral border of the sternocleidomastoid muscle or sensory branches of the cervical plexus Anterior border of the trapezius muscle Vertical plane defined by the spinal accessory nerve Posterior (lateral) Anterior belly of the ipsilateral digastric muscle Stylohyoid muscle 222 K Omura Management of the Neck include the facial and retropharyngeal nodes, which rarely harbor metastases from the oral cavity [6–8] • Level I contains the submental (IA) and submandibular (IB) nodes; it is bounded by the body of the mandible superiorly, the anterior belly of the contralateral digastric muscle anteriorly, the hyoid bone inferiorly, and the stylohyoid muscle posteriorly • Level II contains the upper jugular lymph nodes; it extends from the skull base superiorly to the hyoid bone (clinical definition) or the carotid bifurcation (surgical definition) inferiorly; this group consists of the following two sublevels: nodes anterior to the spinal accessory nerve (IIA) and nodes posterior to the spinal accessory nerve (IIB) • Level III contains the middle jugular lymph nodes; it extends from the hyoid bone (clinical definition) or the carotid bifurcation (surgical definition) superiorly to the cricoid cartilage (clinical definition) or the omohyoid muscle (surgical definition) inferiorly • Level IV contains the lower jugular lymph nodes; it extends from the cricoid cartilage (clinical definition) or the omohyoid muscle (surgical definition) superiorly to the clavicle inferiorly • Level V contains the lymph nodes in the posterior triangle; it is bounded by the anterior border of the trapezius muscle posteriorly, the posterior border of the sternocleidomastoid muscle anteriorly, and the clavicle inferiorly; this group consists of the following two sublevels: nodes superior to the level of the cricoid cartilage (VA, spinal accessory group) and nodes inferior to the level of the cricoid cartilage (VB, transverse cervical group) • Level VI contains the anterior lymph nodes from the hyoid bone superiorly to the suprasternal notch inferiorly, and the lateral border is formed by the common carotid artery 8.3 Patterns of Regional Node Metastases OSCCs are likely to present with nodal metastases in levels I, II, and III Initial involvement of level IV is quite uncommon; metastatic spread to level V nodes is even more infrequent [9] However, “skip metastases” or metastases to the inferior cervical nodes in level III or IV without demonstrable involvement of levels I and II are currently of concern [10, 11] 8.4 Evaluation of Regional Nodal Status All patients with OSCC require careful assessment of their cervical nodal status for optimal treatment planning and determination of their prognosis 223 8.4.1 Physical Examination Palpation remains the first step in evaluating the neck of patients with OSCC However, the diagnostic accuracy of this method varies depending on the body habitus of the patient and experience of the examiner Both the specificity and sensitivity of the palpation method for diagnosing nodal disease are reportedly 60–70 % [12, 13] In addition, some nodal regions are inaccessible to palpation, such as the parapharyngeal and retropharyngeal areas 8.4.2 Imaging Studies Imaging modalities currently available in routine clinical practice include ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) with or without CT US is a useful diagnostic imaging modality, which has been reported to have high sensitivity but low specificity for evaluating nodal diseases [14, 15] US is advantageous because of its relatively low cost, its ability to capture accurate measurements of nodal size, and its compatibility with guided fine-needle aspiration (FNA); however, its usefulness is dependent on the experience of the clinician Cross-sectional imaging studies play a large role in the evaluation of nodal status Although both MRI and CT can provide valuable supplemental information, CT appears to be slightly superior when appropriate criteria are used [15–18] Regardless of the type of imaging studies performed, clinicians use the following criteria that were developed as an aid to determine whether a node is metastatic: (1) a node >1.0 cm (or >1.5 cm in the jugulodigastric region, >0.8 cm in the retropharyngeal region), especially when round; (2) decreased central attenuation in the node; (3) a poorly defined mass in the lymph node-bearing region; and (4) the combination of ill-defined borders and structures If any of these criteria are present, the node must be considered to harbor metastasis [19, 20] PET differs from other imaging modalities in that it evaluates metabolic activity rather than anatomical structures PET has a lower resolution compared with CT or MRI, but this has been overcome with the advent of fusion-imaging technology, which combines the physiological data observed on a PET scan with the anatomical detail observed on a CT scan (PET/CT) [21, 22] Although recent advances in modern technology have led to the development of various diagnostic imaging modalities as discussed above, none of these modalities alone can confirm a cervical lymph node metastasis (Fig 8.1, Table 8.2) 224 K Omura obtained If a definitive diagnosis cannot be determined after repeated FNAs, the patient may require an open biopsy procedure 8.4.3.2 Open Biopsy The prognostic impact of an open biopsy of a suspicious lymph node remains controversial Some reports have stated that an open biopsy increases the rates of local complications, local recurrences, and distant metastasis [20] However, other reports indicate that biopsy of the neck does not imply a poor prognosis as long as adequate treatment is subsequently administered [25–27] Currently, from a practical standpoint, an open biopsy of a suspicious node is rarely recommended for patients with OSCC 8.4.3.3 Sentinel Lymph Node Biopsy Currently, sentinel lymph node biopsy receives considerable attention as a procedure for assessing the stage of regional disease Although this technique is promising, it is under investigation [28–30] 8.5 The staging system of regional lymph node metastases established by the UICC (outlined in Table 8.3) considers factors such as size, number, and laterality of the involved nodes Fig 8.1 Occult metastasis (micrometastasis) Table 8.2 Sensitivity and specificity of imaging modalities used in evaluation of neck disease Modality US CT MRI PET/CT 8.4.3 Sensitivity (%) 50–58 40–68 55–80 57–79 Staging of Regional Node Metastasis Specificity (%) 75–82 78–92 82–92 82–96 Pathological Examination A patient’s cervical node status can be pathologically evaluated; however, pathological confirmation should be obtained only for clinically and radiologically suspicious nodes 8.4.3.1 FNA FNA is an accurate and reliable procedure with minimal morbidity that allows for a quick cytological diagnosis of suspicious nodes For nodes that are difficult to access, guidance with US or CT is helpful [15, 23] Sensitivity and specificity of FNA for masses of the head and neck have been reported as 97 % and 96 %, respectively [24] The accuracy of FNA is directly related to the diagnostic capability of the cytopathologist and the quality of the material 8.6 Prognostic Implications of Regional Node Metastasis The presence of clinically apparent, histologically confirmed lymph node metastasis is the single most significant prognostic factor in patients with OSCC In general, it has been observed that patients with lymph node metastasis have a 50 % lower overall survival rate than patients with earlystage disease, owing to neck metastases [1, 2] However, the unfavorable impact of metastasis on survival varies depending on several factors The presence of extracapsular spread (ECS) of tumor, which is usually considered one of the most important predictor of poor prognosis, is not included in N-staging system (Fig 8.2) ECS has been associated with higher rates of regional nodal recurrence, as well as significantly lower survival rates [31, 32] As expected, ECS correlates with the size of the metastatic node and is typically found in cases of nodal metastases >3 cm [33] However, it must be kept in mind that approximately 20 % of all lymph node metastases with ECS are 20 % [49] Treatment is also indicated when the patient is unlikely to return for close follow-up Furthermore, elective neck dissection is indicated when the neck has need to be entered either for resection of the primary tumor (e.g., mandibulotomy) or reconstruction (e.g., free tissue transfer) The modality of elective treatment is dictated by the modality selected to treat the primary tumor, which may include neck dissection or external beam irradiation Elective neck dissection offers a distinct advantage over observation or elective neck irradiation, i.e., it provides important prognostic information that can be used for treatment planning, 227 Fig 8.6 Lateral view of the surgical field after partial glossectomy and SND (I–III) (digastric, stylohyoid, and mylohyoid muscles included in the surgical specimen) such as the need for adjuvant treatment [50] When neck dissection is indicated, SND (I–III) is generally required However, because “skip metastasis” to level IV nodes has been documented in up to 15 % of patients with tongue SCC, SND that addresses levels I–IV is advocated in such cases [10] Recent prospective multi-institutional studies have demonstrated that sublevel IIB is rarely involved by isolated metastasis from OSCCs, except in some tongue SCC cases Thus, it is justifiable to omit the dissection of sublevel IIB in the elective treatment of most OSCC cases [51] Elective neck irradiation is generally performed when the primary tumor is treated by using radiotherapy Radiation portals usually cover levels I to III as with neck dissection, with a minimum dose equivalent to 45–50 Gy over 4.5–5 weeks [52, 53] 8.7.2.3 Management of N1–3 Neck The generally accepted approach to treating regional node metastasis is surgery, usually with postoperative radiotherapy The type and extent of neck dissection performed is influenced by several factors, including the site of the primary tumor, treatment modality for the primary tumor, extent of nodal metastasis, and invasion of nonlymphatic structures 228 K Omura Fig 8.8 Lateral view of the surgical field after partial glossectomy and END (right half of the hyoid bone removed: digastric, stylohyoid, and mylohyoid muscles included in the surgical specimen) Fig 8.7 Anterolateral view of the surgical field after partial glossectomy, lateral pharyngectomy, and END (retropharyngeal nodes dissected: digastric and stylohyoid muscles included in the surgical specimen) In general, for the clinically N1 neck, MRND is usually performed [54] However, SND (I–III or I–IV) may be also indicated for patients with a single mobile node in level I or II [55, 56] Usually, postoperative radiation therapy is recommended if multiple nodes are involved or ECS is present [57] For patients with the clinically N2 neck, RND or MRND is recommended with postoperative radiotherapy or chemoradiotherapy In some selected cases, SND (I–IV) is applicable In N2c cases, MRND or SND (I–III or I–IV) should be considered for the less involved side of the neck In the treatment of the clinically N3 neck, MRND can be attempted, but usually RND is required in combination with adjuvant radiotherapy or chemoradiotherapy OSCCs can also metastasize to the nodes situated outside the region treated by using RND These include the facial nodes and retropharyngeal nodes [6–8], and they are dissected in combination with some type of ND procedure (END) Because patients with multiple node metastases or ECS often present with neck failure and/or distant metastasis after neck dissection, postoperative radiotherapy or concomitant chemoradiotherapy is recommended [58, 59] In such cases, the dose of radiation therapy should be at least 60 Gy to the entire operative field, and 66 Gy to the site at increased risk for recurrence, such as the site wherein ECS was detected Concomitant cisplatin (100 mg/m2) is usually administered every weeks Moreover, radiation therapy should begin as soon as possible, no later than weeks after surgery [60, 61] 8.7.2.4 Treatment Outcome Regional recurrence rates in the pathologically N0 neck are consistently low, at 3–7 %, irrespective of the treatment modality Recurrence rates following neck treatment vary depending on other factors, such as control of the primary tumor, ECS, and the pathological N stage In cases where the primary tumor has been controlled, overall recurrence rates are approximately 10–15 % for N1 disease without ECS, 20–30 % for N2 disease, and as high as 70 % for N3 disease [62, 63] Adjuvant radiotherapy decreases the regional recurrence rate by approximately half for all stages of the disease Management of the Neck Conclusions Management of regional disease in patients with OSCC remains one of the most challenging issues for head and neck surgeons Appropriate management requires a full understanding of the incidence, patterns, evaluation methods, and prognostic implications of regional metastasis 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A systematic review J Clin Oncol 21:555–563 62 Mastronikolis NS, Fitzgerald D, Owen C et al (2005) The management of squamous cell carcinoma of the neck The Birmingham UK experience Eur J Surg Oncol 31:461–466 63 Chan SW, Mukesh BN, Sizeland A et al (2003) Treatment outcome of N3 nodal head and neck squamous cell carcinoma Otolaryngol Head Neck Surg 129:55–60 ... patients with oral/ head and neck cancer J Oral Maxillofac Surg 65 :25 2 4 2 535 23 de Bondt RB, Nelemans PJ, Hofman PA et al (20 07) Detection of lymph node metastases in head and neck cancer: a meta-analysis... Larynx 32: 17 5–1 83 11 Rogers SN, Fisher SE, Woolgar JA (1999) A review of quality of life assessment in oral cancer Int J Oral Maxillofac Surg 28 (99):117 doi:10.1034/j.1399-0 020 .1999 .28 228 020 4 12 Skevington... (QLQ-EN24), oesophago-gastric (QLQ-OG25), gastric (QLQ-STO 22) , ovarian (QLQ-OV28), prostate (QLQ-PR25), and elderly cancer patients (QLQ-ELD14) [20 ] The Japanese Version of the EORTC QLQ-C30 [17, 21 ]