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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.30 no.3 Barcelona may./jun. 2008

 

ARTÍCULO CLÍNICO

 

Contralateral neck metastasis in squamous cell carcinoma of the oral cavity. An analytical retrospective clinical study of 315 patients primarily treated with surgery

Metástasis cervical contralateral en el carcinoma epidermoide de la cavidad oral. Estudio clínico analítico retrospectivo en 315 pacientes primariamente tratados con cirugía

 

 

R. González-García, L. Naval-Gías, F.J. Rodríguez-Campo, J. Sastre-Pérez, M.F. Muñoz-Guerra, F.J. Díaz-González

Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario La Princesa. Madrid. España

Correspondence

 

 


ABSTRACT

Objectives. There are numerous studies in the literature on the prognostic factors involved in the appearance of ipsilateral neck metastasis in squamous cell carcinoma of the oral cavity. However, there are no extensive clinical studies on the association of clinicopathological factors and the appearance of contralateral neck metastasis after the surgical resection of the primary tumor. The object of this study is to analyze the factors implied in the appearance of contralateral neck metastasis in patients with squamous cell carcinoma of the oral cavity treated primarily with surgery.
Patients and methods. A series of 315 consecutive patients with squamous cell carcinoma of the oral cavity, who had not been treated previously, were analyzed. A complementary study of a subgroup of 203 patients with squamous cell carcinoma of the lateral border of the mobile tongue was carried out, as this was a very prevalent group in the series analyzed. The patients all received surgical treatment with or without adjuvant radiotherapy treatment. Various clinical and histopathological variables were analyzed, such as the clinical characteristics of the tumor, tumor stage, degree of histological differentiation, type of neck dissection, disease-specific survival, surgical margins of the resected specimen, extracapsular lymph node extension, perineural dissemination and bone involvement.
Results. The mean follow-up of patients who survived was 70.9 ± 49.6 months. Eighty-three patients died as a result of the disease during the follow-up period. Forty-six of these belonged to the subgroup of patients with squamous cell carcinoma of the tongue. A total of 147 patients remained alive with no evidence of diseaserecurrence at the end of the follow-up period, 116 of whom corresponded to the subgroup of patients with squamous cell carcinoma of the tongue. The mean rate of disease-free survival was147± 6 months. Twenty-nine (9.1%) of patients developed ipsilateral neck recurrence, while 18 (5.69%) showed contralateral neck recurrence. For patients with squamous cell carcinoma of the tongue, and considering the percentages in relation to the 203 patients with this entity, these figures were 20 (9.8%) and 9 (4.4%) respectively. The mean time it took for neck metastasis to appear following surgery was 12.52 months (range 3-49), somewhat less for the subgroup of patients with squamous cell carcinoma of the tongue (11.4 months, range 3-27). Eighteen of the 29 patients with ipsilateral neck recurrence finally died of the disease. Seven of the 18 patients with contralateral metastasis also died of the disease. In the subgroup of patients with squamous cell carcinoma of the tongue these figures were: 14 of the 20 patients with ipsilateral neck metastasis and eight of the nine patients with contralateral neck metastasis. Various clinicopathological factors showed an association that was statistically significant (p<0.05) with regard to the appearance of contralateral neck metastasis such as: time until diagnosis, tumor stage, histopathological differentiation, surgical margins with regard to primary tumor resection, tumor thickness, type of neck dissection and perineural infiltration. Only the ipsilateral clinical N stage showed a statistically significant association (p<0.05) in the subgroup of patients with squamous cell carcinoma of the mobile tongue.
Conclusion. A delay of 12 months or more in the diagnosis of squamous cell carcinoma of the oral cavity is associated with an increased risk of contralateral neck metastasis. Other predictive factors for the appearance of contralateral neck metastasis are stage IV tumor by TNM classification, the poor histopathological differentiation of the primary tumor, the presence of surgical margins of less than 1 cm in the resection specimen of the primary tumor, carrying out ipsilateral functional neck dissection in an isolated fashion and perineural involvement. The presence of ipsilateral neck nodes that are clinically positive at diagnosis is associated with an increased incidence of contralateral neck recurrence of squamous cell carcinoma of the oral cavity and mobile tongue. The appearance in most cases of contralateral neck recurrence in the two years after surgery, implied that carrying out a close following of these patients is necessary.

Key words: Squamous cell carcinoma; Oral cavity; Tongue; Neck metastasis.


RESUMEN

Objetivos. Existen en la literatura numerosos estudios en relación con los factores pronósticos implicados en la aparición de metástasis cervicales ipsilaterales en el carcinoma epidermoide de cavidad oral. Sin embargo, no existen estudios clínicos amplios acerca de la asociación de factores clínico-patológicos y la aparición de metástasis cervicales contralaterales tras la resección quirúrgica del tumor primario. El propósito de este estudio es el análisis de los factores implicados en la aparición de metástasis cervical contralateral en pacientes con carcinoma epidermoide de cavidad oral primariamente tratados con cirugía.
Pacientes y métodos. Se analizó una serie de 315 pacientes consecutivos con carcinoma epidermoide de la cavidad oral no tratados previamente. Se realizó un estudio complementario del subgrupo de 203 pacientes con carcinoma epidermoide del borde lateral de la lengua libre, por tratarse de un grupo muy prevalente en la serie analizada. Todos los pacientes recibieron tratamiento quirúrgico con o sin tratamiento radioterápico adyuvante. Varias fueron las variables clínicas e histopatológicas analizadas, como son: las características clínicas del tumor, el estadio tumoral, el grado de diferenciación histológica, el tipo de disección cervical, la supervivencia enfermedad-específica, los márgenes quirúrgicos en la pieza resecada, la extensión ganglionar extracapsular, la diseminación perineural y la afectación ósea.
Resultados. La duración media del seguimiento de los pacientes que sobrevivieron fue de 70,9 ± 49,6 meses. Ochenta y tres pacientes murieron a causa de la enfermedad a lo largo del seguimiento. Cuarenta y siete de estos pertenecían al subgrupo de pacientes con carcinoma epidermoide de lengua. Un total de 147 pacientes permanecía vivo sin evidencias de recurrencia de la enfermedad al final del periodo de seguimiento, 116 de los cuales correspondían al subgrupo de pacientes con carcinoma epidermoide de lengua. El tiempo de supervivencia medio libre de enfermedad fue 147± 6 meses. Veintinueve (9,1%) pacientes desarrollaron recurrencia cervical ipsilateral, mientras que 18 (5,69%) mostraron recurrencia cervical contralateral. Para los pacientes con carcinoma epidermoide de lengua, y considerando los porcentajes en relación a los 203 pacientes con esta entidad, estas cifras fueron de 20 (9,8%) y 9 (4,4%), respectivamente. El tiempo medio de aparición de las metástasis cervicales desde la cirugía fue de 12,52 meses (rango: 3-49), algo menor para el subgrupo de pacientes con carcinoma epidermoide de lengua (11,4 meses, rango: 3-27). Dieciocho de los 29 pacientes con recurrencia cervical ipsilateral murieron finalmente de la enfermedad. Siete de 18 pacientes con metástasis contralateral murieron igualmente de la enfermedad. En el subgrupo de pacientes con carcinoma epidermoide de lengua, estas cifras fueron: catorce de 20 pacientes con metástasis cervical ipsilateral y ocho de 9 pacientes con metástasis cervical contralateral. Varios factores clínicopatológicos mostraron asociación estadísticamente significativa (p<0,05) con respecto a la aparición de metástasis cervical contralateral, como: tiempo hasta el diagnóstico, estadio tumoral, diferenciación histopatológica, márgenes quirúrgicos en la resección del tumor primario, espesor tumoral, tipo de disección cervical e infiltración perineural. Por el contrario, el estadio N clínico ipsilateral no mostró una asociación estadísticamente significativa en el subgrupo de pacientes con carcinoma epidermoide de lengua llibre, y sí lo hicieron el grado histológico tumoral y la inflamación peritumoral.
Conclusiones. La demora de 12 meses o más en el diagnóstico de carcinoma epidermoide de cavidad oral se asocia a un riesgo aumentado de metástasis cervical contralateral. Otros factores predictivos de la aparición de metástasis cervical contralateral son el estadio tumoral IV de la clasificación TNM, la pobre diferenciación histopatológica del tumor primario, la presencia de márgenes quirúrgicos menores de 1 cm en la pieza de resección del tumor primario, la realización de disección cervical funcional ipsilateral de modo aislado y la afectación perineural. La presencia de adenopatías cervicales ipsilaterales clínicamente positivas en el momento del diagnóstico se asocia con una incidencia aumentada de recurrencia cervical contralateral en el carcinoma epidermoide de cavidad oral. La aparición de la mayoría de los casos de recurrencia cervical contralateral en los dos años siguientes a la cirugía, hace precisa la realización de un seguimiento estrecho de estos pacientes.

Palabras clave: Carcinoma epidermoide; Cavidad oral; Lengua; Metástasis cervical.


 

Introduction

Numerous clinical and pathological factors have been considered as prognostic factors in neck recurrence of squamous cell carcinoma of the oral cavity, such as the location of the primary tumor, tumor size, stage, degree of histological differentiation, tumor thickness and perineural invasion. 1-3 Similarly, the appearance of recurrence in the neck after radical neck dissection invariably proves fatal.5

Traditionally, squamous cell carcinoma of the oral cavity that is located in the midline has been associated with an increased rate of bilateral and contralateral neck metastasis.6 This applies to the different sites: tongue, alveolar gingiva, buccal mucosa and floor of the mouth. In order to avoid the possible explication for the appearance of contralateral neck metastasis (CNM) as a result of the primary tumor site being in the midline of the oral cavity, the selective inclusion of tumors that arise primarily in lateral zones of the oral cavity is mandatory. The analysis of the primary characteristics of the tumor is in this way possible, together with those arising from surgical manipulation that can be associated with the appearance of CNM.

To our knowledge, there are no clinical series that examine specific prognostic factors with regard to the appearance of CNM from squamous cell carcinoma of the oral cavity that has been treated primarily with surgery. The aim of this study is to determine the clinical and histological characteristics that are prognostic factors in the appearance of CNM in squamous cell carcinoma of the oral cavity.

 

Patients and methods

This series is based on 507 patients who were diagnosed with squamous cell carcinoma of the oral cavity and who were primarily treated by the department of Oral and Maxillofacial Surgery of the Hospital Universitario La Princesa, Madrid, Spain from June 1979 to December 1999. The patients were chosen from a data base and in a prospective fashion. The patients were treated with surgery, with or without coadjuvant radiotherapy. The surgery was carried out in all cases by the same surgical team. Factors related to the surgery were taken into account, and those patients who had received radiotherapy or chemotherapy as primary treatment were not included. Only a small proportion of patients (less than 2%) with squamous cell carcinoma of the oral cavity were not included in the study. These cases were the result of advanced disease together with the poor general health of the patient at diagnosis.

A series of exclusion criteria were established: (1) tumors that appeared primarily in the midline of the oral cavity, (2) patients with multiple oral or head and neck cancers (87 of the 517 patients), (3) patients with recurrence of a previous primary tumor (52 of 517 patients), (4) distant metastasis at diagnosis, (5) contraindication for surgery, irremovable tumor or inoperable patient. The presence of just one of these criteria was sufficient to exclude the case. Patients were chosen with tumors that were primarily located in the lateral area of the oral cavity. Within these, squamous cell carcinoma of the lateral border of the mobile tongue, alveolar gingiva distal to both canines, floor of the mouth distal to the height marked by the prolongation backwards of both lower canines and jugal mucosa were included. No limit was set for tumor stage, and patients with Stage I to IV by TNM classification were included. The following inclusion criteria were established: (1) histologic confirmation of squamous cell carcinoma of the oral mucosa, and (2) absence of previous treatment. Diagnosis by imaging was established by means of computerized tomography (CT) and/or nuclear magnetic resonance (NMR). A total of 315 patients were included with squamous cell carcinoma of the oral cavity and a subgroup of 203 patients with squamous cell carcinoma of the tongue.

The following variables were analyzed for each patient: age, sex, toxic habits, date of diagnosis, clinical characteristics of tumor, degree of histological differentiation, clinical stage by TNM classification, number and location of neck nodes involved, type of surgical reconstruction, neck dissection, administration of postoperative radiotherapy, local regional or distant recurrence, and results of disease-specific survival. The histologic study included the following variables: pTNM classification, tumor size, surgical margins, perineural infiltration, peritumoral inflammation and bone involvement.

All patients underwent surgical resection of the primary tumor with macroscopic margins (greater than 1 cm). The tumors were classified by TNM classification regarding tumor stage.7 Different types of neck dissection were carried out: (1) Ipsilateral Type 3 modified radical neck dissection in patients with (T2,T3,T4) N0 tumors, or with tumors with neck node involvement of less than 3 cm without extracapsular extension (unattached nodal swelling); (2) Bilateral Type 3 modified radical neck dissection when there was invasion of the midline of the oral cavity as a result of extension from the lateral area of the oral cavity in N0 and N1 patients; (3) ipsilateral classical radical neck dissection when there was swelling of 3 cm or more, attached nodes or spinal nerve involvement; (4) ipsilateral classical radical neck dissection together with contralateral Type 3 modified radical neck dissection in patients with N2 or N3 ipsilateral necks and contralateral N0 necks, but with midline involvement of the oral cavity as a result of extension from the lateral area; and (5) contralateral classical radical neck dissection together with ipsilateral Type 3 modified radical neck dissection in one patient with contralateral pathological swelling greater than 3 cm (N2) at diagnosis. In spite of initial aggressive treatment, this last patient showed contralateral neck recurrence during the follow-up. It was considered a true recurrence and it was included in the study.

In accordance with the Department of Oncological Radiotherapy, coadjuvant radiotherapy treatment was administered that was between 60 and 70 Gy for those patients whose specimen had margins of less than 1cm. Tumors that were classified as pT3 or greater, also received coadjuvant radiotherapy treatment. Regional coadjuvant radiotherapy was used when more than three pathological neck nodes or extracapsular extension were demonstrated. Only those cases with contralateral neck involvement were treated by means of coadjuvant radiotherapy of the contralateral neck after the neck dissection.

The patients were grouped together and analyzed according to the type of neck dissection carried out (Table 2). The necks were classified as positive or negative for neck metastasis after histological analysis. The incidences of ipsilateral and contralateral neck recurrence were registered during the follow-up. The following variables were evaluated in relation to a hypothetical association with the appearance of contralateral neck recurrence: age, sex, time the lesion had been evolving until diagnosis, clinical T stage, clinical N stage, pathological T stage, pathological N (pN) stage, tumor stage, degree of histopathological differentiation, surgical margins after resection of primary tumor, tumor thickness (<2mm o >2mm), type of neck dissection, perineural infiltration, bone involvement, extracapsular extension of metastasis via lymph vessels and postoperative radiotherapy.

The purpose of the study was to determine those characteristics related with the primary tumor and its treatment that can predict the appearance of contralateral neck metastasis from squamous cell carcinoma in the lateral area of the oral cavity. SPSS 6.12 (SPSS Inc, Chicago, IL) software was used for analyzing data. The possible association between clinical and pathological characteristics of the primary tumor with regard to the appearance of contralateral neck metastasis was determined by the Chi_square test for qualitative variables and Student’s T- test was used for the quantitative variables data following a Gaussian distribution. Survival curves were calculated using the Kaplan-Meier method. A p<0.05 difference was considered statistically significant.

 

Results

Of a total of 517 patients with squamous cell carcinoma of the oral cavity, 315 met the inclusion criteria. Of these, 203 had squamous cell carcinoma of the mobile tongue. The male/female rate was 10:7 (10:3.9 for the subgroup of patients with squamous cell carcinoma of the tongue). The mean age was 59.99 with ages ranging between 18 and 90. The mean time from the onset of the first clinical signs until diagnosis was 3.94 months (4 months for the subgroup of patients with squamous cell carcinoma of the tongue) with a mean of two months and a range of 0 to 84 months. The clinicopathological factors and the appearance of contralateral lymphatic metastasis appear in table 1.

Eighty-three patients died as a result of the disease (26.34%), while 27 died because of another disease that was not related to squamous cell carcinoma of the oral cavity. With regard to the subgroup of patients with squamous cell carcinoma of the tongue, 47 patients died as a result of the disease (23.15%), while 19 did so because of another disease not related to the first. Mean disease-specific survival time for the whole group was 147± 6 months (confidence interval 95%: 134 to 159 months). With regard to the subgroup of patients with squamous cell carcinoma of the tongue this value was 149 ± 7 months ((confidence interval of 95%: 135 to 166 months). The rate of disease-specific survival at 1 year, 2 years and 5 years was 85.6%, 75.8% y 71.8% respectively for all groups together (Figs. 1 and 2).

Most patients in the series underwent neck dissection (n=214 (67.9%)): 137 (43.5%) ipsilateral Type 3 modified radical neck dissection, 55 (17.4%) bilateral Type 3 modified radical neck dissection, 13 (4.1%) ipsilateral classical radical neck dissection, 5 (1.6%) ipsilateral classical radical neck dissection together with contralateral Type 3 modified radical neck dissection, and 4 (1.3%) Type 3 modified radical neck dissection with contralateral classical radical neck dissection. With regard to the subgroup of patients with squamous cell carcinoma of the tongue, the data were as follows: (n=141 (73.1%)): 80 (40.6%) ipsilateral Type 3 modified radical neck dissection, 49 (24.9%) bilateral Type 3 modified radical neck dissection, 5 (2.5%) ipsilateral classical radical neck dissection, 6 (3%) ipsilateral classical radical neck dissection together with contralateral Type 3 modified radical neck dissection, and 1 (0.5%) Type 3 modified radical neck dissection together with contralateral classical radical neck dissection. Tables 3 and 4 synthesize the data referring to the type of neck surgery and the appearance of contralateral neck metastasis during the follow- up period.

One hundred and six patients received radiotherapy treatment (33.7%) after surgery. Of the patients with squamous cell carcinoma of the tongue this figure rose to 73 (37.6%). Sixty-four (20.3%) developed local recurrence after definitive treatment. Twenty-nine patients developed ipsilateral neck recurrence (9.1%) while 18 (5.7%) had contralateral neck metastasis. The frequency with which local and regional recurrence appeared simultaneously was 6.3% and metastasis at a distance was 7.9%. For those patients with squamous cell carcinoma of the tongue this last figure was 9.8% and 7.4% respectively. For the global series, 18 out of 29 patients with ipsilateral neck recurrence finally died of the disease. Seven of the 18 patients with contralateral neck recurrence also died of the disease. The mean period between surgery and the appearance of CNM was 12.52 months (with a range of 3 to 49 months). Most patients (72.2%) that presented with CNM had been managed initially with a Type 3 modified radical neck dissection. One of these cases received in addition a contralateral classical radical neck dissection. This was due to the absence of ipsilateral neck involvement but the presence of CNM at diagnosis. Two patients did not receive neck dissection primarily and they underwent a Type 3 modified radical neck dissection when CNM finally appeared. To sum up, ten out of the 18 patients with CNM were candidates for later neck dissection. The remaining eight were not candidates for surgery and they were only given palliative or radiotherapy treatment. At the end of the follow-up period only seven of the 18 patients remained alive with no evidence of the disease (Table 5).

With regard to the clinicopathological factors analyzed, a statistically significant association was observed with regard to p<0.05 in relation to the appearance of contralateral neck metastasis for: time in terms of months until diagnosis, tumor stage by TNM classification, ipsilateral clinical N stage, degree of histopathological differentiation, surgical margins of the primary tumor resection, type of neck dissection and perineural infiltration. In this sense predictive factors for contralateral neck metastasis appeared to be a delay of 12 months or more in the diagnosis (p=0.03), tumor stage IV by TNM classification (p=0.03), the presence of ipsilateral positive N at diagnosis (p=0.04), the poor histopathologic differentiation of the primary tumor (p=0.04), the presence of surgical margins of less than 1 cm of the resected specimen of the primary tumor (p=0.007), carrying out ipsilateral functional neck dissection in an isolated fashion (p=0.04), perineural involvement (p=0.0002). In the subgroup of patients with squamous cell carcinoma of the mobile tongue, only ipsilateral clinical N stage showed an association that was statistically significant, to the extent that the presence of ipsilateral pathological lymph nodes in the neck at diagnosis was seen as a predictive factor for contralateral neck recurrence.

 

Discussion

Local recurrence and recurrence in the lymphatic system of the neck affect prognosis and reduces survival for patients with squamous cell carcinoma of the oral cavity.1,2,3 The unfortunate outcome of patients who develop contralateral neck metastasis is well-known. Various authors have analyzed the different factors related to a high risk of developing contralateral neck metastasis in tumors of the oral cavity, although there are no lengthy clinical series. With regard to squamous cell carcinoma of the oral cavity, recurrence of contralateral neck metastasis has been reported between 0.9% y 34.7%.4,6 Kowalski et al.7 reported an incidence of 14% for contralateral neck metastasis in consonance with the data published by Kurita et al. 8 Our results (5.7%) were below these figures. The influence of certain factors in the primary tumor and the appearance of contralateral neck metastasis, such as a midline location are well-known. Increased rates of contralateral neck recurrence for those patients with tumors in the anterior region of the floor of the mouth and anterior third of the tongue. However, the existence of properly contrasted data on the greater incidence of contralateral neck metastasis in patients with squamous cell carcinoma of the lower gingiva (25%) compared with those tumors that were primarily located in the mobile tongue (15.4) makes a greater number of clinical series necessary in order to determine the degree of influence of tumor location.

Considering the location of the primary tumor, the importance of invasion of the midline has been emphasized by Martin et al.4 In their series, 16% of patients with tumors crossing the midline by less than 1cm developed contralateral neck metastasis. This value increased to 46% in cases when invasion of the midline was over a centimeter. All cases in the series presented by our group affected primarily the lateral part of the oral cavity, and all those tumors that were situated in the area between both canines were expressly ruled out. This selection was carried out in an attempt to obviate the influence of primary tumor location in the subsequent development of CNM. With regard to this aspect, Kurita et al,8 found an association that was statistically significant between radiologically observed tumor extension that was over the midline, and the appearance of CNM. However, multivariate analysis shows that this is not the only factor that stands out and that other factors should be taken into account globally.3

Clinical stage by TNM classification and tumor size could be considered important prognostic factors in the appearance of CNM. With regard to squamous cell carcinoma of the oral cavity, tumor stage by TNM classification was predictive of contralateral neck recurrence in our series, although we could not demonstrate an association that was statistically significant with regard to tumor size. 6.7% of patients with clinical stage IV by TNM classification developed CNM, as opposed to 2.6% of patients with a stage I tumor. Also, we did not find a statistically significant association between earlier stages (T1-2) and contralateral neck recurrence in the subgroup of patients with squamous cell carcinoma of the tongue. Other authors have obtained similar results.7,8

The possibility of tumor thickness being influential in the appearance of contralateral neck recurrence was considered. In this sense, we did not find any association that was statistically significant between tumor thickness greater than 2mm and the appearance of CNM (p=0.06). This situation can be explained by an insufficient number of patients, as 7.1% of patients with a tumor thickness greater than 2mm developed CNM, compared with an absence of cases of contralateral neck metastasis in patients with tumors of a thickness of less than 2mm. Perineural infiltration, on the other hand, was strongly predictive of CNM. Precisely 17.02% of patients with perineural infiltration developed metastasis, as opposed to just 4.1% of those that did not have it. On the other hand, surgical margins of less than 1cm in the histological study were associated with the development of CNM, in a statistically significant fashion. Only 4% of patients with resection margins that were equal to or larger than 1cm in the histological study developed CNM, as opposed to 11.6% of patients who underwent a resection with margins of less than 1 cm in the histological study.

The histological grade of the primary tumor and the number of metastatic neck nodes has been reported as predictive of contralateral neck recurrence. We have been able to demonstrate that the histologic grade of the tumor is a prognostic factor of CNM. In fact 13.5% of patients with poorly-differentiated squamous cell carcinoma developed contralateral neck recurrence, as opposed to 5.2% of patients with well-differentiated squamous cell carcinoma. With regard to neck lymph node involvement, the presence of positive ipsilateral neck nodes has been reported as an important predictive factor for the appearance of CNM in squamous cell carcinoma of the oral cavity.4,6,9 Moreover, the appearance of CNM has been described mainly in the context of simultaneous ipsilateral neck metastasis (INM). With regard to squamous cell carcinoma of the oral cavity, Chow et al 10 demonstrated, in a series of 72 patients, a similar incidence between the appearance of INM (n=7) and CNM (n=5). Our results do not support these findings, as in our series the frequency of CNM (5.7%, n=18) was nearly half the INM rate (9.1%, n=29). We were able to demonstrate the presence of INM at diagnosis as a prognostic factor in the appearance of contralateral neck metastasis.

Early diagnosis is fundamental for the purpose of reducing the rate of contralateral neck recurrence. In our series, 23.8% of patients who were diagnosed after a delay of 12 months or more from the appearance of the primary lesion, presented CNM compared with 2.4% of patients who were diagnosed with a development of less than 12 months. With regard to the initial neck surgery management, we were able to confirm that 7.4% of patients with squamous cell carcinoma of the oral cavity who received unilateral neck dissection developed CNM, as opposed to 1.8% of patients who were subjected to bilateral neck dissection. This association was not significant in the subgroup of patients with squamous cell carcinoma of the tongue, probably as a result of the lower number of these patients, in concordance with reports by other authors.10 In any event, there is no doubt as to the need for carrying out bilateral neck treatment in patients with midline squamous cell carcinoma of the oral cavity, due to the lower rate of contralateral neck recurrence in these patients.6,10,11

Some authors have demonstrated the association with p<0.05 between pN stage and CNM. However, although carrying out bilateral neck treatment in patients with positive ipsilateral N could arise from this study, given the scant percentage of patients who finally develop CNM, its application or not has to be established in an individual and personalized fashion.

According to other series, most patients with CNM develop this during the first two years after surgery. Only one patient presented contralateral neck recurrence after this time, as opposed to the remaining 89.9%. These data clearly indicate the need for a close following during this period of time.

To conclude, the possibility of gathering information with a prognostic factor with regard to the appearance of CNM before surgery could improve the prognosis of patients with squamous cell carcinoma of the oral cavity. This rule would help the surgeon decide among the different surgical options that are more or less aggressive. A delay in diagnosis of over 12 months from the appearance of the primary tumor, clinical stage IV tumor by TNM classification, positive ipsilateral clinical N stage, primary tumor with a poorly differentiated histopathologic grade, resection specimen with surgical margins of less than 1 cm, carrying out of ipsilateral neck dissection on its own and perineural infiltration of the primary tumor, are prognostic factors for the appearance of CNM in squamous cell carcinoma of the oral cavity. The presence of ipsilateral pathologic neck nodes at diagnosis is predictive of CNM in squamous cell carcinoma of the oral cavity and tongue. A close following for the first two years after surgery is necessary, due to the increased rate of contralateral neck recurrence during this period in patients with squamous cell carcinoma of the oral cavity.

 

 

Correspondence:
R. González García
Hospital Universitario La Princesa
Servicio de Cirugía Oral y Maxilofacial
Diego de León, 62
28006 Madrid, España.
Email: gonzalez-garcia@hotmail.com

Recibido: 12.07.2006
Aceptado: 16.06.2008

 

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