Prof.S.M.Haider Faisal Hameed Wahab Kadri NECK DISSECTION; AN ESSENTIAL TOOL IN THE MANAGEMENT OF ORAL SQUAMOUS CELL CARCINOMA IN PAKISTAN Prof.S.M.Haider Faisal Hameed Wahab Kadri

Oral cancer is a 6th lading cancer worldwide Every year, more than 300 thousand new cases of oral cancer are diagnosed and unfortunately among them 126 thousands dies Squamous cell carcinoma is the predominant form of oral cancer

Oral cavity squamous cell carcinoma is the sixth leading cause of cancer worldwide . It accounts for 0.6% to 5% of all cancers in Europe, United States, and Australia, respectively, but up to 45% of cancers in sub- continent ] Landis SH, Murray T, Bolden S, et al. Cancer statistics, 1999. CA Cancer J Clin 1999;49:8–31. Tytor M, Olofsson J. Prognostic factors in oral cavity carcinoma. Acta Otolaryngol 1992;(Suppl 492):75–8

The most important prognostic factor in the management of oral squamous cell carcinoma is the status of the cervical lymph nodes . The presence of metastasis to cervical lymph nodes can reduce the cure rate by 50%. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg 1990;160:405–9

Rationale for the Elective Neck Dissection Level I 20% II 17% III 9% IV 3% V 0.5% 192 patients  resection + Elective RND 34% had positive nodes----Shah et al., Cancer, 1990 Study Conducted at our center showed 20% had positive nodes

Byers et al noted a skip metastasis rate of 15% to level IV in squamous cell carcinoma of the oral tongue and advocated that dissection of level IV should be included in a selective neck dissection. Recently it has been demonstrated that level IV need be dissected only if there are suspicious nodes in level II or III. Khafif A, Lopez-Garza JR, Medina JE. Is dissection of level IV necessary in patients with T1–3 N0 tongue cancer? Laryngoscope 2001;111:1088–90

Relying on evolving literature and better understanding of cervical lymphatic drainage patterns SOHND was performed in patients with oral SCC with NO neck.

The aim of this study was to evaluate the efficacy and outcome of a common SND-supra-omohyoid neck dissection (SOHND) with or without adjuvant radiation therapy in the management of cervical metastasis in squamous cell carcinoma of the oral cavity.

Material & Methods Two year Prospective analysis of 61 consecutive patients of oral squamous cell carcinoma with clinically Node Negative neck who underwent SOHND.

Exclusion Criteria Persistent or recurrent disease after any oncological treatment, such as chemotherapy, radiation therapy or surgery. Patients planned to have SOHND initially but converted to MRND based on Intra Operative frozen section pathology

Results Average number of lymph nodes dissected were 21/ side in SOHND group

AGE DISTRIBUTION n=61 The average age of the patients was 47.41±12.21 years (95%CI: 44.28 to 50.54) The average age of the patients was 47.41±12.21 Age

GENDER DISTRIBUTION n=61 75% were male patients and 25% were female

Duration of habit (Years) Descriptive Statistics n=61 Variables Mean ± SD 95%CI Median (IQR) Max-Min Age (Years) 47.41 ± 12.21 44.28 to 50.54 46(15) 75-25 Duration of habit (Years) 23.43 ± 9.46 21 to 25.85 20 (15) 35-15 These are the descriptive statistics with respect to age and duration of habits showing mean, median and the lemits

DURATION OF HABIT (years) PERCENTAGE Around 44% patients are prone to their oral habits for more then 20 year DURATION OF HABIT (years)

NECK DISSECTIONS ( 11 patients) ( 50 patients) Regarding neck dissection 50 patients gone through complete SOHND and11 neck dissections were converted into functional or modified redical neck dissection ( 11 patients) ( 50 patients)

In this study FREQUENCY OF CERVICAL LYMPH NODE METASTASIS was found to be 34%

41% 59% RADIATION Reasons for Metastasis 25 Patients 36 Patients Nodal metastasis, Close margins Advance Primary tumor 41% 25 patients i.e 41 % gone through radiations reasons for radiations were the same as mentioned earlier 59% 25 Patients 36 Patients

Cervical Lymph Node Metastasis NODAL METASTASIS & HABIT DURATION Duration of Habit n Cervical Lymph Node Metastasis Percentage ≤ 15 Years 16 3 18.8% 16 to 20 Years 18 10 55.6% >20 Years 27 9 33.3% Nodal involvement is also found irrespective to duration of habits

Of the 3 neck recurrence cases, 2 (66 Of the 3 neck recurrence cases, 2 (66.66%) occurred within the limits of previous SOHND, and he died of diseases within 1 year after detecting the neck recurrence One (33.33%) recurrence occurred on the Contralateral neck which was successfully salvaged by MRND In 2 years follow up 3 neck recurrence cases, 2 within the limits of previous SOHND One recur in contralateral neck which was successfully salvaged by MRND

Occult Metastasis with respect to tumor size Count Interestingly no nodal involvement found at T1 level while 7 pts. at T2 level 11 at T3 & 3 at T4 level Tumor Size

Lymph node involvement Tumor Depth & Nodal Involvement Lymph node involvement Tumor Depth Total ≤ 5 mm > 5 mm Involvement 13.11 % 8 21.31% 13 34.42 % 21 No involvement 6.55 % 11 59.01% 29 65.57 % 40 Tumor depth is considered as a independent predictor of nodal metastasis in various articles but in our study mix results are shown at tumor depth < 5mm and >5mm Patients Patients Patients Patients Patients Patients

DISCUSSION High Incidence 61 patients Occult metastasis 34% T1 & T2 33.33% T3 & T4 66.66% Oral Oncology 38 38 (2002) 309–312. Efficacy of supraomohyoid neck dissection in patients with oral squamous cell carcinoma and negative neck Shibin et al 34.7% In this series of 61 patients, the occult cervical metastatic rate was 34%. Which is comparable to study by shibin et al This high incidence of occult cervical metastasis stands for elective treatment of neck in clinically negative neck This high incidence of occult cervical metastasis stands for elective treatment of neck in clinically negative neck

In our study, the overall regional control rate achieved in Node Negative patient was 95.1%. Case of SOHND overall control is 96.7% SOHND appears to have a therapeutic role in patients with PN ( - ) neck Oral Oncology 38 38 (2002) 309–312. The role of supraomohyoid neck dissection in patients of oral cavity carcinoma S.-P. Hao, N.-M. Tsang 93.4% In our study, the overall regional control achieved is 95.1%. Which is comparable with study by SP HAO While in case of SOHND overall control is 96.7% So it appears to have a therapeutic role in patients with no neck disease and addition of radiotherapy did not significantly improve the regional control rate Oral Oncology 38 38 (2002) 309–312. Efficacy of supraomohyoid neck dissection in patients with oral squamous cell carcinoma and negative neck Shibin Yu et al 94.4%

The dilemma Only 30-35% of patients have occult metastasis So 65-70% of patients have an “unnecessary” procedure BUT It allows us to stage the patient Can be therapeutic in early stage neck disease For free flaps

Conclusion SOHND is both a diagnostic and therapeutic procedure in PN ( - ) oral squamous cell carcinoma patients Adjuvant postoperative radiation therapy may significantly improve control Neck Disease as neck recurrence may be beyond salvage.