CASE REPORT

The lymph node neck metastasis in oral cancer and elective neck dissection as method of the choice
M. Alkhalil1, A. Smajilagic2, A. Redi3 Department of Surgery, Plastic-Reconstructive & Craniomaxillofacial Surgery, Hamad Medical Corporation, Doha, Qatar; 2Department of Maxillofacial Surgery, Clinical Center of the University of Sarajevo, Bosnia and Herzegovina; 3Department of Biology and Human Genetics, School of Medicine, University of Sarajevo, Bosnia and Herzegovina
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ABSTRACT A report of 10 patients who suffered from oral cancer and underwent radical excisions of the oral cancer lesion with functional neck dissection at the Department of Plastic Reconstructive and CranioMaxilloFacial Surgery, Hamad Medical Corporation Doha, Qatar from 2003 to 2004 was presented. Five of each, males and females were involved with the average age of 47,2 years. Five patients had positive cervical lymph nodes proven by ultrasound examination. Metastases were detected in only one case. The two of other five cases showed positive nodes in contrast to negative ultrasound. The level II of the neck was found in two cases and level I in one case. A prophylactic elective neck dissection in patients with a clinically negative node neck achieved better disease-free survival. Key words: oral cancer, lymph node metastasis, neck dissection, clinical data

INTRODUCTION Between 90 and 95 percent of all cases of oral cancer arise from the cells of the oral mucosa (1). However, the signs and symptoms of oral cancer are relatively easy to see and feel, and easy to watch (2). The main routes of the cervical lymph node spreading go through the first station nodes (Level I and II) and second station nodes including the Level III, IV, and V (3). Predicting the lymphatic spread can help in choosing the appropriate surgical procedure and may also help in predicting the outcome (4). In the case of the lymph node metastasis, neck dissection should be performed (5). With modern approaches, a surgeon can successfully ablate large posterior oral cavity tumors and with reconstructive methods can achieve satisfactory functional results. In this report we presented results of the operative treatment of 10 patients with oral cancer.

CASE REPORT Between March 2003 and July 2004, 10 patients from the Department of Plastic Reconstructive and CranioMaxillo-Facial Surgery, Hamad Medical Corporation, Doha Qatar, underwent primary surgery for the treatment of the oral cavity carcinoma. The records with variable data according to age, sex, histopathology level grade and Tumor-Node-Metastasis (TNM) classification were collected from patients files. After pre-operative biopsy-proven carcinoma of the oral cavity and ultrasound examination of the neck defining the size and site of the mass as potential node metastasis, tumor resection and functional neck dissection were performed in all patients. Distant metastases were excluded by chest radiography. Male female ratio was 1:1. The patients age ranged from 33 to 75 years with the average of 47,2 years. Eight patients underwent ipsilateral neck dissection, out of which six were functional and two supraomohyoid, and two were bilateral functional and supraomohyoid neck dissection. Histopathological examination of the excised specimens showed that most common type of carcinoma was moderately invasive differentiated squamosus cell carcinoma found in 94

Corresponding author: A Redi Department of Biology and Human Genetics, School of Medicine, University of Sarajevo, ekalua 90, 71 000 Sarajevo, Bosnia and Herzegovina; Tel/Fax: + 387 33 534819/ +387 33 203 670 E-mail: amira_redzic@yahoo.com

Medicinski glasnik, Volume 4, Number 2, August 2007 seven patients. Well-differentiated squamosus cell carcinoma and verrucosus carcinoma detected in one and the two patients, respectively. In five patients ultrasound examination showed enlarged nodes in different levels, only one with the T1N2M0 determinate stage, and histopathologic analysis confirmed metastatic lymph node. Ultrasound examination did not detect enlarged nodes in other five patients, but histopathological metastases were confirmed in two cases with T1N0M0 stage. All metastatic lymph nodes were detected in moderately differentiated Squamosum Cell Carcinoma (SCC). Level II of the neck region was commonly affected (in two patients) and Level I neck region in one patient. The metastases have not been observed in either Level III or Level IV. None of the patients had a positive resection margin. All resected margins had between 1 to 2 cm free edges. The median follow-up was 12 months and all patients were in good conditions with no recurrence. Carcinoma of the oral cavity has a great potential for metastatic spread to neck lymph nodes with incidence reported to be 34% to 50% (6). While the importance of treatment of the neck in clinically detected lymph nodes is beyond doubt, elective treatment of the clinically negative neck continues to bring controversy (7). Our results correspond to the result by Nithya, who found that Level II was the most commonly involved REFERENCES
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site (63,3%) in the patients with SCC of the oral cavity (6). Shah had documented similar results (8). On the contrary, Byers et al showed that 16% of patients with the oral cancer had metastasis in level IV without nodes in level I, II or III (9). Kligerman reported that from total 67 patients group who had undergone resection plus elective neck dissection developed fewer neck recurrences than those on which resection was performed alone (24% versus 42%) . The disease-free survival rate at 3.5 years in his study for the group treated with the elective neck dissection was 72% compared with 49% in the group treated with the resection alone (10). In our report all patients were treated with elective neck dissection and rate of metastasis was higher in patients with no ultrasound detected enlarged nodes than in patients with ultrasound detected nodes. Low sensitivity and specificity value of ultrasound examination strongly favor elective neck dissection as the only method for clearl diagnosis and prediction of the neck metastases (11). The role of elective treatment of the clinically negative neck in the management of early cell carcinoma of the oral cavity remains a controversial subject. The high incidence of occult cervical metastases , poor salvage rates (12,13,14) and the increased incidence of extracapsular spread in cases that have developed palpable lymphadenopathy (15) provide a strong argument in favor of elective treatment of the neck.

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