Buccal carcinoma commonly presents as a slow-growing mass on the buccal mucosa. Small lesions tend to be asymptomatic and are often noted surprisingly on dental examination. Pain commonly occurs as the lesion enlarges and ulceration develops. Oral intake may worsen the pain and lead to malnutrition and dehydration. Associated symptoms include bleeding, poor denture fit, facial weakness or sensory changes, dysphagia, odynophagia, and trismus.
A detailed medical history is important to determine the patient’s candidacy for surgery or radiation therapy. The person often has a history of betel nut chewing, tobacco, and alcohol use. A history of previous malignancies of the upper aero digestive tract should be ascertained. The appropriate management of the neck in patients with squamous head and neck cancers is critically important because the presence of cervical metastasis is the most powerful independent indicator of locoregional recurrence and overall survival rate. Clinically undetectable nodal metastasis is the worst possible scenario for treatment failure. Incidence of neck metastasis in oral SCC is reported to be 34% to 50%[13, 14].
Sixty patients with squamous cell carcinoma (SCC) fulfilling the inclusion criteria who presented in the Department of Oral & Maxillofacial Surgery in 6 months’ duration of this study were included. Forty-five (75%) patients were men; 15 (25%) patients were women. The male:female ratio was 3:1, this shows male predominance which is in agreement to earlier studies by Amador et al.. This is probably due to the fact that in Southeast Asia, snuff dipping and other tobacco-related habits are more common among men compared to women. However, gender of the patient does not significantly influence the survival rate. Among the total 60 patients reported in our study, mean age was 56.55 years. Similar results have been found by Manuel et al. that SCC is a disease of middle age from the third to fifth decades.
SCC can involve any of the oral subsites and each primary site of the tumor has its own significance regarding the behavior of the tumor and its growth pattern as well as metastasis to cervical lymph nodes. Buccal mucosa is a very common presenting site of oral SCC, the higher rates of buccal mucosa carcinoma in Pakistan are likely related to the widespread practice of betel nut chewing and snuff dipping. Betel nut, composed primarily of the fruit of the areca palm and often mixed with tobacco, is placed along the buccal mucosa to induce a feeling of euphoria. Buccal carcinoma related to betel nut chewing tends to develop at an earlier age, with most cases occurring between the ages of 40 and 70 years.
The time of presentation of the cases was very late as compared to the previous other studies and most of the cases were T4 73.3% (n=44), followed by T3 lesions which were 16.7% (n=10), and only 10% (n=6) cases were T2 lesions in our case series.
In cases of oral SCC, metastasis in the cervical lymph nodes may occur even in T1 or T2 cases of primary tumor, which is a problem when establishing a therapeutic regimen. However, a possible predicting factor has not been established. Although control of the primary tumor of the oral cavity, particularly in the early stages, is often achieved, treatment failure frequently results from recurrence in the cervical lymph nodes, even among patients who initially present with no clinical evidence of neck disease. In the present study, we found that the incidence of metastasis in lymph nodes in T4 (n=44) was the highest, that is level I was 100% (44/44), level II was 43.18% (19/44), level III was 15.90% (7/44), and level IV was 4.5% (2/44); level V was free of any metastatic evidence of the disease. Among T3 (n=10) lesions, incidence of metastasis in level I was 100% (10/10), level II was 20% (2/10), and levels III, IV, and V were free of metastasis. Among T2 (n=6) lesions incidence of lymph node metastasis in level I was 100% (6/6) and all other levels of lymph nodes were found free of the disease so the above said results coincides with the results of Tzu-Chen et al..
Also the previous studies support our finding that tumor size is a predictor of lymph node metastasis though they propose that tumor thickness is a more reliable factor[19, 20]. This is further explained by Di Troia who points to difficulty for the tumor emboli to form in small caliber lymphatics of the superficial areas, compared with wider lymphatics of deeper tissues. However, tumor thickness is a radiological or histological parameter, which cannot be assessed preoperatively by clinical examination or biopsy[21–23].
This study was very selective in the sense that we selected patients only with N1 disease. On ethical grounds, patients fulfilling the criteria for functional neck dissection were only selected. There is an important controversy in treatment of neck in cases of oral cavity carcinoma as to whether to perform radical, modified, or selective neck dissection. If selective neck dissection is to be carried out, which levels need to be removed? Radical neck dissection produced significant long-term morbidity and deformity secondary to sacrifice of the spinal accessory nerve, sternocleidomastoid muscle, internal jugular vein (particularly if bilateral), and to the large incisions, skin flaps, and extent of resection. Shoulder dysfunction, paraesthesia, and chronic neck and shoulder pain were, and still are, sequelae of the radical neck dissection.
As the world is moving towards more and more conservative and less invasive approaches in treatment of oral cavity carcinomas, supraomohyoid neck dissection with the removal of level I, II, and III lymph nodes is advocated by many surgeons. Supraomohyoid neck dissection has been quite satisfactory regarding clearance of metastatic nodes, in context to 5-year survival and recurrence rates. We have found that level IV involvement in our study and we recommend removal of level IV lymph nodes along with the removal of levels I, II, and III. Many studies support that level IV must also be removed along with levels I to III. Few studies showed involvement of level IV lymph nodes <10% of the cases[6, 25]. In another study, level IV involvement was found to be 7%. We have found the involvement of level IV nodes in 3% of the cases, so we advocate selective neck dissection (levels I to IV) in patients presenting with buccal mucosa carcinoma with N1 neck disease.