|Year : 2022 | Volume
| Issue : 4 | Page : 494-500
A clinical study of resections in oral cavity carcinomas
Amit Parasnis, Virendra S Athavale, Prachi Athavale, Benod Kumar, Omkar Gutta
Department of Surgery, Dr DY Patil Medical College, Hospital and Research Centre, Dr DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||31-Oct-2020|
|Date of Decision||10-Feb-2021|
|Date of Acceptance||27-Mar-2021|
|Date of Web Publication||02-May-2022|
Virendra S Athavale
Department of General Surgery, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Background and Aims: Oral carcinoma is one of most common cancers reported globally of which most arise in developing countries such as India. In our study, the presentation of disease in oral cavity, types of resection with closure and clinical with histopathological correlation has been described. Methods: Prospective study done in Dr. D. Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune, under General Surgery Department. Carcinomas of the oral cavity operated from July 2012 to September 2014 were included. Diagnosis was confirmed by biopsy/fine-needle aspiration cytology. Patients were subjected to appropriate surgeries, which were performed by the same surgeon and the histopathological specimens had been evaluated by the same pathologist. Results: Of the 50 patients in our study, age of the patients varied from 32 years to 91 years with highest number of patients were found in the age group of 41–50 years, with 32 (64%) patients were male accounting for male preponderance. Composite resections for the primary were done in 72% and wide local excisions in 28%. A total of 5 radical neck dissection, 40 MRND 10 Supraomohyoid neck dissection were performed according to the stage of the neck and their reconstruction. Conclusion: Oral cavity carcinomas are one of the most commonly occurring malignancies in India and most of them are detected in the low socioeconomic strata of the society. Although the distribution of primary site was varied, it was possible to achieve some uniformity in the treatment of these patients on the background of diversity in clinical presentation.
Keywords: General surgery, oral malignancy, plastic and reconstruction surgery, surgical oncology
|How to cite this article:|
Parasnis A, Athavale VS, Athavale P, Kumar B, Gutta O. A clinical study of resections in oral cavity carcinomas. Med J DY Patil Vidyapeeth 2022;15:494-500
|How to cite this URL:|
Parasnis A, Athavale VS, Athavale P, Kumar B, Gutta O. A clinical study of resections in oral cavity carcinomas. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Jul 5];15:494-500. Available from: https://www.mjdrdypv.org/text.asp?2022/15/4/494/344578
| Introduction|| |
Cancer is a disease characterized by uncontrolled, uncoordinated, and undesirable cell division. There are multiple types of cancer, many of which can today be effectively treated so as to eliminate, reduce, or slow the impact of the disease on patients' lives. Oral carcinoma is the sixth most common cancer reported globally with an annual incidence of over 300,000 cases, of which 62% arise in developing countries. The variation in incidence and pattern of oral cancer is due to regional differences in the prevalence of risk factors. About 75% of oral cancer is attributable to tobacco use and alcohol consumption. Tobacco use and heavy alcohol consumption have been proven to increase the risk of oral cancer. Squamous cell carcinoma comprises approximately 94% of all oral cavity cancers., Since most of these patients belong to lower socioeconomic strata, they often procrastinate in taking treatment and as a consequence present in advanced stage.
| Methods|| |
This is a prospective study done between July 2012 to September 2014 in Dr. D. Y. Patil Medical College, Hospital and Research Center, Pimpri, Pune, under General Surgery Department. All cases of Carcinomas of different subsites in the oral cavity operated from July 2012 to September 2014 were included. Cases of oral carcinomas which are advanced and inoperable receiving palliative chemoradiation or symptomatic treatment were excluded. A total of 50 patients have fulfilled the above criteria.
Institutional ethical committee approval was taken prior to commencement of study. (Institutional Ethical Clearance Letter reference number is DPU/209(69)/2013, dated 11/05/2013) A written and informed consent was taken from the patient after explaining details of treatment modalities. The diagnosis was confirmed by biopsy or fine-needle aspiration cytology and relevant imaging was done. Clinical tumor, node, and metastasis (TNM) staging was done. Patients were subjected to appropriate surgeries, which were performed by the same surgeon and all the histopathological specimens had been evaluated by the same pathologist.
The evaluation and analysis of the data is based on the type of surgery done with respect to type of neck dissection and type of mandibulectomy performed. The extent of surgery required with respect to the site and stage of tumor the need for reconstruction. Total number of lymph nodes dissected and the number of positive lymph nodes with or without perinodal extension with respect to the primary site and stage of the tumor.
Clinicopathological correlation of TNM staging done. Involvement of bone and distance of closest margin from the tumor in the pathological specimens which was correlated with tumor site and stage. This was correlated with tumor site and stage.
| Results|| |
Out of the 50 patients in our study, age of the patients varied from a minimum of 32 years to a maximum of 91 years. The highest number of patients were found in the age group of 41–50 years and >60 years with 36% and 30% each. Twelve patients (24%) were found in 51–60 years of age group and the minimum 5 (10%) patients were found in 31–40 years of age group.
Thirty-two (64%) patients were male followed by 18 (36%) female patients accounting for male preponderance. 78% gave the history of chewing tobacco and consumption of alcohol in 46% of cases. Twelve (24%) patients gave a history of smoking.
Of the 50 patients in the study, 30 (60%) patients the malignant lesion showed more predilection towards buccal mucosa which is the most common and correlating with the tobacco use, alveolus in 8 (16%), tongue and lip sharing 6 (12%) patients each [Table 1].
|Table 1: Association between primary site and bone involvement in study group|
Click here to view
Squamous cell carcinoma was the most common accounting for 92% population of study group. Well differentiated (46%) being the commonest, moderately differentiated (40%), poorly differentiated (6%). Verrucous cell carcinomas shared a minor percentage of 8%.
Of the 50 patients in the study bone involvement was found in 11 (22%) cases and absent in 39 (78%) patients clinically.
Composite resection done in 36 (72%) of patients. Twenty of 22 (44%) patients with T4 tumor underwent composite resections correlating with presentation of tumor in advanced stage.
Fourteen (28%) patients underwent non composite resections or wide local excisions most common with T2 and T3 group of patients sharing the study [Table 2].
|Table 2: Association between T-stage and operative procedure in study group|
Click here to view
Mandibulectomies was done dominantly in malignant lesions of buccal mucosa 22 (55.5%) patients. All the patients 8 (22%) with primary tumor of the alveolus or gingivobuccal sulcus underwent mandibulectomies because of the close proximity of the tumor with the mandible. Cases with primary lesion in the tongue and lip shared 4 (11%) patients each [Table 3].
|Table 3: Association between primary site and mandibulectomy in study group|
Click here to view
Mandibulectomy was performed in clinical suspicion of the involvement of the bone. Depending on the close proximity of the tumor and the need for reconstruction and clinical suspicion of bone involvement, 36 (72%) patients underwent mandibulectomy, hemimandibulectomy being the most common 16 (32%) dominantly in buccal mucosa lesions. Arch preserving mandibulectomies 11 (22%) done in posterior lesions and for better cosmesis. In 5 patients of buccal mucosa lesions marginal mandibulectomy was done where there is no clinical evidence of bone involvement but the lesion is in close proximity with the bone.
In 3 patients of carcinoma lip, 2 patients underwent middle 3rd mandibulectomy where the lesions are restricted to midline, 1 patient underwent extended hemi mandibulectomy where there is suspicion of lesion crossing the midline.
A total of 45 (90%) patients underwent unilateral neck dissection and 5 (10%) patients operated for bilateral neck dissections. 55 neck dissections were done in total, counting bilateral neck dissections as 2 making total as 55 in the study group. In the total study, N0 necks were 13 of which 12 patients underwent unilateral neck dissection and 1 patient underwent bilateral (Modified neck dissection + Supraomohyoid neck dissection [MND + SOHD]) because of the lesion arising from midline.
Twenty-seven patients with clinically N1 neck underwent unilateral neck dissections. There are 9 patients with N2 neck, 5 operated for unilateral and 4 bilateral (i.e., MND + SOHD in 2 patients, radical neck dissection [RND] + MND in 1 patient, RND + SOHD in 1 patient). Unilateral RND was done in 1 patient with N3 neck. 5 Bilateral neck dissections which were done in 3 cases of carcinoma tongue and 2 cases of carcinoma lip [Table 4].
|Table 4: Association between N-stage and type of neck dissection in study group|
Click here to view
Primary closure was the option in 28 (56%) cases. Reconstruction was done in total of 22 (44%) cases. T4 group of lesions 15 (30%) underwent maximum number of reconstructive surgeries. T2 group lesions 11 (22%) underwent maximum number of primary closures which is statistically significant.
Pectoralis Major Myocutaneous (PMMC) flap was done in 11 cases. T3-2, T4-9.
Masseteric flap was done in 5 cases. T2-3, T3-1, T4-1.
Split skin graft in a single T2 case
OMCF flap in a single T4 case.
PMMC and DP flap was done in 1 T4 case.
PMMC and OMCF flap was done in 1 T4 case.
PMMC and MASSETERIC flap was done in 2 T4 cases.
PMMC was the most versatile flap used most commonly in T4 lesions [Table 5].
|Table 5: Association between T-stage and type of reconstruction study group|
Click here to view
Double flaps were needed in T4 lesions owing to the use of reconstruction after surgery.
Of the total of 50 patients 35 (70%) patients underwent mandibulectomy and one patient underwent mandibulotomy, i.e., mandibular swing.
In the total 35 mandibulectomy specimens bone involvement was present clinically in 11 (22%) cases only.
In these 11 cases, bone metastasis is present in all the 11 (22%) specimens.
Total of 24 mandibulectomies were done in suspicion of bone involvement, in close proximity to the bone.
From the above 24 (48%) clinically negative mandibulectomy specimens, bony metastasis was present histopathologically in 11 (22%) specimens and absent in 13 (26%) specimens which was statistically significant encouraging the need for mandibulectomy in oral cavity carcinomas due to high propensity of invading surrounding structures [Table 6].
|Table 6: Association between primary site and level of metastasis pathological in study group|
Click here to view
In our study of 50 cases buccal mucosa tumors metastasized to all the levels without any skip metastasis with Level I (73.33%), Level II (46.67%), Level III (20%), Level IV (16.67%), and Level V (10%).
Alveolar malignancies metastasized to Level I, II, III with 75%, 62.5%, 25% respectively with no level IV and V positivity.
Malignancies of tongue metastasized unilaterally and bilaterally also with highest propensity to level I (83.33) followed by II (66.67%), III (50%), IV (16.67%) with no evidence of level V positivity.
Lesions from the lip also metastasized unilaterally and bilaterally with metastasis to all the levels I to V with level I and II sharing 66.67% each, level III having 33.33%, level IV and V sharing 16.67% each. This observation suggests when primary tumor to be treated surgically, neck dissection must be accompanied either radical or functional depending on the site of the tumor if there is suspected metastasis.
In our study of 50 cases Level I, II are clinically positive in 35 (70%), 14 (28%) cases respectively which was increased in pathological examination of the specimens accounting for 37 (74%), 27 (54%), respectively. Level III, IV were not clinically positive in any of the cases but positive pathologically in 13 (26%), 7 (14%) of the cases.
Level V was clinically positive in 1 (2%) of cases which was positive pathologically in 4 (8%) of patients.
There was no skip metastasis observed directly to Level III, IV, and V.
| Discussion|| |
Advanced oral cancers are a challenge for treatment, as they require complex procedures for excision and reconstruction. Despite being occurring at a visible site and can be detected easily, many patients present in advanced stages with large tumors. Timely intervention is important in improving survival and quality of life in these patients.
The surgical treatment of patients with carcinoma of oral cavity must include the objectives of complete tumor removal as well as maintaining acceptable quality of life for the patient by reconstruction of the excised defect.
In the present study, a total of 50 cases of oral malignancy admitted to our medical college have been analyzed and followed up for 3 months from discharge.
The highest incidence of age is seen in the 6th decade of life and lowest in the 3rd decade of life with male preponderance of 64% in the population group. Females share a percentage of 36%.
In a study by Patel and Pandya 75% of patients were males. Mehrotra et al. from Allahabad reported a male: female ratio of 3.27:1. Iype et al. from Trivandrum, Kerala, found a higher preponderance in males (70%) compared to females (30%).
In a study conducted in Maharashtra the overall highest occurrence (29.85%) was at the age group >60 years, followed by 23.54% at the age group of 50–60 years, with the lowest occurrence (4.10%) was at the age group of <30 years.
Among oral cancer, the buccal mucosa was the most common site involved (37.12%) followed by tongue (36.80%) and alveolus (12.16%). Oropharynx (4.74%), floor of mouth (2.84%), and lip and palate (3.15%) were the other sites involved in the study.
In our study among the risk forming habits, 78% had habit of tobacco chewing which was the commonest followed by alcohol and smoking 46% and 24%, respectively. A history of consuming smokeless tobacco like mishry and gutka was found in 26% and 20% each in the study group.
The most common site for oral cancer in the older age group was the buccal mucosa (37%), followed by tongue (21%), and gingiva (20%). In the younger age group, OSCC was most commonly seen on the tongue (47%), followed by buccal mucosa (22%), gingival (14%), and floor of mouth (11%) in a study conducted by Sherin et al.
In a study conducted by Jena et al. in south India the most common site of oral cancer was buccal mucosa (26.7%), gingivobuccal sulcus (20.8%), retromolar trigone (40%), tongue (50%), and floor of mouth (100%). Majority of the patients (38.5%) got oral cancer in 4th decade, followed by 35.2% patients in 3rd decade.
It is observed in various studies that anatomically more anterior parts (buccal mucosa, anterior 2/3 of the tongue, alveolus, lips, and base of tongue) are the frequently involved sites in oral cavity. Palatal carcinoma is less observed in present study owing to lower incidence of reverse smoking and the overall decline in smoking trends.
In our study, histopathologically, squamous cell carcinoma was the most common accounting for 92% population of study group. Well differentiated (46%) being the most common, moderately differentiated (40%), poorly differentiated (6%). Verrucous cell carcinomas shared a minor percentage of 8% in the study group.
Composite resection done in 72% of patients. 44% patients with T4 tumor underwent composite resections correlating with presentation of tumor in advanced stage. 28% patients underwent noncomposite resections or wide local excisions most common with T2 and T3 group of patients sharing the study.
In a study conducted by Trivedi et al. in Gujarat 75% composite resections were done and 30% wide local excisions with neck dissections in 120 cases was done which is comparable with our study. Composite resections for the primary were done in 60% and wide local excisions in 40%.
The need for composite resections correlates with the late presentation and aggressiveness of the tumor leading to cosmetic and functional disability.
In a study conducted by Deepanandan et al. all showed that irrespective of the primary location whether the buccal mucosa, floor of the mouth or the tongue, which were involving the mandible, invaded the cortical bone.
In our study, 55 neck dissections were performed in 50 cases of oral cancer. Thirteen of these were N0 necks, 27 were N1, 9 were N2, 1 patient presented with N3. A total of 5 RND, 40 MRND 10 SOHD were performed according to the stage of the neck. Primary closure was the option in 56% cases. Reconstruction was done in 44% cases. 30% of T4 group of lesions underwent maximum number of reconstructive surgeries. 22% of T2 group underwent maximum number of primary closures which is statistically significant. 22% of patients underwent PMMC reconstruction. Double flaps were needed in 8% of the total study group.
The buccal mucosa metastasized unilaterally involving all the levels of neck with a higher propensity to Level I (73.33%) followed by II (46.67%), Level III (20%), Level IV (16.67%), and Level V (10%). Lesions from the lip also metastasized unilaterally and bilaterally with metastasis to all the levels I to V with Level I and II sharing 66.67% each, Level III having 33.33%, Level IV and V sharing 16.67% each.
Malignancies of tongue metastasized unilaterally and bilaterally also with highest propensity to level I (83.33) followed by II (66.67%), III (50%), IV (16.67%) with no evidence of level V positivity. Alveolar malignancies metastasized to Level I, II, III with 75%, 62.5%, 25% respectively with no level IV and V positivity. Level I, II are clinically positive in 35 (70%), 14 (28%) cases respectively which was increased in pathological examination of the specimens accounting for 37 (74%), 27 (54%), respectively. Level III, IV were not clinically positive in any of the cases but positive pathologically in 13 (26%), 7 (14%) of the cases. Level V was clinically positive in 1 (2%) of cases which was positive in 4 (8%) of patients. There was no skip metastasis observed directly to level III, IV, and V. Chi-square test was applied for lymph node involvement in relation to primary but there was no significance revealed.
In a study conducted in Gujarat Cancer Institute during the period of 2004–2006. A total of 127 comprehensive neck dissections were performed; 71% patients underwent modified neck dissection and 30% patients underwent classical RND. Nearly 50% of the patients in each group had no nodal metastasis clinically. In all, 63 of 127 patients (50%) had no nodal disease on final HPE. Chi-square test to find out the difference between the lower alveolus and buccal lesions in the development of nodal involvement was performed and no significant difference was observed which is the same in our study. The prevalence of nodal metastasis to level V was 4% for buccal cancers and 3% for alveolar cancers. There was no case with isolated Level IV or V involvement in the absence of nodal disease at level I to III. Among those with pathologically involved nodes (pN+), levels I and II cervical nodes were the most commonly involved sites which is comparable to our study.
It is interesting to note that Woolgar has reported no metastasis at Levels IV and V among 78 patients with cancers of buccal mucosa and lower alveolus (56 of 78 patients were pT4 status) in his study of 439 patients with oral cancers.
Cervical node metastasis have variable incidence and are widely accepted as one of major prognostic factors in OSCC patients. The rate of metastasis in the cervical nodes was reported to be 35.3 − 60% in OSCC patients. Metastasis in the cervical nodes was detected in 43% of the cases (90 RND = 51 pN and 39 pN[+]) reported between 2007 and 2010.
Histopathologically, positive lymph nodes in patients were as follows: level I nodes were 50, Level II 32, Level III 15, Level IV 2, and 2 patients had Level V positive nodes. Many patients had a positive lymph node at more than one level. Node positivity was observed for different sites as follows: buccal mucosa, 31 out of 116 patients (26.7%); gingivobuccal sulcus, 25 out of 72 patients (34.7%); retromolar trigone, 4 out of 10 patients (40%); tongue, 5 out of 10 patients (50%); and floor of mouth, 1 out of 1 patient (100%).
Carcinomas of the oral cavity rarely spread to lower jugular or posterior cervical nodes in the absence of involvement of level I-III. An elective SND (Levels I–III) provides staging information and may be the only therapy necessary for occult disease. It has minimal morbidity and it reduces the risk of occult disease evolving into clinically evident metastases. Both sides of the neck have to be addressed in midline, or near the midline primaries. Nevertheless, as stated in the guidelines of oral cavity cancer neck dissections should be performed as part of the concept to complete the oncological therapy of this complex tumor entity including its biological behavior.
Reconstruction of oral cavity defects can be challenging due to the need for preservation of function and recreation of the esthetic appearance of the lower third of the face. Oral cavity defects from oncologic resection can be characterized by their subsite. The surgeon will then consider the original function, size, location, soft tissue and/or bony involvement of the defect and refer to the reconstructive ladder.
Primary closure is simple and preferred for smaller defects in area where soft tissue is easily advanced together without fear of excessive tethering. Defects of about 30% of the oral tongue are best closed primarily, as this shows superior function compared to the placement of flaps which is done in our study.
Most buccal carcinomas present at advanced stage resulting in larger full thickness or composite defects. Flap reconstruction should be inset with the mouth in maximal opening to prevent debilitating trismus. Reconstruction of soft tissue only defects can be accomplished with regional myocutaneous flaps like PMMC.
Composite defects that include soft tissue and bone can be reconstructed with osteocutaneous flaps.
| Conclusion|| |
Oral cavity carcinomas are one of the most commonly occurring malignancies in India and most of them are detected in the low socioeconomic strata of the society due to paucity of tertiary cancer treatment centers, most of these patients will report to the nearest medical college for treatment. From our study, we can conclude that it is easily possible to undertake the surgical treatment of such patients in a medical college.
It is observed in our study that the highest incidence of oral carcinoma is seen is male and highest during the 6th decade of life.
It was noted that there was a variable gap between the onset of symptoms and reporting for treatment and although most patients presented with large tumor volume, it was possible to do a complete resection of the tumor.
It was observed that there were discrepancies in clinicopathological correlation of lymph node positivity and the number of positive lymph nodes in the level IV and V region was more than the expected incidence.
Despite having access to limited modalities of reconstruction, these patients demonstrated a significant increase in the quality of life after surgery.
Although the distribution of primary site was varied, it was possible to achieve some uniformity in the treatment of these patients on the background of diversity in clinical presentation.
The study was approved by Institutional Ethics Committee of Dr. D Y Patil Institution of Medical Science and Research Centre before the commencement of the study.
Informed consent was obtained from the patients, and approval was obtained from the designated review board of the institution involved.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kulkarni MR. Head and Neck Cancer Burden in India. Int J Head and Neck Surg 2013;4:29-35.
Elango JK, Gangadharan P, Sumithra S, Kuriakose MA. Trends of head and neck cancers in urban and rural India. Asian Pac J Cancer Prev 2006;7:108-12.
Pfister DG, Ang K, Brizel DM, Burtness B A, Cmelak AJ,Colevas A, et al
. Head and neck cancers. J Natl Compr Netw 2011;9:596-650.
Kowalski LP, Carvalho AL. Influence of time delay and clinical upstaging in the prognosis of head and neck cancer. Oral Oncol 2001;37:94-8.
Patel MM, Pandya AN. Relationship of oral cancer with age, sex, site distribution and habits. Indian J Pathol Microbiol 2004;47:195-7.
Mehrotra R, Singh M, Kumar D, Pandey AN, Gupta RK, Sinha US. Age specific incidence rate and pathological spectrum of oral cancer in Allahabad. Indian J Med Sci 2003;57:400-4.
] [Full text]
Iype EM, Pandey M, Mathew A, Thomas G, Sebastian P, Nair MK. Oral cancer among patients under the age of 35 years. J Postgrad Med 2001;47:171-6.
] [Full text]
Giri PA, Singh KK, Phalke DB. Pattern of oral cancer registered at a tertiary care teaching hospital in rural Western Maharashtra. Int J Res Med Sci 2013;1:233-6.
Sherin N, Simi T, Shameena PM, Sudha S. Changing trends in oral cancer. Indian J Cancer 2008;45:93-6.
] [Full text]
Jena A, Patnayak R, Vamsi RN, Reddy SK, Banoth M. Surgical management of the neck in oral cancers: A single institute experience from South India. Arch Int Surg 2013;3:106.
Trivedi NP, Trivedi P, Trivedi H, Trivedi S, Trivedi N. Optimizing multimodality treatment for head and neck cancer in rural India. Indian J Cancer 2012;49:225-9.
] [Full text]
Deepanandan L, Narayanan V, Baig MF. Mandibular invasion of squamous cell carcinoma: Factors determining surgical resection of mandible using computerized tomography and histopathologic study. J Maxillofac Oral Surg 2010;9:48-53.
Narendra H, Tankshali RA. Prevalence and pattern of nodal metastasis in pT4 gingivobuccal cancers and its implications for treatment. Indian J Cancer 2010;47:328-31.
] [Full text]
Woolgar JA. The topography of cervical lymph node metastases revisited: The histological findings in 526 sides of neck dissection from 439 previously untreated patients. Int J Oral Maxillofac Surg 2007;36:219-25.
Acharya S, Sivakumar AT, Shetty S. Cervical lymph node metastasis in oral squamous cell carcinoma: A correlative study between histopathological malignancy grading and lymph node metastasis. Indian J Dent Res 2013;24:599-604.
] [Full text]
Mücke T, Mitchell DA, Wagenpfeil S, Ritschl LM, Wolff KD, Kanatas A. Incidence and outcome for patients with occult lymph node involvement in T1 and T2 oral squamous cell carcinoma: A prospective study. BMC Cancer 2014;14:346.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]