The Laryngoscope Lippincott Williams & Wilkins, Inc.

2006 The American Laryngological, Rhinological and Otological Society, Inc.

Cervical Metastasis From Squamous Cell Carcinoma of the Maxillary Alveolus and Hard Palate
Alfred A. Simental, Jr., MD; Jonas T. Johnson, MD; Eugene N. Myers, MD

Objectives: Squamous cell carcinoma has a predilection for regional lymphatic metastasis. The occurrence of occult cervical metastases from squamous cell carcinoma of the hard palate and maxillary alveolar ridge has not been studied systematically. We have observed many patients who have returned after resection of a primary cancer in these sites with a delayed cervical metastasis. Some of these patients have died of regional or distant metastasis despite control of their primary cancer. Methods: We have studied 26 patients with squamous cell carcinoma of the maxillary alveolar ridge and hard palate to define incidence of cervical metastasis. Results: Overall incidence of cervical metastasis was: clinical 2 of 26 (7.6%) and occult 7 of 26 (27%) for a total of 9 of 26 (34.6%). The 5-year disease-specific survival was 13 of 22 (59%). Surgery for regional failure was successful in 66% (6 of 9). Radiation was administered after surgery in eight of nine patients. Conclusion: Cervical metastasis from cancer of the palate and alveolar ridge is significant. Regional surgery for recurrent disease usually requires radical or modified radical neck dissection. Selective elective neck dissection should be offered to patients with cancer of the hard palate and alveolar ridge. It affords the patient and the treatment team valuable histologic information, which may help to guide therapy and reduce the potential need for future hospitalization, chemoradiation, and more radical surgery. Key Words: Alveolar ridge, cervical metastasis, maxillary, squamous cell carcinoma. Laryngoscope, 116:16821684, 2006

apparent or be present as an occult focus of carcinoma. Untreated occult metastases manifest themselves as delayed regional recurrence despite control of the primary. Proper treatment planning for these cancers requires knowledge of the incidence of occult metastases from various sites in the head and neck. The incidence of occult metastasis from the hard palate and maxillary alveolar ridge has not been studied systematically. There are very little clinical data published on the actual incidence of cervical metastasis from these individual subsites, but the rate is generally perceived to be low. Over the past 2 decades, we have observed patients after resection and control of a primary cancer in the upper alveolar ridge/hard palate develop delayed cervical metastasis. Some of these patients have died of regional or distant metastasis despite control of their primary cancer. This retrospective study presents data from patients with squamous cell carcinoma of the maxillary alveolar ridge and hard palate.

METHODS
After approval of the University of Pittsburgh Institutional Review Board, The University of Pittsburgh Department of Otolaryngology Cancer Registry was searched for patients with previously untreated squamous cell carcinoma arising in the hard palate or maxillary alveolus from March 1974 through May 1999. All patients were followed for a minimum of 24 months or until death. Patients were stratified according to first site of recurrence. Patients with more than one site of recurrence were classified according to the recurrence closest to the primary site. Deaths resulting from intercurrent disease were analyzed on the basis of time to recurrence. Patients dying with recurrent disease present were assumed to be failure of therapy. Patients dying of intercurrent disease earlier than 24 months with no evidence of disease were counted as indeterminate and were excluded for inadequate follow up. Patients dying of intercurrent disease after 24 months who were free of recurrent disease were considered cured. Successful salvage was considered if patients were alive at least 24 months after treatment of recurrence. Sixty-one patients were identified. Thirty-five patients were excluded as a result of previous malignancy, inadequate follow up, indeterminate records, or tumors that involved the oropharynx or mandible. This resulted in 26 evaluable patients for analysis of incidence of cervical metas-

INTRODUCTION
Squamous cell carcinoma, the most common malignancy of the oral cavity, has a predilection for regional lymphatic metastasis. The metastasis may be clinically

From the Department of Surgery (A.A.S.), Loma Linda University, Loma Linda, California, U.S.A.; and the Department of Otolaryngology (J.T.J., E.N.M.), University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A. Editors Note: This Manuscript was accepted for publication June 5, 2006. Send correspondence to Dr. Alfred A. Simental, Jr., Department of OtolaryngologyHead and Neck Surgery, 11234 Anderson Street #2584, Loma Linda, CA 92350, U.S.A. E-mail: asimenta@ahs.llumc.edu DOI: 10.1097/01.mlg.0000233607.41540.28

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TABLE I. Clinical and Pathologic Staging.

Initial Clinical Staging Pathologic Staging Current Status

TABLE III. Clinical Follow-up.

No. Average Follow Up Range of Follow Up

Patients (N) T stage T1 T2 T3 T4 N stage N0 N1 N2 N3 M stage M0 M1 Site Maxillary alveolus Hard palate

26 7 15 1 3 23 3 0 0 0 0 13 13

26 8 13 2 3 23 3 0 0 0 0

No evidence of disease Dead of disease Died of other causes Indeterminate Cured AOD*
*AOD

10 10

96 months 33 months

29183 months 7138 months

2 2 2

3.5 months 132 months 67.5 months

07 months 66198 months 6471 months

alive without disease.

tasis. Twenty-four of these twenty-six patients were eligible for follow-up analysis regarding survival and patterns of recurrence.

RESULTS
The average follow up in these 26 patients with squamous cell carcinoma of the hard palate and maxillary alveolar ridge was 65.4 months (range, 0 198 months), which included one patient who died perioperatively after pathologic nodal disease had been detected. Pathologic staging resulted in the altered T staging of five patients (Table I). Three patients were staged N and were confirmed by lymph node biopsy in one and therapeutic neck dissection in two. Elective neck dissection (END) was performed in three patients and all were found to be pathologically N0. Observation of the regional lymphatics was used in the 20 remaining patients, clinically staged as N0. Thus, the clinically and pathologically positive nodal disease at the time of initial surgery was three of 26 (11.5%). Two patients died in the first 7 months with no evidence of disease. One patient died perioperatively from pancreatitis but was pathologically node-positive. Another patient found to be N0 by END died of other causes at 7 months. Because the lymph node status for both patients was known, these two patients were included in the anal-

TABLE II. Patterns of First Recurrence. Patterns of First Recurrence (N Local Regional Distant Second primary None 24) 7 (29.2%) 7 (29.2%) 1 (4.1%) 2 (8.3%) 7 (29.2%)

ysis of lymph node metastasis but were excluded from survival data. Local failure was observed in seven of 24 patients as the initial site of recurrence (Table II). Two patients experienced a regional recurrence, in which the neck recurrence was subsequently followed by local recurrence 2 and 4 months later. It is assumed that the regional recurrence was a result of persistent local disease. Surgical salvage for recurrence at the primary site was successful in 33% (two of six), with 58 and 62 months of follow up, respectively. Four of the six recurrences at the primary site died of uncontrolled disease at an average of 3.3 months after initial recurrence. One patient experienced distant metastasis to both the lung and bone despite locoregional control. Two patients developed second primary neoplasms. Regional failure, despite local control, was observed in seven of 24 patients as the first site of recurrence at an average of 10.4 months (range, 125 months). Salvage treatments consisted of modified radical neck dissection in one patient and radical neck dissection in six patients. Surgical salvage and postoperative radiation therapy for regional failure was successful in five of seven (71%) patients. Postoperative radiation therapy was administered after surgical salvage in six of seven patients. One patient did not receive postoperative radiation because of the development of widespread metastasis to the lung, resulting in death 4 months after initial recurrence. Another patient developed metastasis to the liver and died of disease at 45 months from recurrence. The patients experiencing regional recurrence as site of first failure were felt to represent occult metastasis. Thus, the overall incidence of cervical metastasis was clinical in 2 of 26 (7.6%) and occult 7 of 26 (27%) for a total of 9 of 26 (34.6%). Overall outcome at the conclusion of the study was as follows (Table III). At the completion of the study period, 10 patients were alive with no evidence of disease with an average follow up of 96 months (range, 29 183 months), 10 patients were dead of disease at an average of 33 months (range, 7138 months), and two patients were alive after recent salvage 9 and 61 months after initial treatment. Four patients died of other causes. Two were classified as indeterminate: one patient, staged both clinically and pathologically as T4N1, died in the immediate perioperaSimental et al.: Cervical Metastasis From SCC

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tive period of pancreatitis as a result of chronic alcoholism, whereas the second died 7 months posttreatment. Two patients died of other causes 66 and 198 months after treatment and were considered cured, one of which had successful salvage of cervical recurrence 2 months after initial treatment. In 21 patients who were followed 5 years or to death from disease, 5-year survival was 12 of 21 (57%). Patients were excluded from this analysis as a result of perioperative death from other causes in two patients and less than 60 month follow up in three patients.

study, we were unable to evaluate the value of adjuvant radiation for the primary or regional disease at any statistical level as a result of the limited numbers and that fact that only the patients with recurrent disease-positive margins, invasion of bone, or perineural spread tended to receive radiation.

CONCLUSION
The overall incidence of cervical metastasis from cancer of the palate and alveolar ridge is significant (34.6%). Regional salvage surgery consists of radical and modified radical neck dissections. Elective neck dissection may be offered to patients with cancer of the hard palate and alveolar ridge, affording the patient and the surgical team the valuable histologic information needed to guide adjuvant therapy and reduce the potential need for future hospitalization and morbidity from more radical therapies.

DISCUSSION
There are little data specifically reporting on metastasis from squamous cell carcinoma arising on the maxillary alveolar ridge and hard palate. We report only patients with a cancer confined to the maxillary alveolus and hard palate and only squamous cell carcinoma in an effort to specifically evaluate the risk of regional metastasis from these subsites. A high incidence of cervical metastasis (30%) observed in the subsites of tongue and floor of mouth cancer has been well documented.13 Our observed data suggest the behavior of squamous cell carcinoma of the hard palate and alveolar ridge to be similar to other oral sites such as the tongue and floor of the mouth. Recent retrospective reports from our institution document that END reduces the incidence of cervical node recurrence (P .001), reduces the need for salvage therapies, and is associated with modest improvement in survival (P .05).4 We acknowledge that the therapeutic benefit of END is controversial at best, especially because the majority of patients (71%) who recurred with cervical metastasis were successfully treated when regional disease appeared.5 However, salvage consisted of modified or radical neck dissection rather than selective neck dissection. There is clear evidence that the functional outcome is better and the morbidity is less with selective neck dissection.6 8 In addition, when patients have a recurrence, they require a second hospitalization and recovery times, which increases overall treatment package time and impacts their remaining quality of life as they recuperate for a second time. Recurrence at the primary site appeared to represent a worse outcome than that of regional recurrence. In this

BIBLIOGRAPHY
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