Resection of the submandibular gland is generally undertaken as an integral component of level I neck dissection for oral cancer. However, it is unclear whether lymph nodes are present within the submandibular gland which may form the basis of lymphatic spread. Our purpose was to investigate the frequency of lymph nodes within the submandibular gland, and the incidence and mechanism of submandibular gland involvement in floor of mouth cancer. Retrospective review of 177 patients with oral cancer undergoing neck dissection. Original pathology slides of floor of mouth cases were re-reviewed by two pathologists to determine frequency of intraglandular lymph nodes, and incidence and mechanism of submandibular gland involvement by cancer. The overall incidence of cervical metastases was 36.4 %, of whom 44 % had level I metastases. Level I metastases were significantly more common in floor of mouth than tongue cancers (p = 0.004). Among 50 patients with floor of mouth cancer undergoing re-review of pathology slides, intraglandular lymph nodes were not found in any of 69 submandibular glands. Submandibular gland involvement by cancer was present in two patients, representing 1 % of all oral cancers, and 4 % FOM cases. Mechanisms of involvement were direct extension, and by an apparent novel mechanism of carcinoma growing along bilateral Wharton’s ducts. Despite the high incidence of level I metastasis in floor of mouth, lymphatic metastases to submandibular gland are unlikely based on absence of intraglandular lymph nodes. We describe a previously unreported mechanism of submandibular gland involvement.

Incidence of intraglandular lymph nodes within submandibular gland, and involvement by floor of mouth cancer.

Metastasis to submandibular glands in oral cavity cancers: Can we preserve the gland safely?

Objectives/Hypothesis
Preservation of the submandibular gland (SMG) during a neck dissection is gaining popularity and is showing an increasing tendency. The potential benefit, if the SMG is preserved, can be manifold. The aim of this study was to assess the benefit of the preservation of the SMG and the associated risk of recurrent disease in patients with oropharyngeal or oral cavity squamous cell carcinoma.

Study Design
Retrospective data analysis of 168 patients, with a follow-up of at least 3 years.

Methods
Log-rank test, univariate, and multivariate data analyses and P values for prediction of the excision of SMG on overall-, recurrence free-, and lymph node recurrence free survival.

Results
In patients with cancer of the floor of the mouth or tongue, lymph node recurrence-free survival was highly influenced by excision of the SMG (P < 0.001) and occurred in 28.5% of patients in whom the SMG was preserved. In all other tumor sites of the oral cavity and oropharyngeal region, excision of the SMG did not influence lymph node recurrence-free survival (P = 0.455).

Conclusions
Patients with squamous cell carcinoma (SCC) of the oral cavity or oropharyngeal region will benefit from preservation of the ipsilateral SMG. This is not true for patients with SCC of the surrounding tissue nearest the SMG (i.e., floor of the mouth or the tongue). In such patients, the SMG must be excised.

Level of Evidence
4. Laryngoscope, 124:2070–2074, 2014

Preservation of ipsilateral submandibular gland is Ill advised in cancer of the floor of the mouth or tongue

The growth of aging populations in an increasing number of countries has led to a concomitant increase in the incidence of chronic diseases. Accordingly, the proportion of older aged patients with oral cavity and oropharyngeal cancers and comorbidities has also increased. Thus, improvements must be made in the tolerance and safety of surgical procedures for these patients with complex medical conditions. In this study, we investigated combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers in terms of surgical methods, safety, and clinical outcome. Between January 2011 and May 2012, 8 patients over the age of 65 years (7 men, 1 woman; aged 66 to 75 years (median, 69.6)) with oral cavity and oropharyngeal cancers underwent combined submandibular gland and sternocleidomastoid myocutaneous flaps for postoperative reconstruction at Ganzhou Tumor Hospital. All eight patients had comorbid cardiovascular, cerebrovascular, or chronic respiratory disease or diabetes. Clinical outcomes, complications, and tolerance to surgical treatment were observed. Surgical treatment was successful in all eight patients. All submandibular gland flaps survived with well-mucosalized surfaces and with no complications. During the postoperative follow-up period of 12 to 28 months, no patient developed local recurrence or distant metastasis, and all had good recovery of function and local contour. This combined reconstruction technique enables appropriate restoration of oral function, facial aesthetics and improved quality of life. Further, this technique has several advantages: it is easier to perform, reduces operation time and surgical risk, causes less surgical injury, and has minor impact on contour. The technique provides a new and safe reconstruction option for older aged patients with oral cavity and oropharyngeal cancers.

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Combined submandibular gland flap and sternocleidomastoid musculocutaneous flap for postoperative reconstruction in older aged patients with oral cavity and oropharyngeal cancers

The aim of this study was to investigate the oncological outcomes in patients affected by oral carcinoma treated with radical compartmental surgery followed by microvascular flap reconstruction. We conducted a retrospective analysis on a cohort of 130 patients. All patients underwent ablative tumour resection (compartmental surgery) followed by immediate reconstruction with free flaps and adjuvant chemoradiotherapy, when necessary according to our tumour board and international guidelines. Disease-specific survival (DSS) curves were obtained using the Kaplan-Meier method. Log-rank test and generalised Wilcoxon test were used to investigate the most important prognostic factors on 5-year DSS. A Cox proportional hazards model was constructed to provide hazard ratios or relative risks for individual variables. 88.5% of patients were affected by SCC. There were 46 (35.4%) women and 84 (64.6%) men in the sample with a mean age of 58.5 years. At the end of the follow-up period, 36 (27.7%) patients died, only 3 of which for other causes. The 5-year DSS rate was 67.8% (S.E. 4.9%). In univariate Kaplan-Meier analysis and in multivariate Cox regression model, seven variables were found to have a significant relationship with DSS: T (p = 0.026) and N (p = 0.0001) status, clinical stage (according to the UICC TNM Sixth Edition) (p = 0.007), margins of resection (p = 0.001), extracapsular spread (p = 0.005), recurrence of disease (p = 0.00002) and treatment modality (evaluated as surgery alone or surgery + RT/CHT) (p = 0.004). Our results confirmed findings already reported in the literature, and allowed us to conclude that compartmental surgery combined with free flap reconstruction can increase survival in oral cancer patients.

/pdf/impact-of-microvascular-free-flap-reconstruction-in-oral-5glmhf95yz.pdf

Impact of microvascular free flap reconstruction in oral cavity cancer: our experience in 130 cases.

SUMMAry The aim of this study was to determine the frequency and the mechanism of submandibular gland (SMg) involvement in oral cavity squamous cell carcinomas (oCSCC), and to discuss the necessity of extirpation of the gland. The authors investigated and analyzed the retrospective charts of 236 patients who underwent surgery for oCSCC over a 10-year period and the pathology reports of 294 neck dissections with SMg removal. SMg involvement was evident in 13 cases (4%). Eight cases were due to direct invasion, which was the most common mechanism. Four cases had infiltration from a metastatic periglandular lymphadenopathy, and in 1 case, metastatic disease was confirmed. The tongue and floor of the mouth were the most frequent primary sites associated with SMg involvement. The study found no bilateral cases, and in 135 SMg specimens benign pathologies were detected. involvement of the SMg in oCSCC is not frequent. it is appropriate to preserve the gland unless the primary tumour or metastatic regional lymphadenopathy is adherent to the gland.

Is it necessary to remove submandibular glands in squamous cell carcinomas of the oral cavity? È necessaria l'asportazione chirurgica delle ghiandole sottomandibolari nel carcinoma squamoso del cavo orale?

Y. Suoglu

Papers

Is it necessary to remove submandibular glands in squamous cell carcinomas of the oral cavity? È necessaria l'asportazione chirurgica delle ghiandole sottomandibolari nel carcinoma squamoso del cavo orale?