Year : 2019 | Volume
: 10 | Issue : 1 | Page : 1--2
Oral cancer: A study in retrospection
Department of Oral and Maxillofacial Surgery, SCB Dental College and Hospital, Cuttack, Odisha, India
Dr. Niranjan Mishra
Department of Oral and Maxillofacial Surgery, SCB Dental College and Hospital, Cuttack, Odisha
|How to cite this article:|
Mishra N. Oral cancer: A study in retrospection.Natl J Maxillofac Surg 2019;10:1-2
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Mishra N. Oral cancer: A study in retrospection. Natl J Maxillofac Surg [serial online] 2019 [cited 2019 Dec 7 ];10:1-2
Available from: http://www.njms.in/text.asp?2019/10/1/1/259826
India is considered oral cancer capital of the world, and it accounts for one-third of all cases. Oral cancer ranks among the top three types of cancer in the country with 75,000–80,000 new cases being reported every year. The age-adjusted rate of oral cancer in India is 12.6 per 100,000 population, which is approximately 30% of all cancers in the country. These cases are treated with surgery or radiotherapy or chemotherapy or combination of these methods. Surgery is often the preferred modality for the treatment of oral cancer.
In the 19th century, the focus of surgery was merely to eradicate the disease and prolong life expectancy of patients with oral cancer. The outcome hoped for, in the 21st century, is not just disease-free survival but also a quality of life that helps patients to integrate into the society to their fullest potential. This is evidenced in the evolution of the neck dissection from the classical radical procedure in the old days to selective and elective neck dissection (END) along with the advancements made in the field of reconstructive surgery now. It has significantly reduced the morbidity, improving the quality of life for the patients.
All aspects of treatment planning have been fiercely debated on various platforms. The surgical community, however, has been rather slow and reluctant in accepting changes. The clinically negative neck in the modern era has been managed variously by cancer specialists. The first is the wait-and-watch way: observing the patients at regular follow-up intervals and treating the neck when clinical disease manifests. The second and more common is elective treatment using neck dissection, with removal of the echelon nodes for the affected subsite. A few also opt for elective radiotherapy either alone or along with neck dissection.
END is the most preferred treatment by contemporary surgeons. Many studies have proven that the lymphatic drainage from various subsites follows very specific and predictable patterns, thus enabling the selective removal of only the nodal levels at risk of harboring occult metastases. In a clinically negative neck, it is more often than not a “staging” procedure, however. Although the various imaging techniques such as USG, CT, MRI, and FDG PET have high sensitivity and specificity, there remains the inevitable interobserver difference. They also have the limitation of not being able to detect microscopic nodal metastasis and extranodal extension. END alone can overcome these disadvantages. It helps in assigning a prognostic value and counseling of the patient. In cases with subclinical metastasis, it becomes therapeutic and allows determining whether adjuvant treatment is necessary. Furthermore, wherever access through the neck is needed for excision or reconstruction, it is prudent to go for neck dissection as well.
Recent statistics on END, however, have shown that for every patient who has an occult metastasis in a clinical N0 setting, there are at least twice the number who do not. Many cases clinically diagnosed as N+ turn out to be uninvolved on histopathological examination, leading to downstaging of their disease.
The proponents of the wait-and-watch policy argue that conversion rates of N0 to N+ in wait-and-watch cases are similar to the incidence of subclinical disease in END specimens. With diligent follow-up and regular imaging, those cases can easily be caught and treated.
Hence, the question arises, are surgeons over treating the neck? It has been said that a positive neck reduces survival by approximately 50%. This fear is the primary reason that prompts most to go for END, to be safe rather than sorry. In India, where the onus of decision-making often falls upon a clinician, the burden is high, and follow-up is irregular, overtreatment may even seem justified.
There is no level I evidence that END in N0 cases reduces the neck recurrence or increases the overall survival any more than wait-and-watch cases, but it does increase the morbidity. It has also not been shown if observation and delayed treatment of neck increase the incidence of distant metastasis or have any adverse survival outcome. Robbins et al. introduced the idea of a “superselective” neck dissection where chemoradiation was used. Might we dare take it a tad further, be superselective in all N0 cases? It is not an absurd idea altogether. People have been debating the elective removal of level IIB for a long time now. Sentinel node biopsy in head-and-neck cases is another concept that entreats attention. Recently, it has also been suggested that the submandibular gland need not necessarily be removed in selected cases.
My own experience of treating oral cancer patients for the past 10 years has led me to believe that overzealous dissection of tissues hardly ever serves the purpose. On the contrary, preserving the perineural tissues around the spinal accessory nerve, for instance, goes a long way in alleviating the shoulder dysfunction associated with its injury.
It is a known fact that failures in oral cancer cases are primarily due to local recurrence rather than nodal or distant. Advancements in reconstructive surgery have allowed the ablative surgeon to excise the primary tumor with much more freedom than being possible earlier. It is this we have to strive for: to achieve a disease-free, functional rehabilitation, instigating as less harm as possible.
I have observed that majority of oral cancer cases presenting in earlier stages can be treated with good excision of primary, selective neck dissection, reconstruction, and adjuvant radiation if indicated. Some cases which present at an advanced stage may require adjuvant chemotherapy in addition to the above. The few cases that present in the very last stages or with poor biological behavior are candidates for chemotherapy or concurrent chemoradiation, followed by surgery if possible.
Time has come to get out of our comfort zones and challenge the dogmas. Since majority of maxillofacial surgeons in India are private practitioners and do not have the privilege to be associated with institutes dedicated solely to cancer with the benefits of interdisciplinary resources, they should seek out the help of peers and online tumor boards. Each oral cancer case should be a study in itself, thoroughly analyzed, and dissected, with a treatment plan individually tailored on three-dimensional excision of primary followed by proactive reconstruction and dissection of neck with the intent of reducing morbidity. And last but not the least, conscientious posttreatment follow-up and record maintenance are of utmost importance in delivering patient care.
Further development in noninvasive imaging and diagnostic techniques might deliver us from this quandary and preclude the need for unnecessary surgical procedures altogether. The future will bring advances in molecular biology and along with it, better understanding of biological behavior of cancer. Multiple researches and trials are already underway, and prevention strategies are being designed accordingly. As our understanding in this area increases even further, therein 1 day we can hope to find the answer.
I would like to thank Dr. Dipti Samal, without whom this editorial may not have seen light of the day. Thanks also to Dr. Rosalin Kar and Dr. Akhilesh Kumar Singh, for their encouragement in all my endeavors.