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Complications of modified radical neck dissection type III in oral squamous cell carcinoma.

Byline: ARSALAN AHMED SHAIKH SALMAN SHAFIQUE MUHAMMAD SHAFI and SUNEEL KUMAR PUNJABI BDS FCPS (OMFS)

Abstract

Modified radical neck dissection type III is considered as relatively safe procedure for manage- ment of metastatic cervical lymphadenopathy with low complication rate. This Descriptive study was conducted to evaluate complications of modified radial neck dissection type III from April 2007 to March 2010 at Department of ENT-Head and Neck Surgery Civil Hospital Karachi. The surgical record of 115 patients of oral squamous cell carcinoma who underwent Modified Radical Neck Dis- section type III was evaluated for frequencies and pattern of complications. Out of 115 patients age of the patients was ranging from 26 to 66 years (std Dev: 10.62). 80% of patients were male and 20% of patients were female and male and female ratio was 4:1. The overall complications were 48.7%. Marginal mandibular nerve palsy (15.7%) and seroma (12.2%) were frequent complications. Although complications may occur despite the best efforts to prevent them proper preoperative planning early recognition of perioperative complications and prompt effective management can minimize the impact of complications that may occur.

Key Words: Complication Modified Radical Neck Dissection Squamous cell Carcinoma.

INTRODUCTION

The surgical management of the metastatic nodal disease in oral squamous cell carcinoma has evolved during the past 50 years. Neck dissection has been a well-established procedure for diagnosing (staging) and treating head and neck cancer for almost acentury.1

Radical neck dissection was first described by Crile in

1906 and popularized by Hayes Martin and still2 and it was the main surgical modality of metastatic cervical lymphadenopathy secondary to squamous cell carcino- ma (SCC) until the last third of the 20th century. The cosmetic and functional defects associated with radical neck dissection prompted the search for less morbid alternatives. According to Ferlito and Rinaldo Suarez

suggested a modified dissection preserving the jugular vein sternocleidomastoid muscle and spinal accessory nerve based on an understanding of the facial planes and lymphatic anatomy of the neck.4 Bocca and Pig- nataro subsequently presented this procedure in the English-language literature and Ballantyne pioneered its use in the United States.5 Modified radical neck dissection (MRND) is often oncologically equivalent to radical neck dissection but with a significant reduction in postoperative morbidity gradually replaced radical neck dissection in the treatment of the neck for many patients with SCC of the oral cavity.6

Complications of neck dissection are frequent and frustrating encounter for every surgeon regardless of experience and technical skill. In addition to the var- ious complications that may occur after any surgical procedure in head and neck region a number of surgical complications may be related to the neck dissection.7

Complications associated with various type of neck dissection have been discussed thoroughly in various international studies.89 The purpose of this study was to evaluate patterns and frequencies of various complications associated with MRND type III particularly. Although neck dissection is not frequent surgical procedure in major head and neck surgery in

this region however sparse local literature is available on this aspect. Considering frequency of complications of MRND type III surgeon may anticipate early and late post-operative outcome of procedure for early identification thus minimizing morbidity.

METHODOLOGY

This study was carried out in the department of ENT-Head and Neck Surgery Civil Hospital Karachi Dow University of Health Sciences Karachi from April

2007 to March 2010.

Surgical record of 155 patients with squamous cell carcinoma of oral cavity was reviewed who underwent Modified Radical Neck Dissection. The following criteria were used for inclusion histologically confirmed diag- nosis for primary site; absence of previous oncological treatment for this primary tumor; complete clinical laboratory and radiological evaluation; absence of distant metastasis at diagnosis and surgical treat- ment especially modified radical neck dissection type III with a curative purpose exclusive or as part of a multidisciplinary approach. A total of 115 patients met the criteria for inclusion in this study. Patients from both gender and all age group were also include. Detailed record of complications was retrieved from patient's file. Case record with inadequate information previous treated patients and those with the diagnosis other than squamous cell carcinoma were excluded.

Data were analyzed by using SPSS version 10. Fre- quency and percentage were computed for presentation of all variables including age gender and various com- plications of modified radical neck dissection type III. No inferential test was applicable for this descriptive study.

RESULTS

Out of 115 patients 92 (80%) were male and 23 (20%) were female (Fig 1). Age was ranging from 26 years to 66 years with mean as 43.5. (Std Deviation10.6) (Fig 2). Buccal mucosa was the most common site of oral squamous cell carcinoma (59.1%) followed by tongue (25.2%). Gingiva and lower lips were least common site (9.6%) and (6.1%) respectively (Table 1).

This study showed that 48.7% patients encountered complications of modified radical neck dissection type III where as 51.3% didn't report any (Fig 3). The most common complication encountered was marginal man- dibular nerve palsy 15.7% followed by seroma 12.2%. wounddehiscence and residual/recurrence was observed in 7.8% respectively. Whereas haemorrhage chyle leak and accessory nerve palsy was noted in 1.7% for each entity (Table 2).

DISCUSSION

Carcinoma of oral cavity is amongst the first ten commonest malignancies in Pakistan and many

TABLE 1: SITES OF THE ORAL SQUAMOUS CELL CARCINOMA (n=115)

S. Site###No. of pa-###Percent-

No.###tients###age

01###Buccal Mucosa###68###59.1%

02###Tongue###29###25.2%

03###Gingive###11###09.6%

04###Lower Lip###07###06.1%

Total###115###100%

TABLE 2: COMPLICATION OF MODIFIED RADICAL NECK DISSECTION

S. Complication###No.###Percent-

No.###age

01###Haemorrhage###02###1.7%

02###Marginal Mandibular nerve###18###15.7%

###palsy

03###Accessory nerve palsy###02###1.7%

04###Seroma###14###12.2%

05###Chyle leak###02###1.7%

06###Wound Dehiscence###09###7.8%

07###Recurrence / Residual###09###7.8%

Total###56###48.6%

other countries of the world.1011 Incidence varies from country to country and from region to region within the countries. The highest rates of occurrence of the tumor are found in countries of South and South-East Asia. An over-whelming majority of patients present with an advance stage of the disease rendering mul- timodality treatment mandatory that include surgery and radio-chemotherapy.12

A surgical complication can be considered as a development which is generally to the patient's det- riment arising at the time of operation or during the post-operative period. Complications after major sur- gery for patients with oral cancer increase treatment costs delayed adjuvant treatment augment late sequel affect quality of life and also can cause a patient's death if not diagnosed and promptly treated. Modified radical neck dissection due to its low morbidity has replaced its radical neck dissection counterpart.

This study presents mean age as 43.5 years whereas western literature reports higher mean age Ascani and colleagues et al13 reported 66.6 years as mean age group in their study. Whereas Ranak AA et al14 in his audit of oral cancer reported 6th decade as most common age group which is in contrast to our observation and other International studies where mean age group was close to that of ours.1516 Ehsan M and Waraich RA at el17 reported 47.2 years as mean age. Isaac at el18 in his study reported 55.5% of his patients from 41-60 years. Local and regional studies frequently reporting lower age group effected by OSCC and alarming trends have also been reported because of the fact that tobacco consumption is now prevalent in society at younger age therefore risking them to develop oral cancer at earlier age and that is why mean age for OSCC has slide down from older to younger group.19

Male preponderance was obvious in our observation. A western study reported 88.6% male and 11.4% female patients. Mehrotraet al20 also reported closer findings with 76.8% of his patients as male. However other regional study reported different gender distribution with 1.7:1 male to female ratio.11 Zakai has documented slight higher male to female ratio (3:1).21

As far as the complications are concerned in this present research approximately 49% of patients devel- oped complications of MRND. Marginal mandibular nerve (MMN) palsy was the most common complication. Identical findings were observed by Dedivitis RS et al25 where they reported MMN palsy as most frequent com- plication. Prim MP et al26 reported accessary nerve palsy as most common neurological complication followed by MMN palsy although no significant association with clinical parameters were observed in his researches.

Regarding wound complications seroma was the most common one and generally was the 2nd most common complication in our study. A Brazilian study documented seroma in 6.4% of their patients.27 Even higher incidence was reported i-e 20% in another international study.28 Incidence of hemorrhage in our study was almost similar to the frequency reported by international literature29 but lower incidence reported by Cheah WK et al.30 Higher frequency of Wound dehis- cence was reported by various international studies2830 when compared with our study.

Lower incidence of wound break down was reported by Ferrier MB et al in his research.31 This variation in incidence may be explained by many influencing factors including tumor staging nutritional status co-morbid surgical finesse and pre-surgical radiotherapy use of post-operative antibiotics and level of wound care provided.

Chyle leak was the rarest complication in our ex- perience. Slightly lower incidence was documented by Santolalla F32 while other international researchers have stated closer or identical observations.2728 Various techniques for prevention of this complication have been proposed but their effectiveness has not been validated and no measure can be considered superior to the other.

Tragically residual or recurrent disease was also observed in certain cases. Minghua G et al9 had slightly higher rate as 10% of his patients who under- went MRND. Whereas lower incidence of recurrence reported by Schiff BA et al.33 He reported loco regional recurrence in 5.3% of his patients treated with MRND. While considering loco-regional recurrence one has to keep in mind that various clinical and pathological

parameters including stage and site of disease access and compliance for follow up and pathological grading and pattern of invasion have their role.

MRND has become a standard procedure for most of node positive neck carrying low complication profile and even lower incidence of major or life threatening complications. Our experience also endorsed this obser- vation. Attending surgeon should be familiar precisely with loco-regional anatomy and ensure vigilant and quality post-operative care in order to minimize the incidence of adverse outcomes of MRND.

CONCLUSION

Present study concludes that life threatening complications are extremely rare in MRND type III. Marginal mandibular nerve palsy and seroma are the most frequent complications encountered.

Modified radical neck dissection requires a high lev- el of expertise and familiarity with the complex anatomy of the region. Complications in modified radical neck dissection may occur despite the best efforts to prevent them. Proper preoperative planning early recognition of perioperative complications and prompt effective management can minimize the impact of complications that may occur.

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Article Details
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Author:Shaikh, Arsalan Ahmed; Shafique, Salman; Shafi, Muhammad; Punjabi, Suneel Kumar
Publication:Pakistan Oral and Dental Journal
Article Type:Clinical report
Geographic Code:9PAKI
Date:Jun 30, 2014
Words:2775
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