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Table of Contents
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 37-39

Risk of submandibular gland metastasis in early-stage oral cavity cancer: A national multicentric study

1 Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Majmaah University, Al-Majmaah, Saudi Arabia
2 Department of Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh; Department of Otolaryngology Head and Neck Surgery, Ohoud Hospital, Madinah, Saudi Arabia
3 Department of Otolaryngology-Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
4 Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, Saudi Arabia
5 Department of Otolaryngology-Head and Neck Surgery, Najran University, Najran, Saudi Arabia
6 College of Medicine and Research Center, King Saud University, Riyadh, Saudi Arabia
7 Department of Otolaryngology-Head and Neck Surgery, King Saud University, Riyadh, Saudi Arabia

Date of Submission23-Jan-2019
Date of Decision15-Mar-2019
Date of Acceptance19-Apr-2019
Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. Jabir Alharbi
Department of Otolaryngology-Head and Neck Surgery, College of Medicine, Majmaah University, Al-Majmaah 11952
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SJOH.SJOH_3_19

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Background: The objective of this study was to evaluate the safety of preserving the submandibular gland in early-stage oral cavity cancer. Materials and Methods: We retrospectively collected the data for all patients who present with early-stage oral cavity cancer and underwent local wide excision with concomitant neck dissection over 8 years from 2008 to 2016 at two tertiary oncology centers in Saudi Arabia. Results: Forty-seven patients, comprising 26 males (55.3%) and 21 females (44.7%), were included in the study; the primary presentation, documented risk factors, and postoperative pathological results were evaluated. Conclusion: The present study showed that risk of submandibular gland metastasis in clinically early-stage oral cavity squamous cell carcinoma was almost nil.

Keywords: Carcinoma, metastasis, oral cavity cancer, submandibular gland

How to cite this article:
Alharbi J, Sebeih H, Alshahrani M, Algarni M, Al-Hakami H, Alnemare A, Assiri AM, Islam T, Alqahtani K. Risk of submandibular gland metastasis in early-stage oral cavity cancer: A national multicentric study. Saudi J Otorhinolaryngol Head Neck Surg 2019;21:37-9

How to cite this URL:
Alharbi J, Sebeih H, Alshahrani M, Algarni M, Al-Hakami H, Alnemare A, Assiri AM, Islam T, Alqahtani K. Risk of submandibular gland metastasis in early-stage oral cavity cancer: A national multicentric study. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2019 [cited 2023 Feb 6];21:37-9. Available from: https://www.sjohns.org/text.asp?2019/21/2/37/269710

  Introduction Top

Oral cavity cancer accounts for about 1.5% in males and 1.3% in females per 100,000 population in the Kingdom of Saudi Arabia,[1] and there are around 354,864 estimated new cases and approximately 177,384 estimated deaths worldwide in 2018.[2]

By far, the gold standard treatment for oral cavity cancer is wide local excision with concomitant neck dissection with or without reconstruction that could be followed by radiation or chemoradiation.[3]

Recently, due to increased understanding of tumor behavior and advances in the medical literature, the practice of neck dissection has changed from radical neck dissection that includes the removal of lymph nodes from (Level I–V with or without sacrifice of the internal jugular vein, spinal accessory nerve, and sternocleidomastoid muscle) to be more selective, especially in N-negative neck that leads to less morbidity and better function.

Oral cavity squamous cell carcinoma (OSCC) is known to metastasize to Level IA and Level IB, Level IB this is where the submandibular gland (SMG) is located. Consequently, SMG is usually removed during Level IB neck dissection.

Hence, we decided to evaluate the rate of metastasis to SMG in early-stage oral cavity cancer. Preserving the SMG if it is oncologically safe has a great impact on the patients quality of life. It prevents xerostomia and decreases the incidence of dental caries, especially if no radiation was giving postoperative which usually the case in early-stage oral cavity cancer.[3]

  Materials and Methods Top

A retrospective chart review was carried out for all patients who underwent wide local excision of oral cavity cancer with concomitant neck dissection from 2008 to 2016 at two oncology centers from two different provinces. All patients who presented with biopsy-proven early-stage oral cavity cancer and underwent surgical treatment were included in this study. However, patients who were managed outside our institutions or those who receive radiation as a primary treatment were excluded from the study. As well as, those who presented with advanced stage oral cavity cancer; because preservation of SMG in advance stage is not always feasible and it will not be oncologically safe or it may prevent the resection of the primary tumor.

We have followed the American Joint Committee on Cancer Seventh Edition (2007) for staging our patients.

  Results Top

We had 104 patients of oral cavity carcinoma, of which 47 fit our inclusion criteria comprising 26 males (55.3%) and 21 females (44.7%). Age of the participants ranged from 18 to 83 years, with a mean of 56 years. All patients underwent wide local excision of the primary tumor with concomitant neck dissection (modified radical vs selective neck dissection). Patient characteristics and tumor location and presentation are shown in [Table 1].
Table 1: Patient characteristics

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The primary presentation was on the tongue in 36 patients (76.6%) followed by the buccal mucosa in 7 patients (14.9%). The most common presentation was in the form of ulcer (72.3%). Eighteen patients (38.3%) had oral cavity cancer in Stage I and 29 patients (61.7%) in Stage II.

Margin was positive for malignant cell in 6.4% of patients and that necessitated further radiotherapy. Perineural invasion was found in 12 patients (25.5%). Patients with risk factors smoking 8 patients (17%) and Schamma 2 patients (4.3%) and smokeless tobacco 1 patient 2.3%.

In pathological assessment, majority of the patients (70.2%) had moderate SCC. Although this study initially included only clinically Stage I and II carcinoma patients, pathological staging revealed four patients (8.5%) with Stage III carcinoma and seven patients (14.9%) with Stage IVa carcinoma. Those who turned to be in pathologically advanced stage could be due to initial understaging during primary clinical evaluation. However, there was no SMG metastasis even in those patients.

Thirty-two patients were managed by unilateral neck dissection, whereas 15 patients were managed by bilateral neck dissection, resulting in the removal of a total number of 62 SMG.

Pathology of both the ipsilateral and contralateral SMG was negative for malignancy, as shown in [Table 1].

  Discussion Top

The most important prognostic factor in OSCC is the status of lymph node metastasis,[4] a single lymph node metastasis may decrease the survival up to 50%.[5] This explains why neck dissection is an integral part of surgical procedure for OSCC. The SMG is located at Level IB, which should be addressed in neck dissection for OSCC. However, SMG is the main unstimulated secreting salivary gland and it helps in keeping the oral cavity moist and helps in speech, mastication, and swallowing. In addition, it has IgA and lactoferrin that has antimicrobial action. Therefore, dysfunction of SMG can lead to xerostomia, speaking and swallowing problems as well as difficulty in oral hygiene and dental caries. As there is a growing evidence to preserve the SMG in early stages of oral cavity cancer. However, the routine practice so far is removing the SMG with concomitant neck dissection.

Unlike other organs, SMG has poorly developed lymphatics, DiNardo has divided lymph node surrounding SMG into the following six groups: preglandular, prevascular, retrovascular, retroglandular, intraglandular, and deep. Of these, the intraglandular and deep groups are of little clinical significance, as some cases have few nodes, or none, in these positions.[6]

In reviewing the literature SMG metastasis, although rare has three mechanisms either by direct invasion (0.6%–3%). The second mechanism by metastasis to Level IB LN (0%–1.5%). Third is invasion by metastases to intraglandular lymph node.[7]

A well-established risk factor for the invasion of SMG is the location of the primary tumor or extension of the primary tumor on the floor of the mouth (P = 0.042).[8] Basaran et al. reported 13.9% probability of SMG involvement in these tumors.[7] In contrast to these two reports, Naidu et al. did not detect any metastatic lesions of the SMG in 69 patients, despite the fact that the primary tumor site in 71% of them were either tongue or floor of the mouth.[9] This factor should be considered before taking decision to preserve the SMG.

In this study, we assessed the incidence of SMG involvement by carcinoma of the oral cavity. In accordance with literature data,[8],[9],[10],[11],[12],[13],[14],[15] this study showed that metastasis to SMG in early-stage oral cavity cancer is not common. No evidence of metastases was detected in any of the 62 SMG, even though surgical margin was positive for malignant cells in 6.4% of patients, and perineural invasion was discovered in about one-fourth of the patients. A short-term prospective study[10] conducted over 2013–2014 examined the outcomes of 85 oral cavity carcinoma patients with only N0 neck. Unlike our study, they included patients with both T3 and T4 lesions. Although several patients had Level IB metastasis to superior, anterior, posterior, inferior, and deep to the gland, SMG itself remained free in all of these cases. In a long-term study conducted by Basaran et al.,[7] only one metastatic lesion of SMG was discovered out of 294 resected glands, where the primary site was the tongue (T2 lesion). These data suggest that preserving the SMG during neck dissection in early-stage oral cancer may be a safe option.

Despite the encouraging findings of our study, it is limited by its retrospective nature. Further investigation by a long-term prospective study will shed more light on this matter. Our study's strength is that both the centers included in this study have large catchment area from two different provinces. Second, although the decision to exclude stage three and four cases decreased the sample size, it was a long-term retrospective study (8 years).

  Conclusion Top

Unlike the other organs, SMG does not contain intraglandular lymph nodes. Our results suggest that preservation of the SMG in early-stage oral cancer is a valid therapeutic option, unless there is evidence of tumor invasion to the floor of mouth or tongue.

Bullet point summary

  • The definitive management strategy of oral cavity cancer is wide local excision with concomitant neck dissection
  • Removal of SMG during neck dissection may lead to xerostomia
  • In the current study, no evidence of metastasis to SMG was pathologically detected
  • Preserving the SMG during neck dissection in early-stage oral cancer may be a safe therapeutic option.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Al-Eid HS, Bazarbashi S. Cancer Incidence Report. Saudi Arabia. Kingdom of Saudi Arabia Ministry of Health Saudi Cancer Registry; 2014. p. 108.  Back to cited text no. 1
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.  Back to cited text no. 2
Jacob RF, Weber RS, King GE. Whole salivary flow rates following submandibular gland resection. Head Neck 1996;18:242-7.  Back to cited text no. 3
Shingaki S, Takada M, Sasai K, Bibi R, Kobayashi T, Nomura T, et al. Impact of lymph node metastasis on the pattern of failure and survival in oral carcinomas. Am J Surg 2003;185:278-84.  Back to cited text no. 4
Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg 1990;160:405-9.  Back to cited text no. 5
DiNardo LJ. Lymphatics of the submandibular space: An anatomic, clinical, and pathologic study with applications to floor-of-mouth carcinoma. Laryngoscope 1998;108:206-14.  Back to cited text no. 6
Basaran B, Ulusan M, Orhan KS, Gunes S, Suoglu Y. Is it necessary to remove submandibular glands in squamous cell carcinomas of the oral cavity? Acta Otorhinolaryngol Ital 2013;33:88-92.  Back to cited text no. 7
Cakir Cetin A, Dogan E, Ozay H, Kumus O, Erdag TK, Karabay N, et al. Submandibular gland invasion and feasibility of gland-sparing neck dissection in oral cavity carcinoma. J Laryngol Otol 2018;132:446-51.  Back to cited text no. 8
Naidu TK, Naidoo SK, Ramdial PK. Oral cavity squamous cell carcinoma metastasis to the submandibular gland. J Laryngol Otol 2012;126:279-84.  Back to cited text no. 9
Malik A, Joshi P, Mishra A, Garg A, Mair M, Chakrabarti S, et al. Prospective study of the pattern of lymphatic metastasis in relation to the submandibular gland in patients with carcinoma of the oral cavity. Head Neck 2016;38:1703-7.  Back to cited text no. 10
Panda NK, Patro SK, Bakshi J, Verma RK, Das A, Chatterjee D. Metastasis to submandibular glands in oral cavity cancers: Can we preserve the gland safely? Auris Nasus Larynx 2015;42:322-5.  Back to cited text no. 11
Lanzer M, Gander T, Lübbers HT, Metzler P, Bredell M, Reinisch S. Preservation of ipsilateral submandibular gland is ill advised in cancer of the floor of the mouth or tongue. Laryngoscope 2014;124:2070-4.  Back to cited text no. 12
Byeon HK, Lim YC, Koo BS, Choi EC. Metastasis to the submandibular gland in oral cavity squamous cell carcinomas: Pathologic analysis. Acta Otolaryngol 2009;129:96-100.  Back to cited text no. 13
Chen TC, Lo WC, Ko JY, Lou PJ, Yang TL, Wang CP. Rare involvement of submandibular gland by oral squamous cell carcinoma. Head Neck 2009;31:877-81.  Back to cited text no. 14
Razfar A, Walvekar RR, Melkane A, Johnson JT, Myers EN. Incidence and patterns of regional metastasis in early oral squamous cell cancers: Feasibility of submandibular gland preservation. Head Neck 2009;31:1619-23.  Back to cited text no. 15


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