ARTICLE IN PRESS

Journal of Cranio-Maxillofacial Surgery (2004) 32, 16–18

r 2003 European Association for Cranio-Maxillofacial Surgery.
doi:10.1016/S1010-5182(03)00095-7, available online at http://www.sciencedirect.com

Management of patients with squamous cell carcinoma

of the lower lip and N0 - neck

Alexandru Bucur, Lidia Stefanescu

Department of Maxillofacial Surgery (Chief: Prof. Dr. A. Bucur, DDS, MD, PhD), University of Medicine
and Pharmacy ‘‘Carol Davila’’, Bucharest, Romania

SUMMARY. Aim: For lower lip carcinoma, an incidence of 15% of cervical lymph node metastasis at presentation
is generally accepted. This is an argument in favour of an expectant approach. The purpose of this study was to
compare the results of the different approaches to the clinically negative neck: prophylactic neck dissection,
prophylactic neck irradiation and follow-up. Material and method: The retrospective study included 200
patients with lower lip carcinoma. The following data were evaluated: (1) the incidence of cervical lymph node
metastasis in patients with a clinically negative neck; and (2) pathological confirmation of cervical lymph node
metastasis. Results: In the group undergoing prophylactic neck dissection, lymph node metastasis was
found microscopically in 20% of the cases. More than half of the patients receiving prophylactic radiotherapy
developed bulky neck lymph node metastases. Out of the patients attending the 2-year follow-up 64% developed a
clinically positive neck. Cervical lymph node metastases in these patients was proven microscopically in 88% of
cases. Conclusion: The high incidence of a clinically positive neck, along with the high incidence of neck node
metastasis found in neck dissection specimens suggest that elective neck dissection is the treatment of choice for the
neck in patients with lower lip carcinoma. r 2003 European Association for Cranio-Maxillofacial Surgery.

Keywords: Lower lip cancer; N0 - neck; Prophylactic neck dissection

INTRODUCTION but no local recurrence, after surgical removal of

In lower lip cancer, cervical lymph node metastases
occur late, affecting mostly the submental and
submandibular groups. In many cases, the evolution
of the cervical metastatic masses is slow, progressive,
continues to spread to the lower (juxtajugular)
lymphnodes, and gradually invade the cheek and
submandibular tissues after invading the nodal
capsule.
For lower lip T1, T2 tumours with a clinically
negative neck (N0, M0) certain authors (Ariyan,
1987) recommend either a strict follow-up after
primary tumour excision and lip reconstruction, or
prophylactic radiotherapy of the cervical region.
Statistical data in the literature indicate that malig-
nant tumours of the lower lip have a low incidence of
neck metastasis, follow-up being the recommended
management of these patients: Soutar and Tiwari
(1994), reviewing the literature, report a rate of
cervical lymph node metastasis of 10–15%, Myers
and Suen (1996) indicate that approximately 80% of
patients with cancer of the lower lip will not develop
cervical metastasis, and hence have no need for neck
treatment.
However, our experience in the Department of
Maxillofacial Surgery in Bucharest revealed a
disturbing fact: more and more patients present
with neck nodes, sometimes spread into the skin,
malignant tumours of the lower lip (Bucur, 2003).
These data led us to start a retrospective study
on the incidence of cervical metastases in the patients
with lower lip cancer who had been treated
in the Department of Maxillofacial Surgery in
Bucharest.
MATERIAL AND METHOD
This 5-year retrospective study covered the period
1993–1997. Patients were followed up for another 2
years.
The study was based on the evaluation of case
history documents of 200 patients with confirmed
squamous cell carcinomas of the lower lip. No
selection was made regarding the T stage.
In order to evaluate the need for a prophylactic
neck dissection in patients with lower lip cancer and
clinically negative neck, the following data were
sought:
1. Incidence of cervical lymph node metastasis in
patients with a primary tumour and with a
clinically negative (N0) neck.
2. Microscopical confirmation of cervical lymph
node metastasis in order to eliminate reactive
lymphadenitis.

16
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RESULTS
Incidence of cervical lymph node metastasis in patients
with a primary tumour and with clinically negative
(N0) neck
From the 200 patients with lower lip cancer,
only 15 (7.5%) presented with a clinically positive
neck.
Out of the 185 N0 patients, 20 agreed to undergo a
prophylactic neck dissection, 11 accepted prophylac-
tic radiotherapy of the neck, and the remaining 154
did not accept any type of active treatment. They
were also included in the follow-up.
The results of the prophylactic neck dissections will
be discussed in the next section of this paper
(‘‘Pathological confirmation of neck metastasis’’).
The 11 patients who received prophylactic radio-
therapy of the neck could not be controlled any
further by the Maxillofacial Surgery follow-up;
however, six of them presented after variable inter-
vals (between 1.6 and 2.3 years, on average 1.9 years
after radiotherapy) with bulky cervical masses,
with no other option but palliative radio- and
chemotherapy.
The remaining 154 patients were included in a
2-year follow-up.
During the first 6 months, 32 patients developed
positive necks, 77 remained negative and 45 stopped
attending follow-up. The patients with a positive neck
underwent therapeutic neck dissection.
After 1 year, out of the 77 patients with negative
neck, 35 had developed positive necks, 38 remained
with negative necks and 4 stopped attending follow-
up. The patients with positive neck underwent
therapeutic neck dissection.
After two years, 32 out of the 38 patients remaining
within the follow-up programme had presented with
positive necks, 2 patients remained negative and the
Table 1 – Status and management of patients included in the study, for a period of 2 years
No. of patients
Postoperative status N(+) 15
Postoperative management TND a 15 PND b 20 PRT c 11
Status at 6 months
Management at 6 months
Status at 1 year
Management at 1 year
Status at 2 year N(+) bulky 6
Management at 2 years Palliative 6
a
Therapeutic neck dissection.
b
Prophylactic neck dissection.
c
Prophylactic neck radiotheraphy.
d
Missing from follow-up programme.
Lower lip carcinoma 17
other 4 ceased attending follow-up. The patients
with a positive neck underwent therapeutic neck
dissection.
In summary, out of the 154 patients included in the
follow-up, 99 presented within 2 years with a
clinically positive neck. All these underwent thera-
peutic neck dissection (Table 1).
Pathological confirmation of neck metastasis
In the surgical specimens submitted to pathological
examination after the therapeutic neck dissection
(standard staining with haematoxylin–eosin), 89% of
the nodes were found to be metastatic.
From the group of 20 patients with a clinically
negative neck at the first evaluation undergoing
prophylactic neck dissection, microscopy revealed
neck lymph node metastasis in four of them.
Six of the 11 patients initially with a clinically
negative neck receiving prophylactic neck radio-
therapy presented later with bulky neck lymph node
metastases (confirmed by biopsy).
Ninety-nine patients out of the 154 attending the
follow-up programme developed a clinically positive
neck sooner or later, and underwent a therapeutic
neck dissection. Cervical lymph node metastases in
these patients were proven histologically in 87 cases.
DISCUSSION
The literature indicates that squamous cell carcinoma
of the lip is associated with the lowest incidence of
cervical metastasis among all the cancers of the oral
cavity – 10–15% (Leemans et al., 1990).
In this study, however, it was found that out of the
154 patients with clinically negative neck at the time
of their first evaluation, a clinically positive neck
developed in 32 patients (21%) during the first
200
N( − ) 185
Follow-up 154
N(+) 32 N( − ) 77 Missingd 45
TND a 32 Follow-up 77
N(+) 35 N( − ) 38 M issingd 4
TND a 35 Follow-up 38
N(+) 32 N( − ) 2 Miss d 4
TND a 32
 ARTICLE IN PRESS
18 Journal of Cranio-Maxillofacial Surgery
6 months, a total of 67 patients (43.5%) within
1 year and a total of 99 patients (64%) within 2 years
of follow-up.
All the 99 patients who developed a clinically
positive neck sooner or later underwent a therapeutic
neck dissection. Cervical lymph node metastases in
these patients was proven in 87 cases (88%).
It may be that the incidence of cervical metastasis
was even higher than indicated by these data as it is
most likely that some of the patients missing the
follow-up have also developed a cervical metastasis.
Out of the 11 patients receiving prophylactic neck
radiotherapy, six patients (54.5%) still developed
bulky neck metastases at about 2 years after
radiation.
Furthermore, pathology confirmed neck lymph
node metastasis in four (20%) of the 20 patients
undergoing prophylactic neck dissection.
Thus out of the 185 patients with a clinically
negative neck during the first evaluation, 105 patients
developed a positive neck during this study, 99 of
them within 2 years of follow-up, and the other six at
about 2 years after prophylactic neck radiotherapy.
These data are according to studies by Henk and
Langdon (1996), who reported that the incidence of
cervical node metastasis was only 15–25% during the
first year, but had occurred in most of the patients
within 2 years. Same authors indicated that cervical
metastasis rarely occurred after 5 years, and almost
never later.
Most authors agree that cervical metastasis reduces
the 5-year survival rate by 50%. Lower lip cancer has
a good prognosis (survival rate 75–95%), but a much
poorer prognosis when associated with cervical node
metastasis. For this reason, prophylactic neck dissec-
tion is beneficial as it significantly reduces the
incidence of (cervical) metastasis and improves
prognosis.
CONCLUSION
1. At the time of presentation, patients with lower
lip carcinoma usually have a clinically negative
neck.
2. Lower lip carcinoma with clinically negative neck
develop cervical node metastases in the majority of
cases within 2 years.
The results of this study advocate for prophylactic
neck dissection in patients with malignant tumours of
the lower lip and clinically negative neck.
References
Ariyan S: Cancer of the Head and Neck, St. Louis, MO: Mosby,
1987
Bucur A: Chirurgie Maxilo-Faciala—curs, Editura Medicala
Nationala, Bucharest, 2003
Henk JM, Langdon JD: Malignant tumours of the mouth, jaws
and salivary glands, London: Edward Arnold, 1996
Leemans CR, Tiwari RM, Nanta JJP, Snow GB: The efficacy of
comprehensive neck dissection in nodal metastases of squamous
cell carcinoma of the upper respiratory and digestive tracts.
Laryngoscope, 100: 1194–1198, 1990
Myers EN, Suen JY: Cancer of the Head and Neck, third edition,
Philadelphia: Saunders, 1996
Soutar DS, Tiwari R: Excision and Reconstruction in Head and
Neck Cancer, Edinburgh: Churchill Livingstone, 1994
Dr. Alexandru Bucur
Department of Maxillofacial Surgery
(Chief: Prof. Dr. A. Bucur, DDS, MD, PhD)
University of Medicine and Pharmacy ‘‘Carol Davila’’
Calea Plevnei 19, Sector 1
Bucharest, Romania.
Tel./Fax: +40-21-315 8001
E-mail: alex bucur2002@yahoo.com, hionescu@pcnet.ro
Paper received 30 December 2002
Accepted 21 August 2003