Journal of Surgical Oncology 5520-23 (1994)
The Role of Suprahyoid Block Dissection in
Carcinoma of the Floor of the Mouth
DONALD ANTHONY HUDSON, FRCS, CLAIRE E. STANNARD, FF Rad (T),
BERTRAM BINNEWALD, FRCS, AND BERNARD PRICE, MMed
From the Department of Plastic Surgery and Radiotherapy, Croote Schuur Hospital,
University of Cape Town, Cape Town, South Africa
The efficacy of suprahyoid block dissection combined with radiotherapy,
in the management of neck nodal disease was evaluated in 15 patients with
carcinoma of the floor of mouth (abutting on the mandible) between 1983
and 1989. Ten males and 5 females had a mean age of 60.3 years.
Suprahyoid block dissection was performed in 10 patients as initial treatment. Nine of these presented with a submandibular mass and one patient
with a T4NO lesion had a prophylactic block performed. Suprahyoid block
dissection was performed in five patients who developed a submandibular
mass after completion of surgery and radiotherapy. Wound sepsis occurred
in three patients, but resolved with conservative treatment. Clinical assessment of the suprahyoid mass was accurate in 65% of patients. Nodal
recurrence occurred in one patient. Seven patients are alive and disease
free after a mean of 64.5 months. Two other patients are alive, one with
lung metastases, and one with a supraclavicular mass. Six patients have
died, two of whom developed local recurrence, one who developed a
supraclavicular mass, one after nodal recurrence, one with lung metastases, and one of an unrelated cause. Suprahyoid block dissection combined with radiotherapy is effective treatment for nodal control of patients
with carcinoma of the floor of mouth. This procedure is associated with a
low morbidity. 0 1994 WiIey-Liss, Inc.
KEYWORDS:suprahyoid block dissection, carcinoma of the floor of mouth,
radiotherapy
INTRODUCTION
The aim of treatment in patients with head and neck
cancer is to control both local and nodal disease [ 11. The
management of enlarged palpable lymph nodes suggestive of metastases is generally surgical [ 11, while prophylactic treatment can be achieved with either radiotherapy
[2,3] or surgery [4,5]. Classical radical neck dissection,
as advocated by Crile [6] and amplified by Martin et al.
[7], has been the standard treatment for cervical mestastases from head and neck cancer for 50 years [8].
Bocca et al. [9,10] challenged the necessity for every
patient to undergo this disabling procedure; less radical
operations have been described that preserve form and
function without compromising oncological principles.
Furthermore, the close liason between radiotherapist and
oncological surgeon [ 1I] has allowed treatment to be
tailored to each particular patient’s needs.
0 1994 Wiley-Liss, Inc.
The aim of this study was to evaluate the role of suprahyoid block dissection in patients with carcinoma of
the floor of the mouth abutting on the mandible who
presented with a submandibular mass. The management
and outcome of 15 patients treated at a major referral
center is discussed.
MATERIAL AND METHODS
Between 1983 and 1989, 40 patients were treated surgically for carcinoma of the floor of mouth abutting on
the mandible. The surgery consisted of a wide local excision of the primary tumor together with the adjacent inner
Accepted for publication September 8, 1993.
Address reprint requests to Dr. D.A. Hudson, Department of Plastic
Surgery and Radiotherapy, Ward F16, Groote Schuur Hospital, Observatory 7925, Cape Town, South Africa.
Suprahyoid Block Dissection in Carcinoma of Floor of Mouth
21
TABLE I. Clinical Assessment of Submandibular Mass*
~
No. of
pts.
No. of
Shb.
Clinical SM gland
histology
-ve
+ve
7
3
0
0
Clinical nodes
histology
-ve
+ve
~
Initial
Subsequent
10
5
15
6
4
3
Prophylactic
block
~~
3
0
1
0
* Shb, suprahyoid block dissection; SM, submandibular gland; -ve, negative; +ve, positive for metastatic
disease.
table of the mandible and a suprahyoid block dissection
was performed in all patients with a submandibular mass.
Postoperative radiotherapy (50 Gray equivalent in 5
weeks) was administered to the primary tumor bed and to
the suprahyoid region in all patients, and the middle and
lower necks were also treated in those with histologically
positive submandibular nodes.
Suprahyoid block dissection was performed in 10 of
the 40 patients initially (simultaneous bilateral blocks
were performed in five patients). Nine of the patients
initially presented with a submandibular mass and in one
patient with a T4NO lesion the procedure was performed
prophylactically. Five patients had a suprahyoid dissection for a submandibular mass that appeared after completion of surgery and radiotherapy. (One patient who
had a block dissection on presentation subsequently developed a contralateral submandibular mass and then had
a contralateral suprahyoid block dissection.) These 16
block dissections in 15 patients are the subject of this
report. There were 10 males and 5 females, with a mean
age of 60.3 years (range 42-78 years).
Histology of the primary tumor was squamous carcinoma in 13 patients and adenoid cystic carcinoma in two
patients. Clinical staging (UICC 1987) was as follows:
T2 10, NO 6; T3 4, N1 8; T4 1 , N2a 1.
RESULTS
Clinical Assessment (Table I)
In the 10 patients (five had simultaneous bilateral
block dissections) who had initial block dissection, seven
neck masses were thought to be enlarged submandibular
glands clinically, and this was confirmed histologically.
Seven neck masses were assessed as enlarged lymph
nodes, but only three were positive histologically. The
tenth patient had a prophylactic block dissection.
In those patients who developed a submandibular mass
subsequently, the submandibular gland was thought to be
enlarged in three, and this was confirmed histologically.
The other three patients were thought to have enlarged
metastatic nodes, but there was no disease histologically.
Complications
Wound sepsis occurred in three patients and resolved
with regular dressings. Twelve patients complained of
induration after subsequent radiotherapy.
Local Recurrence
Local (primary) recurrence occurred in two patients.
One patient developed local recurrence after 40 months
and died 6 months later. The other patient developed
local recurrence after 9 months and died 2 months later
with lung metastases.
Nodal Recurrence
One patient developed submandibular nodal recurrence after 32 months. He was palliated with radiotherapy and died 9 months later.
Outcome
Seven patients are alive and disease free after a mean
of 64.5 months (range 19-108 months). One patient who
after 30 months developed lung metastases is alive 6
months later. Another patient who subsequently developed a supraclavicular m a s after 20 months has been
treated with palliative radiotherapy and is alive 8 months
later.
Six patients have died, Two patients developed local
recurrence and died after 11 and 46 months respectively.
One patient developed submandibular nodal recurrence
and died after 46 months. One patient developed lung
metastases and died after 6 months. Another patient who
developed a supraclavicular mass after 70 months received palliative radiotherapy and died 29 months later of
distant metastases. One patient died of an unrelated cause
after 70 months.
DISCUSSION
Approximately 30% of patients with carcinoma of the
floor of the mouth will have clinically positive nodes
when first seen [ 121. Byers et al. [4] suggested that modified neck dissection is an excellent therapeutic option
and that the type of block dissection can be selected on
the basis of the site and stage of primary disease aiming to
remove the nodes at highest risk for metastases. Lindberg
[ 131 demonstrated that the nodes involved in carcinoma
of the floor of mouth are usually the submandibular and
subdigastric groups. These nodes are removed by suprahyoid block dissection, which includes all lymph
nodes between the inferior border of the mandible and the
hyoid bone up to the anterior margin of the sternomastoid
22
Hudson et al.
[ 141. Recently, conservative surgery when combined
with radiotherapy has been shown to be effective in patients with head and neck malignancy [ 15-17].
The histopathological status of the neck nodes is the
most significant factor affecting prognosis in patients
with carcinoma of the oral cavity [ 181 and nodal recurrence leads to a doubling of the incidence of metastatic
disease [20]. However, Pearlman et al. [16] demonstrated that less radical surgery combined with radiotherapy is associated with a neck recurrence rate of 8%. In
our series, there was only one neck recurrence in the first
station nodes after combined conservative surgery and
radiotherapy. When subsequent neck disease did occur, it
was situated in the supraclavicular fossa outside of both
the surgical and radiotherapy field. When these nodes are
involved, the patient is likely to have distant metastases
[ 19,201; neck dissection alone would fail to control the
disease and is therefore probably unjustified.
A further advantage of limited dissection is the lower
morbidity to the patient. Radical neck dissection is associated with significant morbidity. Bland et al. [21] reported on overall complication rate of 38%. Complication from another series [22] included 4% wound
infection, 10% seroma, and 10% skin slough. Long-term
complications included pain in the operation site requiring medication in 6% of patients and functional loss in
7% of patients. In contrast, our complications were minor
and related to the local wound. The sepsis that occurred
in three patients resolved with conservative management.
Bilateral simultaneous suprahyoid block dissection did
not lead to increased morbidity.
Suprahyoid block dissection in addition to being a therapeutic procedure is also a staging procedure. Clinical
assessment of the neck is difficult [23,24]. Southwick
[24] noted that even individuals with special training and
interest in the treatment of head and neck cancer have
difficulty in assessing whether an enlarged lymph node
contains metastatic disease. Spiro et al. [23] also recorded at 15% false-negative assessment and a 10%
false-positive evaluation. Others [ 1,261 have reported a
20-25% false-positive diagnosis, and our study showed
false positives in 33% of patients. As a result, patients
with carcinoma of the floor of the mouth may be overstaged and consequently overtreated.
Prophylactic radiotherapy to the cervical nodes has
been shown to be highly effective in controlling neck
disease in patients with no clinical lymphadenopathy.
Fletcher [2] reported a local control rate of 95%. Similar
findings were reported by Million [3,12]. Our patients
routinely received postoperative prophylactic radiotherapy to the first station nodes in a node-negative neck.
None of those who subsequently developed a submandibular mass that was treated surgically had metastatic disease. In most cases the mass was a blocked submandibular salivary gland. We have therefore adopted a
conservative approach to patients who develop a submandibular mass subsequent to their initial treatment. Management in these patients is based on clinical findings,
fine-needle aspiration biopsy [ 1,251, and CT scan [26].
Surgery is not performed for a blocked submandibular
gland.
Clinical assessment of patients with cancer of the floor
of mouth and submandibular mass if difficult. Suprahyoid block dissection is both a staging and a therapeutic
procedure, and is associated with a low morbidity. When
combined with radiotherapy, this procedure is effective
treatment for the nodal control of patients with carcinoma
of the floor of mouth abutting on the mandible.
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