The general consensus in the field of head and neck oncology states that appropriate initial management of these tumors is surgical extirpation with adjuvant treatment. There is controversy in the field regarding the appropriateness of elective lymph node dissection.For maxillary alveolus and hard palate tumors, it has traditionally been believed that the risk of nodal metastases is not high enough to warrant elective lymph node dissection.In the majority of cases, in the absence of clinical evidence of cervical nodal metastases,neck dissection is generally not recommended, independent of the size or depth.
Because of low incidence of neck lymph node metastases, elective neck dissection is in this case not indicated.
Irrespective of the T status, ELND is not indicated in CA Maxilla/ Hard palatr
I found at least one dissenting publication: Br J Oral Maxillofac Surg 48(2010)345–348: "Squamous cancers of the maxillary gingiva, alveolus and hard palate should be treated aggressively, and elective neck dissection should be considered because of the high risk of occult metastases."
Maxilla and hard palate are areas where chances of cervical lymph node metastasis is low.
Hence, traditionally ELND is not indicated for these patients.
However, there is no well designed study to look for the real status for T4 primary. Many times these patients with T4 tumor carry a fairly high chance of lymph node recurrence and merits ELND as part of primary treatment.
ELND is mostly not warranted in NO necks in these patients. However in advanced T stages a close radiological study for retropharyngeal nodes should be performed as this will upstage the tumour and indicate further treatment
I would wait and see, if no metastasis found in the neck clinically and radiologically.
My opinion is the same for salivary gland cancers of the nose, sinuses and palate also.
The tumor in maxilla behaves weird and shows occult metastasis in few cases with aggressive Tumor sizes.
Radiotherapy remains the main stay in such cases and ELND is not advised unless and until CT/MRI/USG suggest otherwise.
The tumor in maxilla behaves weird and shows occult metastasis in few cases with aggressive Tumor sizes.
Radiotherapy remains the main stay in such cases and ELND is not advised unless and until CT/MRI/USG suggest otherwise.
For N0 Cases there is not evidence of benefits for elective neck dissection. Generally the risk of neck involvement is low. However is mandatory to perform a ct scan, MRI or ultrasonography evaluation for more accurate study and follow-up. It could be also considered the use of sentinel node biopsy
There is evidence that an ELND is indicated when there is invasion of the maxillary antrum.
As others have stated above, the consensus for hard palate and maxillary tumors has been to widely excise the primary including underlying bone without performing an ELND. I have held to this practice for T1 and T2 cancers of the hard palate and maxilla. However, in part because of articles such as that posted above by Dr. Doumas and in part because my practice includes many patients who have had other primaries and have had prior XRT, with the hard palate cancer presenting as a second primary, I have taken to a more aggressive approach for T3 and T4 hard palate and maxillary cancers by proceeding with a region I-III neck dissection, with extension of the procedure if positive nodes are identified intraoperatively. Our feeling has been that an ELND is a low morbidity procedure that can potentially improve the locoregional control for these tumors. As Dr. Mallick noted above, the problem in our field is that it is often quite difficult to find randomized controlled trials that address these questions.
Dr Lauretano states a fairly reasonable approach. From what we noticed in Glasgow is that these tumors can behave aggressively.
Regarding the possibility of regional metastasis in early T1/T2 SLNB may give us further clues.
I would agree with Dr Lauretano due to lack of well established prospective trials no safe conclusion could be drawn.
Even a multicentre multinational study could shed light in the consensus of a more definitive management for this subsite.
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