Abstract
Purpose
The aim of this study was to analyze the outcome of surgical therapy for buccal squamous cell carcinoma (SCCA) at a single tertiary care institution during a 40-year period.
Materials and methods
A retrospective review was performed by examining the records and pathology of 48 patients with buccal SCCA treated at a single tertiary care institution from 1970 to 2009.
Results
Treatment entailed surgery alone in 18 patients (37.5%) and surgery followed by radiation therapy in 30 patients (62.5%). Composite resection was performed in 17 patients (35.4%), and ipsilateral neck dissections were performed in 37patients (77.1%). One-year observed actuarial disease-free survival rates were 60%, 46%, 0%, and 40% for T1 through T4, respectively. Univariate analysis revealed increased age as a risk factor for disease recurrence ( P = .062), with skin taken and neck dissection not achieving significance ( P = .24 and .20, respectively). Multivariate analysis demonstrated age as increasing risk and neck dissection as decreasing risk of recurrence ( P = .029 and .023, respectively).
Conclusions
We report relatively high disease-free survival rates in patients who underwent aggressive resection and neck dissection. Performance of neck dissection and younger age were associated with a favorable prognosis. Performance of neck dissection may decrease the risk of recurrence in primary SCCA of the buccal mucosa. Although through-and-through resection of skin decreased risk of disease recurrence, this difference is not statistically significant ( P = .24).
1
Introduction
The anatomy of the buccal mucosa and buccal space allows for extension of carcinoma unimpeded by any anatomic barriers to neighboring intraoral subsites and structures. This oral cavity subsite is defined as the mucosal lining of the cheeks and lips from the oral commissure anteriorly to the pterygomandibular raphe posteriorly, merging with the alveolar ridges superiorly and inferiorly. Involvement of the maxilla, mandible, cheek skin, and lips leads to varied and morbid resections including through-and-through resection of the skin and composite resections of the mandible and/or maxilla. Tumors of the buccal mucosa may also involve multiple subsites, leading to ambiguity of the site of origin .
Buccal squamous cell carcinoma (SCCA) is not uncommon in Southeast Asian and Indian populations because of the prevalence of betel nut use ; however, it is a rare tumor in North America, constituting only 10% of all carcinomas of the oral cavity . Owing to the rarity of buccal SCCA and the wide variation in patient presentations and populations, there is a paucity of high-level evidence on the recommended management of these patients. Management of this malignancy, therefore, has been guided by case series from single institutions .
Buccal carcinoma has traditionally been treated surgically, with postoperative radiation therapy reserved for patients with high-risk histopathologic findings, such asperineural invasion, lymphovascular invasion, bone invasion, extracapsular spread, or close margins . Our institution had previously reported our experience of buccal carcinoma treated over a 20-year period. That study concluded that aggressive surgical treatment of buccal carcinoma may result in better survival rates . Our goals in this present study are (1) to further describe our experience with this rare disease over a longer time period (40 years), (2) to focus our analysis on a homogeneous patient population by including only previously untreated buccal SCCA patients whose disease is isolated to or originating from the buccal mucosa, and (3) to evaluate the oncologic necessity of through-and-through resection of cheek skin.
2
Materials and methods
The current retrospective study was approved by the institutional review board of the University of California at Los Angeles. Our study was Health Insurance Portability and Accountability Act compliant.
2.1
Data collection
The medical records of all patients diagnosed with SCCA of the buccal mucosa at a single academic institution between June 1972 and January 2010 were reviewed. Data regarding diagnosis, treatment and follow-up were all obtained from the clinical record notes.
2.2
Patient characteristics
A computer-assisted search of the institutional pathology database was used to identify patients with biopsy-proven buccal SCCA from January 2000 to January 2010. Our institutional pathology database was established in January 2000. To identify patients before January 2000, a previously maintained tumor database was used to identify patients from June 1972 to April 1990. Because we lacked a systematic mechanism to identify patients treated for buccal carcinoma for the time period of May 1990 to December 1999, we did not include any cases from these years. Inclusion criteria were patients diagnosed with primary and previously untreated SCCA of the buccal mucosa that was surgically treated. Primary buccal carcinoma was defined as a malignant neoplastic process originating from the buccal mucosa. In cases of buccal tumors that included other oral subsites, the case was only included if it was clear from the clinical record that the tumor originally arose from buccal mucosa. Other oral cavity tumors with secondary extension to the buccal mucosa or prior surgical treatment were excluded. Patients with prior treatment of their disease were excluded. The medical charts were retrospectively reviewed to determine patient age, sex, tumor site, pathologic staging, tobacco use, alcohol use, presence of perineural invasion, differentiation, margin status, resection of skin, presence of neck dissection, T-stage, and N-stage.
2.3
Statistical analysis
Time to first recurrence (local, regional, or distant) was the primary outcome measure. Cox proportional hazards regression was used to assess the relationships between each individual patient characteristic and time to first recurrence. In addition, a multiple Cox proportional hazards model was constructed to assess the association of the combined effects of age, T-stage and neck dissection with time to first recurrence. Statistical analysis was performed using S-plus version 6 (Insightful). P < .05 was considered significant, and values less than 0.1 were considered trending toward significance.
2
Materials and methods
The current retrospective study was approved by the institutional review board of the University of California at Los Angeles. Our study was Health Insurance Portability and Accountability Act compliant.
2.1
Data collection
The medical records of all patients diagnosed with SCCA of the buccal mucosa at a single academic institution between June 1972 and January 2010 were reviewed. Data regarding diagnosis, treatment and follow-up were all obtained from the clinical record notes.
2.2
Patient characteristics
A computer-assisted search of the institutional pathology database was used to identify patients with biopsy-proven buccal SCCA from January 2000 to January 2010. Our institutional pathology database was established in January 2000. To identify patients before January 2000, a previously maintained tumor database was used to identify patients from June 1972 to April 1990. Because we lacked a systematic mechanism to identify patients treated for buccal carcinoma for the time period of May 1990 to December 1999, we did not include any cases from these years. Inclusion criteria were patients diagnosed with primary and previously untreated SCCA of the buccal mucosa that was surgically treated. Primary buccal carcinoma was defined as a malignant neoplastic process originating from the buccal mucosa. In cases of buccal tumors that included other oral subsites, the case was only included if it was clear from the clinical record that the tumor originally arose from buccal mucosa. Other oral cavity tumors with secondary extension to the buccal mucosa or prior surgical treatment were excluded. Patients with prior treatment of their disease were excluded. The medical charts were retrospectively reviewed to determine patient age, sex, tumor site, pathologic staging, tobacco use, alcohol use, presence of perineural invasion, differentiation, margin status, resection of skin, presence of neck dissection, T-stage, and N-stage.
2.3
Statistical analysis
Time to first recurrence (local, regional, or distant) was the primary outcome measure. Cox proportional hazards regression was used to assess the relationships between each individual patient characteristic and time to first recurrence. In addition, a multiple Cox proportional hazards model was constructed to assess the association of the combined effects of age, T-stage and neck dissection with time to first recurrence. Statistical analysis was performed using S-plus version 6 (Insightful). P < .05 was considered significant, and values less than 0.1 were considered trending toward significance.
3
Results
The initial search of the 2 pathology databases (from 1972 to 2009) yielded 199 cases of carcinoma involving the buccal mucosa. Lesions originating from adjacent intraoral structures with extension into the buccal mucosa were excluded. In addition, verrucous and basaloid squamous carcinoma subtypes were excluded. These exclusion criteria resulted in 48 patients with primary SCCA of the buccal mucosa who underwent surgical resection for primary disease and postoperative radiation therapy when indicated. The mean age was 69 (range, 40–93), and there were 28 women (58%). The mean follow-up time for all patients was 45 months (range, 1–305) and the median follow-up time was 17 months. Risk factors for buccal carcinoma included a history of smoking in 63%, alcohol use in 38%, and betel nut use in 4% of patients. A summary of the patients staging and demographics can be found in Tables 1 and 2 , respectively.
| T | N0 | N1 | > N1 | Total |
|---|---|---|---|---|
| T1 | 5 | 1 | 1 | 7 |
| T2 | 12 | 4 | 9 | 25 |
| T3 | 1 | 2 | 2 | 5 |
| T4 | 4 | 2 | 5 | 11 |
| Total | 22 | 9 | 17 | 48 |
| Stage | Age | Smoking (%) | Alcohol (%) | |
|---|---|---|---|---|
| Range | Mean | |||
| I (n = 17) | 47–85 | 69 | 35 | 35 |
| II (n = 5) | 64–73 | 70 | 40 | 40 |
| III (n = 3) | 69–81 | 74 | 33 | 33 |
| IV (n = 23) | 40–93 | 67 | 57 | 39 |
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