ASSESSMENT OF LEVEL V LYMPH NODE METASTASIS IN CLINICALLY NODE POSITIVE ORAL CAVITY SQUAMOUS CELL CARCINOMA

Aim & Objectives- To determine the role of level V lymph node dissection in clinico- radiologically cervical node positive oral cavity squamous cell carcinoma & To analyse the potential risk factors (Clinico-radiological and histological) associated with level V lymph node metastasis. Background- Head and neck malignancies represent a significant global health challenge, accounting for 10% of all cancer cases; in India, this burden is particularly severe, reaching 40% of the total oncological landscape. Within this category, oral cavity cancer is the most prevalent, comprising 30% of cases, with squamous cell carcinoma (SCC) representing 95% of these tumors. In India, it is the leading cancer among men (35%) and the third most common in women (18%). While the typical diagnosis age is 60, there is a troubling trend of rising incidence among individuals under 40. The primary drivers of this disease are the combined use of alcohol and tobacco, including chewing tobacco and the traditional betel quid mixture, which is strongly linked to buccal mucosa malignancies. The presence of regional lymph node metastasis is the definitive prognostic indicator; its occurrence slashes survival rates by half and significantly increases the likelihood of recurrence and distant spread. Therapeutic management mandates addressing both the primary lesion and the neck’s lymphatic drainage. While radiation and adjuvant chemoradiotherapy are standard, surgery remains central. Historically, modified radical neck dissection (MND) involved clearing lymph nodes from levels I through V while sparing vital structures like the spinal accessory nerve (SAN), sternocleidomastoid muscle (SCM), and the internal jugular vein (IJV). However, clinical data suggests that metastasis to level V is rare in head and neck SCC unless level IIb nodes are already compromised. Material & Methods- A prospective study was conducted in the department of Surgical Oncology, Bombay Hospital for 18 months between July 2023 to November 2024. All patients with oral cavity squamous cell carcinomas having clinico-radiologically positive cervical lymph nodes and planned for upfront surgery with comprehensive neck dissection were included in the study After obtaining informed consent, a detailed history was obtained, and clinical examination findings noted. Results-In this series Men have a higher total incidence, but women over 50 show a higher frequency. For patients with node-positive disease, the level V metastasis rate was 4%. The buccal mucosa is the most common site of origin (linked to chewing tobacco), while the tongue is most frequently associated with level V metastasis. Clinical nodal stage (cN), nodal burden (specifically cN1 or exceeding cN2b), and advancing clinical stage are strong predictors. Tumor size (cT stage) was not a significant predictor. Conclusion- This prospective study on oral cavity squamous cell carcinoma (SCC) identified several key factors related to the spread of cancer to level V lymph nodes. Although the overall incidence of this disease is higher in men, prevalence peaks among elderly women. While the buccal mucosa often linked to tobacco chewing is the most common primary site, tumors of the tongue are more likely to metastasize to level V. Metastatic risk is significantly predicted by nodal factors, including clinical nodal stage (cN) and nodal burden (specifically cN1 or cases exceeding cN2b), as well as advancing overall clinical stage. Notably, tumor size (cT) does not serve as a significant predictor. Both clinical and pathological ECS are significant markers for level V spread. Poorly differentiated tumors and those with perineural invasion (PNI) are more likely to involve level V nodes. Factors like WPOI and LVSI did not show a significant link.

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