DELAYED REGIONAL METASTASIS FROM MIDFACIAL SQUAMOUS CARCINOMAS

Background. Metastases from mucosal and cutaneous carcinomas can prese nt in a delayed fashion, and this late presentation may confer a diffe rent prognosis after conventional treatment. Methods. We present a ser ies of patients in which there was a significant time delay between th e treatment of a squamous carcinoma of the skin or mucosa of the midfa ce and the detection of regional metastases in 12 of the 13 cases. Pri mary tumors were located on the lower lip and commissure (n = 3), nasa l tip (n = 2), nasal ala (n = 1), columella (n = 1), nasofacial crease (n = 2), maxillary alveolus (n = 3), and mandibular alveolus (n = 1). Metastatic spread manifested by palpable perifacial or submandibular lymph nodes was not evident until greater than 11 months after the tre atment of the primary site in 12 of 13 patients (range, 3-45 months). Nine of the patients were clinically staged as N1, whereas there was o ne each in the N2a, N2b, N2c, and N3 categories. Eleven of the 13 pati ents were initially seen with palpable disease involving the perifacia l nodes within or around the submandibular gland. All patients were tr eated with neck dissection except one, who refused surgical treatment and underwent a second course of radiotherapy to the cervical region. The nine patients initially seen with clinical stage N1 disease underw ent neck dissection with preservation of the sternocleidomastoid, inte rnal jugular vein, and accessory nerve, Results. Of 10 patients with p erifacial node metastases who underwent neck dissection, 8 required sa crifice of the marginal mandibular nerve and overlying platysma to gai n adequate margin. Extracapsular spread was present in 11 patients, (8 of 9 who were clinically N1). Postoperative radiotherapy was recommen ded to all patients with extracapsular spread, although only 7 of the 11 received radiotherapy. There were no regional recurrences after a m inimum follow-up of 1 year (range, 12-65 months; mean, 31.4 months). H istologic grade appeared to have no influence on prognosis. Conclusion s. This cohort demonstrates the ability of midfacial squamous cell car cinoma to manifest regional metastatic disease over a delayed time. Th is delayed presentation appears to confer a more favorable response to treatment. For midfacial cancers, the perifacial nodes are at greates t risk for metastatic spread. For tumors in this region, primary treat ment of the neck is probably not warranted, but careful extended follo w-up for the potential of delayed cervical metastasis is prudent. (C) 1998 John Wiley & Sons, Inc.