Is neck dissection a recommended treatment for verrucous carcinoma of the buccal mucosa?

Neck Dissection in Verrucous Carcinoma of the Buccal Mucosa

Elective neck dissection is not recommended for verrucous carcinoma of the buccal mucosa due to the extremely low risk of lymph node metastasis, and should only be performed therapeutically when clinically positive nodes are present.

Primary Treatment Approach

• Wide local surgical excision is the definitive treatment of choice for verrucous carcinoma of the oral cavity, with excellent tumor control rates approaching 100% 1, 2.
• The buccal mucosa is the most common site for oral verrucous carcinoma, representing approximately 58% of cases 2.
• Verrucous carcinoma is a well-differentiated, slow-growing variant of squamous cell carcinoma with distinctly favorable biological behavior compared to conventional oral squamous cell carcinoma 3.

Neck Management Strategy

Elective Neck Dissection (N0 Neck)

• Routine elective neck dissection should be avoided in verrucous carcinoma, even in advanced T-stage disease 1, 2.
• In a series of 38 patients where only 2 had palpable adenopathy at presentation, elective neck dissection was deemed unnecessary even in advanced stages, with 100% tumor control and no neck recurrences 2.
• Among 23 patients who underwent neck dissection, none had pathologically positive nodes, demonstrating the extremely low yield of elective neck dissection in this disease 1.
• This contrasts with conventional oral squamous cell carcinoma, where elective neck dissection is typically recommended for oral cavity primaries based on occult metastasis risk 4.

Therapeutic Neck Dissection (N+ Neck)

• Neck dissection is indicated only when clinically positive cervical lymphadenopathy is present at initial evaluation 1, 2.
• If therapeutic neck dissection is required, a selective neck dissection encompassing levels I-IV is appropriate for buccal mucosa primaries, following standard oral cavity cancer principles 5.

Reconstruction Considerations

• Free flap reconstruction may be necessary for large defects following wide local excision, with 66% of patients in one series requiring free flap coverage 2.
• The need for microvascular access does not justify elective neck dissection in verrucous carcinoma, unlike the approach sometimes used in mucosal melanoma 4.

Adjuvant Therapy

• Radiation therapy is generally contraindicated as primary treatment for verrucous carcinoma due to historical concerns about anaplastic transformation, though this remains controversial 6, 3.
• Some evidence suggests radiotherapy may have similar efficacy to well-differentiated squamous cell carcinoma without documented anaplastic transformation in modern series 7.
• Adjuvant radiation for close margins is not routinely necessary; in one series, only 1 of 9 patients with close margins received adjuvant radiation, yet none experienced recurrence 1.

Critical Pitfalls to Avoid

• Do not extrapolate conventional oral squamous cell carcinoma protocols to verrucous carcinoma regarding neck management—the biological behavior is fundamentally different with negligible lymph node metastasis risk 1, 2.
• Avoid routine elective neck dissection based solely on T-stage, as even T3-T4 verrucous carcinomas have minimal nodal metastasis risk 2.
• Histologic misdiagnosis is common due to intact basement membrane; ensure pathologic confirmation before proceeding with less aggressive neck management 6.

Surveillance

• Close follow-up is essential given the potential for local recurrence, though disease-specific mortality remains extremely low 1, 6.
• Monitor for the rare development of regional metastases, which would warrant therapeutic intervention 2.