Maxillary Squamous Cell Carcinoma Research Articles

The strategy on managing cervical lymph nodes of patients with maxillary gingival squamous cell carcinoma

PurposeWe aimed to determine the risk of occult cervical metastasis of maxillary gingival squamous cell carcinoma (SCC), the predisposing factors for occult cervical metastasis and the therapeutic value of elective neck dissection (END) in survival of clinically negative neck node (cN0) patients. MethodsA retrospective study of patients with maxillary gingival SCC was conducted in our hospital. Clinical information including age, gender, TNM staging, pathological staging, as well as other demographic and clinical data was acquired and analyzed. The Kaplan–Meier method was used to evaluate overall survival rate. Descriptive and bivariate statistics were computed. ResultsThe sample was composed of 107 patients (43 men, 64 women). The overall lymph node metastasis (LNM) rate was 28%. The LNM rates were 7.1%, 15%, 41.7% and 44.8% for T1 to T4 stage tumors, and were 9.3%, 46.8%, and 50% for pathological grades I to III. The tumor stage and pathological grade showed a significant relationship with cervical metastasis (P < 0.01). The 5-year survival rate was higher in those who had an END (76%) when compared to those who did not receive an END (46.4%; P < 0.05). With regard to the nodal status, pN0 group had a higher survival rate than pN + group (P < 0.01). ConclusionThe results of this study suggest that the risk of LNM for SCC originating from the maxillary gingiva is higher than expected and comparable to that for other oral sites. We recommend END for T3 and T4 stage cN0 patients, especially for moderately and poorly-differentiated tumors.

Cardiac micrometastasis of maxillary squamous cell carcinoma: A rare postmortem finding

Secondary cardiac tumors are rare with an incidence of 2.3%. Common tumors metastasizing to the heart are lung, esophagus, breast, stomach, pancreas, melanoma, and colon. Only few case reports of oral squamous cell carcinoma metastasizing to the heart have been reported. Herein, we are presenting a case of a 17-year-old deceased male previously diagnosed with maxillary squamous cell carcinoma, found having multiple micrometastatic foci to the heart and lung in histopathological examination of tissues received after conducting autopsy. The involvement was limited to the myocardium with a normal pericardium and endocardium, which is not common. The case details and relevant clinical discussion are described to highlight asymptomatic, grossly inappreciable, micrometastatic foci of oral squamous cell carcinoma to myocardium.

Importance of elective neck dissection in cN0 maxillary squamous cell carcinoma

Importance of elective neck dissection in cN0 maxillary squamous cell carcinoma

Particular gene upregulation and p53 heterogeneous expression in TP53-mutated maxillary carcinoma.

It has been demonstrated that tumor protein p53 (TP53) mutation in maxillary squamous cell carcinoma, is more treatment-resistant compared with the carcinoma without TP53 mutation. However, the association between TP53 mutation and treatment resistance remains unclear. As a first step in understanding the biological differences between tumors with and without TP53 mutation, a comprehensive gene expression analysis of maxillary squamous cell carcinoma with or without TP53 mutation was performed. A total of 42 genes were identified to be differentially expressed by >4-fold. Quantification of their mRNA using quantitative polymerase chain reaction indicated 18 genes with high expression and three genes with low expression in TP53 mutated tumors vs. TP53 wild-type tumors. The 18 genes included eight cell adhesion (DSC3, GRHL1, EPPK1, PROM2, ANXA8, DSP, JUP, and KRT6B) and four cell growth inhibition (SFN, CLCA2, SAMD9 and TP63) genes. Among these genes, DSC3, SFN, and CSTA, whose expression was markedly increased, also demonstrated high protein expression in immunohistochemical staining of TP53 mutated tumors. The TP53 mutated tumors demonstrated high nuclear staining of the TP53 protein only in tumor cells at the tumor margins adjacent to the stroma, whereas the tumor interior was negative for TP53. However, all tumor cells of TP53 wild-type tumors exhibited positive nuclear staining for the TP53 protein. The combined findings suggest that TP53 mutated tumors possess a phenotype opposite to that associated with cancer progression and malignant transformation, and exhibit tumor cell heterogeneity between the tumor interior and margins.

Three-Dimensional Image Fusion of 18F-Fluorodeoxyglucose–Positron Emission Tomography/Computed Tomography and Contrast-Enhanced Computed Tomography for Computer-Assisted Planning of Maxillectomy of Recurrent Maxillary Squamous Cell Carcinoma and Defect Reconstruction

The purpose of this study was to describe new technology assisted by 3-dimensional (3D) image fusion of 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) for computer planning of a maxillectomy of recurrent maxillary squamous cell carcinoma and defect reconstruction. Treatment of recurrent maxillary squamous cell carcinoma usually includes tumor resection and free flap reconstruction. FDG-PET/CT provided images of regions of abnormal glucose uptake and thus showed metabolic tumor volume to guide tumor resection. CECT data were used to create 3D reconstructed images of vessels to show the vascular diameters and locations, so that the most suitable vein and artery could be selected during anastomosis of the free flap. The data from preoperative maxillofacial CECT scans and FDG-PET/CT imaging were imported into the navigation system (iPlan 3.0; Brainlab, Feldkirchen, Germany). Three-dimensional image fusion between FDG-PET/CT and CECT was accomplished using Brainlab software according to the position of the 2 skulls simulated in the CECT image and PET/CT image, respectively. After verification of the image fusion accuracy, the 3D reconstruction images of the metabolic tumor, vessels, and other critical structures could be visualized within the same coordinate system. These sagittal, coronal, axial, and 3D reconstruction images were used to determine the virtual osteotomy sites and reconstruction plan, which was provided to the surgeon and used for surgical navigation. The average shift of the 3D image fusion between FDG-PET/CT and CECT was less than 1mm. This technique, by clearly showing the metabolic tumor volume and the most suitable vessels for anastomosis, facilitated resection and reconstruction of recurrent maxillary squamous cell carcinoma. We used 3D image fusion of FDG-PET/CT and CECT to successfully accomplish resection and reconstruction of recurrent maxillary squamous cell carcinoma. This method has the potential to improve the clinical outcomes of these challenging procedures.

Is elective neck dissection needed in squamous cell carcinoma of maxilla?

ObjectivesTo define the risk of occult cervical metastasis of maxillary squamous cell carcinoma (SCC) and the therapeutic value of elective neck dissection (END) in survival of clinically negative neck node (cN0) patients.Materials and MethodsSixty-seven patients with maxillary SCC and cN0 neck were analyzed retrospectively, including 35 patients with maxillary gingiva and 32 patients with maxillary sinus.ResultsOf 67 patients, 10 patients (14.9%) had occult cervical metastasis. The incidence of occult cervical metastasis of maxillary gingival SCC was higher than that of maxillary sinus SCC (17.1% and 12.5%, respectively). The 5-year overall survival rate was 51.9% for the END group and 74.0% for the non-END group. The success rate of treatment for regional recurrence was high at 71.4%, whereas that for local or locoregional recurrence was low (33.3% and 0%, respectively).ConclusionThe incidence of occult cervical metastasis of maxillary SCC was not high enough to recommend END. For survival of cN0 patients, local control of the primary tumor is more important than modality of neck management. Observation of cN0 neck is recommended when early detection of regional recurrence is possible irrespective of the site or T stage. The key enabler of early detection is patient education with periodic follow-up.

Diagnosis and treatment of maxillary squamous cell carcinoma, focusing on partial maxillectomy

Diagnosis and treatment of maxillary squamous cell carcinoma, focusing on partial maxillectomy

High Numbers of Stromal Cancer-Associated Fibroblasts Are Associated With a Shorter Survival Time in Cats With Oral Squamous Cell Carcinoma.

Cancer-associated fibroblasts (CAFs) are fibroblastic cells that express α-smooth muscle actin and have been identified in the stroma of numerous epithelial tumors. The presence of CAFs within the tumor stroma has been associated with a poorer prognosis in some human cancers, including oral squamous cell carcinomas (SCCs). Cats frequently develop oral SCCs, and although these are generally highly aggressive neoplasms, there is currently a lack of prognostic markers for these tumors. The authors investigated the prognostic value of the presence of CAFs within the stroma of oral SCC biopsy specimens from 47 cats. In addition, several epidemiologic, clinical, and histologic variables were also assessed for prognostic significance. A CAF-positive stroma was identified in 35 of 47 SCCs (74.5%), and the median survival time (ST) of cats with CAF-positive SCCs (35 days) was significantly shorter than that of cats with CAF-negative SCCs (48.5 days) (P = .031). ST was also associated with the location of the primary tumor (P = .0018): the median ST for oropharyngeal SCCs (179 days) was significantly longer than for maxillary (43.5 days; P = .047), mandibular (42 days; P = .022), and sublingual SCCs (22.5 days; P = .0005). The median ST of sublingual SCCs was also shorter compared with maxillary SCCs (P = .0017). Furthermore, a significant association was identified between site and the presence of stromal CAFs (P = .025). On the basis of this retrospective study, evaluating the tumor stroma for CAFs in feline oral SCC biopsy specimens may be of potential prognostic value.

Management of the clinically N0 neck in squamous cell carcinoma of the maxillary alveolus and hard palate.

The purpose of this study was to evaluate active surveillance strategy in the clinically negative neck in maxillary squamous cell carcinoma (SCC). One hundred fourteen consecutive patients diagnosed with oral maxillary SCC were analyzed retrospectively from 3 centers in The Netherlands. Analysis parameters included regional disease-free survival of N0 patients stratified for T classification, elective radiotherapy (RT) of the neck; and overall survival of the whole cohort, stratified by N classification; salvage neck surgery rates. Within the N0 cohort, 26.0% of the patients developed neck metastasis in the follow-up visits. Regional recurrence was not related to T classification or postoperative RT of the neck. Regional and locoregional recurrence were associated with diminished overall survival (p < .05). Regional metastasis was operable in 22 of 26 cases (85%). Only 1 patient presented with inoperable neck metastasis without local recurrence. Watchful waiting was feasible in this cohort. If meticulous follow-up is not available, elective neck dissection is recommended. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1794-1798, 2016.

Elective neck dissection in oral squamous cell carcinoma of the upper maxilla: necessary?

Aim: Surgical treatment of clinically negative neck in maxillary squamous cell carcinoma (SCC) of the upper jaw is controversial. The purpose of this systematic review was to define the incidence of cervical metastasis and to assess if elective neck dissection is justified when the neck is not primarily affected.

What is the role of elective neck dissection in patients with squamous cell carcinoma of the upper jaw?

BackgroundSurgical treatment of clinically negative neck in maxillary squamous cell carcinoma (SCC) of the upper jaw is controversial. The purpose of this study was to define the incidence of cervical metastasis and to assess if elective neck dissection is justified when the neck is not primarily affected. MethodsWe retrospectively reviewed 20 patients treated of SCC of the maxillary alveolus and hard palate between 2005 and 2012. ResultsSix (30%) patients presented with cervical lymph metastasis at initial diagnosis. Two of the14 patients who initially had no signs of metastasis in the neck developed cervical metastasis during follow-up and another patient with cervical metastasis at diagnosis developed contralateral cervical metastasis. All the patients with cervical metastasis (45%) were pT3/T4 SCC. Cervical metastasis developed at a mean of 11.6 months. ConclusionsDespite this study being limited by its retrospective nature and the sample size, based on our findings and on an extensive review of the literature, we may conclude that cervical metastasis from maxillary alveolus and hard palate SCC appears most frequently in pT3/T4 tumors. Therefore, we find elective neck dissection appropriate for patients with pT3/T4 SCC of the upper jaw.

Cervical metastases of oral maxillary squamous cell carcinoma: A systematic review and meta‐analysis

Cervical treatment of oral maxillary squamous cell carcinoma (SCC) remains controversial. We determined the metastases incidence and evaluated its predictive factors. Systematic review and meta-analysis was conducted of 23 Chinese and English-language articles retrieved from PubMed, Ovid, Embase, Cochrane Library, China National Knowledge Infrastructure, and Chinese Scientific and Technological Journal databases. Total cervical metastases and occult metastases rate was 32% and 21%, respectively. Positive lymph node detection was likeliest from levels I to III. The maxillary gingival metastases rate was higher than that of the hard palate. Advanced-stage tumors had higher metastatic risk than early-stage tumors. Well-differentiated tumors had a significantly higher metastases rate than medium and poor-differentiation tumors. N0 cases had survival benefit compared with N+ cases. Metastases rate of oral maxillary SCC correlates significantly with T classification and pathological stage. T and N classifications impact outcome significantly. Therefore, levels I to III selective neck dissection is recommended for patients with T3/4 cN0 disease. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2335-E2342, 2016.

Interactive talk and discussion on latest techniques in veterinary surgery

Event Abstract Back to Event Interactive talk and discussion on latest techniques in veterinary surgery Tom Mariën1* 1 Equitom Equine Hospital, Head of Surgery, Belgium ABSTRACT Significant advances in Equine Head Surgery have been made the last years. However, radiographic and ultrasonographic examination provide insufficient information in major head pathologies. The use of CT-scan images on the other hand, allow more accurate visualization and even 3D imaging of head pathologies. This information is of great help for the surgeon not only to decide if a surgical intervention is possible, but also to plan and prepare complex head surgeries. In this regard, different important pathologies will be discussed, such as soft tissue cysts, osteosarcoma of the orbit, maxillary squamous cell carcinoma, infection of the temporomandibular joint and complex ectopic teeth in the sinus. Indeed, the clinical signs, diagnostic imaging, differential diagnosis, treatment and outcome will be presented of all these cases. The main goal of this talk is to assist the equine practitioner to recognize and identify different head pathologies in an early stage so that even life-threatening pathologies can be managed with a positive outcome. AUTHOR BIOGRAPHY Tom began his career at the University of Ghent, where he started veterinary medicine training at the age of 18 and finished six years later with honors. He worked for one year as an assistant at the Department of Surgery from the same University. Tom decided to specialize in surgery and moved to the USA (Kentucky, Ohio, San Francisco) to be trained by renown surgeons. He developed several new surgical techniques that have been published in recognized veterinary journals (such as closing the spleen-kidney area and reducing internal inguinal rings). He has been invited to speak at several international conferences and wrote several books chapters on equine surgery. In 2000, Tom returned to Belgium and opened his own clinic: Equitom. This clinic, has been recently renewed and expanded to include CT, MRI and scintigraphy. Keywords: Head, Surgery, Veterinary, Equine, medical imaging Conference: First and Second Conference on Current Veterinary Practices, Meldert-Lummen and Evergem, Belgium, 5 Mar - 26 Mar, 2016. Presentation Type: Oral Presentation Topic: Current Veterinary Practices Citation: Mariën T (2016). Interactive talk and discussion on latest techniques in veterinary surgery. Front. Vet. Sci. Conference Abstract: First and Second Conference on Current Veterinary Practices. doi: 10.3389/conf.FVETS.2016.01.00006 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 27 Jan 2016; Published Online: 29 Jan 2016. * Correspondence: DVM. Tom Mariën, Equitom Equine Hospital, Head of Surgery, Meldert-Lummen, 3560, Belgium, tom@equitom.be Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Tom Mariën Google Tom Mariën Google Scholar Tom Mariën PubMed Tom Mariën Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Occurrence of cervical lymph node metastasis of maxillary squamous cell carcinoma - A monocentric study of 171 patients.

Fewer than 5% of oral squamous cell carcinomas (SCC) are presented in the maxilla. The absence of cervical lymph node metastasis (LNM) is one of the main positive prognostic factors. This single-centre study analysed the cervical lymph node metastasis behaviour in patients with oral SCC of the upper jaw and serves as a basis for a cervical lymph node treatment suggestion. The retrospective study includes 171 patients with isolated SCC of the maxilla. In addition to tumour resection, 83% of the patients underwent a selective neck dissection (ND). The data of cervical metastasis, TNM-status, tumour grade, tumour location as well as nicotine and alcohol behaviour were statistically analysed. The average rate of cervical metastasis was 44% in total. Tumour stage significantly affected risk for cervical metastasis (T1=6%, T2=41%, T3=60% and T4=60%) (p<0.01). Development of cervical LNM was seemingly influenced by male gender. This study postulates a high rate of cervical metastasis of maxillary SCC. Risk for metastasis is mainly determined by the tumour stage. Alcohol and nicotine abuse have a negative impact on cervical LNM. Reviewing recent literature underlined by the illustrated data, we put up for discussion the treatment of SCC of the maxilla as similar to therapy protocols for SCC of the oral cavity. This would include an ipsilateral ND even in low tumour stage and in T4 staged tumours on both sides. However, prospective multicentre studies are needed to verify and recommend these therapy assumptions.

Management of the neck in maxillary sinus carcinomas.

To discuss and review the role for elective treatment of the neck in maxillary squamous cell carcinoma. Improvements in survival have been seen because of improved local therapies and control; therefore, the treatment of the neck has become a topic of debate. The risk of occult metastases in neck nodes is higher for T3-4 tumors. The rate of nodal relapse in the N0 neck without elective treatment is 8-15%. With elective irradiation the nodal relapse rate decreases. However, most nodal relapses are accompanied by local failure or distant disease. Local failure remains the most common site of failure and cause of death in this patient population. Treatment failure occurs overall in 62% of all patients, with local recurrence by far the most common site of treatment failure, which is rarely amenable to salvage therapy. Therefore, elective neck irradiation is not routinely indicated in the clinically N0 neck; those that recur only in the neck can be surgically salvaged more than 50% of the time.

Maxillary squamous cell carcinoma: diagnosis and evolution of an inoperable case

Squamous cell carcinoma (SCC) is a malignant neoplasia, originating from the oral lining epithelium, responsible for approximately 90-95% of malignancies in this location. Incidence and mortality rates for oral SCC may vary due to personal habits, socioeconomic characteristics, environmental factors and quality of health care. This study reports the aggressive evolution of SCC with a delayed diagnosis and the impossibility of immediate curative therapy. Case report: A 47-year-old brown male patient, smoker and drinker was referred by a primary health care center to the Stomatology Clinic at UFPR (Federal University of Paraná). The diagnosis of well-differentiated SCC was confirmed by histopathological examination. The patient was referred to a specialized service where an oncology team defined the case as inoperable due to lung function limitations and advanced tumor staging. The patient underwent lung physiotherapy sessions until reaching clinical conditions to undergo oncologic therapy which included radiotherapy and chemotherapy. Conclusion: The reported case highlights the importance of establishing an early diagnosis for SCC. There is a need of facilitating and speeding the access to both health care services and information that lead patients to seek professional assistance as soon as the first disease signs appear.

Feline Oral Squamous Cell Carcinoma: Clinical Manifestations and Literature Review.

Squamous cell carcinoma (SCC) is the most commonly encountered malignant oral tumor in cats. The etiology of this locally invasive tumor is likely multifactorial. Several risk factors have been identified, including the use of flea collars, and a history of feeding canned food and canned tuna. Clinical signs vary depending on tumor location. The tumor commonly arises from the gingiva and mucosa of the maxilla, mandible, tongue, sublingual area, or tonsillar region. Maxillary SCC commonly presents clinically as an ulcerative lesion, whereas mandibular SCC is commonly proliferative, expansile, and firm. Lingual/sublingual SCC may be ulcerative, necrotic, infiltrative, or proliferative. In general, feline oral SCC is an invasive and malignant neoplasm regardless of its location. Surgery, radiation therapy, chemotherapy and combinations thereof have been attempted with rarely a satisfactory response. Currently, cures are obtained only in a small subset of cats whose tumors are amenable to complete resection, or where resection with microscopic residual disease is followed by definitive radiation therapy. A multimodal treatment approach likely offers the best chance of success. For cats with advanced disease, palliative care may improve patients' quality of life, albeit transiently. Sequelae associated with tumor progression and local tissue destruction often result in euthanasia of feline patients with oral SCC.

Clinicopathological Characteristics and Outcome Predictors in Squamous Cell Carcinoma of the Maxillary Gingiva and Hard Palate

Squamous cell carcinoma (SCC) located in the maxillary gingiva and hard palate is relatively rare. There are few published guidelines for the treatment of SCC of the maxilla. The aim of the present study was to characterize the clinicopathologic features of SCC of the maxillary gingiva and hard palate and determine factors that predict outcome and lead to a strategic treatment plan. A retrospective cohort study of patients with SCC of the maxillary gingiva and hard palate was conducted from 2003 to 2012 at the Department of Oral and Maxillofacial Surgery, Affiliated Hospital of Stomatology, Nanjing Medical University. Clinicopathologic characteristics, treatments, outcome predictors, and 3- and 5-year overall survival rates were analyzed. The Kaplan-Meier method was used to evaluate 3- and 5-year overall survival rates. Univariate and multivariate Cox regression analyses were used to identify predictors of survival. A P value less than .05 was considered statistically significant. The 3- and 5-year survival rates of the 62 participants were 66.6 and 57.3%, respectively. Univariate analyses showed statistically significant (P < .05) associations between patient survival rate and tumor differentiation grade, T classification, marginal status, cervical lymphatics, and local recurrence. Occult lymph node metastases of maxillary SCC in tumor stages T2 to T4 occurred in 20 to 40% of patients. Patients who presented with lesions located after the first premolar plane area and received postoperative radiotherapy had a better prognosis. Elective neck dissection is recommended for management of T2 to T4 SCCs in the maxillary gingiva and hard palate. Postoperative radiotherapy can improve the prognosis and decrease the recurrence of SCC after the first premolar plane area.

Review of Treatment Modalities for Maxillary Cancers-Institute’s Experience Over 10 Years.

Objective : The treatment of squamous cell carcinoma of the maxilla and paranasal sinuses, radical surgery and reconstruction with free flaps is quoted in literature, but the protocol varies from center to centre. This study was performed to present our experience in the treatment of maxillary squamous cell carcinoma with surgery without reconstruction with post operative radiotherapy. Patients and Methods : Thirty patients with primary resectable squamous cell carcinoma were included in the study. The mean age was 65.6 years (20-80 years) and 53% presented in advanced tumor stage (T4). Two patients already had cervical metastases, underwent neck dissection. All patients were treated by radical surgery without reconstruction, and the resulting defects were closed primarily followed by the use of an obturator at 4-6 weeks. Results : The overall 5-year survival rate was 65.7%; the recurrence rate was 23.3%. Only patients who had stage T4 disease and positive resection margins, died during radiotherapy. The 2 patients with cervical metastases received therapeutic neck dissection and showed no regional recurrence. Conclusions : The surgical treatment without reconstruction and with postoperative radiotherapy for squamous cell carcinomas of the maxillary sinus led to good results, and can therefore be seen as a cost effective and valuable strategy. Free resection margins and early detection of the tumor are the most important factors for success. Our future focus is on orbital preservation & reconstruction of disfiguring defects following radical maxillectomy.

Cervical metastasis of maxillary squamous cell carcinoma

A retrospective study of maxillary squamous cell carcinoma (SCC) patients attending a department of oral and maxillofacial surgery was performed for the period 2000–2010. The clinical information of 100 cases treated during this period was acquired and analyzed. Patient survival was calculated using the Kaplan–Meier method. For these 100 cases, the total metastatic rate was 34.0% and occult metastatic rate was 27.5%. Positive lymph nodes were mostly detected at levels I–III. There was no significant difference in metastatic rate between the primary sites of maxillary gingiva and hard palate. Tumours involving the gingival–buccal sulcus presented a significantly higher risk of metastasis. Advanced stage (T3/4) was significantly correlated with a higher metastasis rate. The pathological grade also showed a significant relationship with metastasis. Twenty-four patients presented regional recurrence. Elective neck dissection could significantly reduce the recurrence rate. The overall 3-year and 5-year survival rates were 66.3% and 56.7%, respectively. Both the T and the N stages had a significant impact on survival rates. Selective neck dissection from level I to III is recommended for T3/4 stage cN0 patients, especially those with gingival–buccal sulcus involvement.