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Carcinoma of the palatine arch
Carcinoma of the Palatine Arch The Rationale of Treatment Selection Gerald B. Healy, MD, Boston, Massachusetts M. Stuart Strong, MD, Boston, Massachusetts Alptekin Uchmakli, MD, Boston, Massachusetts Charles W. Vaughan, MD, Boston, Massachusetts Joseph F. DiTroia, MD, Boston, Massachusetts
Carcinoma of the mucosa of the’upper aerodigestive tract is a diathesis demonstrated by many patients and may involve the mucosa of the oral cavity, pharynx, or larynx. It occurs most often in male smokers with a history of heavy alcohol ingestion [I-3]. In this study the behavior of this disease in 130 patients with carcinoma of the palatine arch will be followed and methods of management will be compared. The traditional approach to this disease will be reviewed and current methods’of treatment will be described. Arbitrarily, the palatine arch includes the mucosa of the soft palate, uvula, the tonsillar pillars, the tonsillar fossa, and the mucosa of the tonsil, if it is present. Carcinoma of the palatine arch is a common variety of carcinoma of the aerodigestive tract and is far more common than carcinoma of the tonsillar crypts which, as pointed out many years ago by MacKenzie [4], is quite rare. The biologic behavior of carcinoma of the tonsil is quite different from that of carcinoma of the palatine arch and demands separate consideration. Hyams and others have shown that there exists deep within the tonsillar crypts a nonmaturing, poorly differentiated epithelial cell at the interface of mesenchymal and ectodermal tissue. Neither an ultrastructural basement membrane nor typical epithelial desmosomes can be demonstrated around these cells. This epithelium permits free migration of lymphocytes through it. It has been demonstrated that the neoplastic manifestation of this epithelial cell has the recognizable features of poorly differFrom the Department of Otolaryngology, Boston University School of Medicine, University Hospital, and the Departments of Dtolaryngology and Radiotherapy, Boston Veterans Administration Hospital, Boston, Massachusetts. Reprint requests should be addressed to Gerald 8. Healy, MD, 300 Longwood Avenue, Boston, Massachusetts 02115. Presented at the Joint Meeting of the Society of Head and Neck Surgeons and the American Society for Head and Neck Svgery, San Diego, California, April 11-15, 1976.
498
entiated squamous epithelium and in the presence of lymphoid tissue free migration of lymphocytes through it is seen [5]. Due to its junctional location between the oral cavity anteriorly and the laryngopharynx posteriorly, the palatine arch has been a neglected area. Perhaps this has caused apathy among surgeons, so that most patients have been treated arbitrarily with radiation therapy without being considered for surgery. This approach has been further fostered by recollection of former problems with anesthesia, blood replacement, and wound breakdown, which made postoperative morbidity and mortality unacceptable. This as well as the exposure of the surgeon to a large number of “late” cases has led surgeons to believe that surgery for these lesions was ill advised. Clinical Material In 1971 our group reported on seventy-three patients with carcinoma of the palatine arch [I]. Data are now available on 130 patients treated at the University Hospital and Boston Veterans Administration Hospital from 1955 to 1975. In addition to the 130 cases of carcinoma of the palatine arch, four cases of carcinoma arising in a tonsillar crypt (carcinoma of the tonsil) are reviewed. Three of these lesions occurred in nonsmoking, nondrinking women; the lesioxis had presented as infections of the tonsil with ulceration and had been treated as such prior ta the diagnosis of carcinoma. Two of the lesions were stage I whereas one was stage III; they responded to a high dose of orthovoltage radiation, and the patients survived three years or more. The fourth patient was a heavy smoking, heavy drinking man who presented with a neck mass and a nodule deep in the substance of the tonsil without ulceration. After receiving 4,400 r of orthovoltage radiation, he refused further treatment and was free of disease for one year; however, he died two and a half years later of recurrence at the primary and metastatic sites. In none of these patients did second primary tumors develop. Carcinoma of the tonsil is exquisitely sensitive to radiotherapy and does not appear to have anything in common with carcinoma of the aerodigestive tract mucosa.
The American
Journal of Surgery
Carcinoma
I
3 Year
Interval after Admission (years)
Alive at Beginning of interval
1
II
Interval after Admission (years)
1 2 3
3 Year
of all 77 Patients
Died of Cancer during Interval
Died of Other Causes during Interval
25
77 44 27
2 3
TABLE
End-Results
Lost to Follow-up Study during Interval
4 3 0
10 7
End-Results
Treated
Treated
Alive at Beginning of Interval
Died of Cancer during Interval
Died of Other Causes during Interval
Lost to Follow-up Study during Interval
48 36 30
8 4 3
2 2 2
0 0 0
Volume 132, October 1976
Treatment and Results Radiation therapy was the primary mode of treatment in seventy-seven patients and was delivered in doses of 5,000 r or more by 250 kv machines, by 2,000 kv machines, and by cobalt 60 apparatus. Among patients treated by radiation, there were fifty-three determinate cases admitted to the study prior to December 1972. The three year survival rate by stage is as follows [7]: stage I, two of five patients; stage II, five of eighteen; stage III, two of sixteen; stage IV, zero of fourteen. The three year survival was nine of fifty-three patients or 17 per cent. When all seventy-seven cases treated by radiation are evaluated by the actuarial method, the three year survival rate is 31 per cent. (Table I.) Surgery either by transoral local resection or a composite operation was the primary method of treatment in thirty-three patients. An additional fifteen patients required operation because of residual disease after the completion of radiation therapy. There were, therefore, forty-eight patients treated surgically. The three year determinate survival rate by stage is as follows: stage I, six of seven patients; stage II, twelve of eighteen; stage III, three of six; stage IV, one of two. Twenty-two of thirtythree patients (67 per cent) survived three years. Analysis of forty-eight patients by the actuarial method gives a three year survival of 55 per cent. (Table II.) by Radiation
P21
dzi Alive during Interval
Effective Number Exposed to Risk
2 4 0
75 42 27
2 0 0
of 48 Patients
Arch
years after their initial treatment. In eight patients second primary carcinomas developed within the field of their prior radiation.
These tumors appear to be more closely related to carcinoma of the nasopharynx and should be considered similar tumors in terms of their biologic behavior and response to treatment [6]. Of the 130 patients, 125 were male and 5 female. The mean age was fifty-seven years for the males and fifty-one for the females. Etiologic Factors. All patients with neoplasms of the palatine arch in this series were heavy users of tobacco and 118 had a history of excessive alcohol intake for many years; many of these patients presented with severe liver damage. Four males had had tuberculosis and one male and one female had had syphilis. Histology. All of these lesions were squamous cell carcinoma and four patients presented with adjacent areas of leukoplakia. The degree of differentiation varied widely from patient to patient and did not appear to have prognostic significance. Staging. All patients were staged on the basis of pretherapy findings according to the American Joint Committee Staging System for Carcinoma of the Pharynx (lateral wall of the oropharynx) rather than the oral cavity. It should be noted, however, that a Ts tumor of the soft palate or uvula almost always involves the base of the tongue and hence more properly belongs to the lateral wall of the oropharynx as is done in the UICC staging system. A T3 tumor was allocated to stage III only if regional nodes were clinically palpable. There were thirteen patients with stage I disease, fifty-one with stage II, thirty-one with stage III, and thirty-five with stage IV. Multicentricity. Twenty-two patients presented with two or more primary carcinomas in the upper aerodigestive tract at the time of their original diagnosis. Second primary tumors developed in the head and neck region in fifteen patients in the follow-up period of five TABLE
of Palatine
by Surgery Withdrawn Alive during Interval
2 0 0
Percentage Dying
38.7 31 25.9
Percentage Surviving in Interval
61.3 69 74.1
Cumulative Percentage of Survivors
61.3 42.3 31.4
1221 Effective Number Exposed to Risk
Percentage Dying
Percentage Surviving in interval
47 36 30
21.3 16.7 16.7
78.7 83.3 83.3
Cumulative Percentage of Survivors
78.7 65.5 54.6
499
Healy et al
Planned combined therapy was employed in five patients; two patients received 2,000 r of cobalt 60 preoperatively in five days followed by a composite resection (as part of a protocol). Of these, one patient died in one year of massive recurrence in the neck and one patient is alive and well eight years after surgery. Three patients received a full tumor dose of cobalt 60 preoperatively followed in four to six weeks by a composite resection. Of these, two died with recurrent disease in less than one year and one patient is alive without disease one year after treatment.
or 35 per cent. Many investigators have alluded to this problem, with the reported incidence of second primary tumors varying from 10 to 38 per cent [lU,ll].
Inconspicuous Lesions. Early tumors of the palatine arch may present as areas of erythroplasia and are often considered inflammatory. Thus, they may escape detection. Recognition of these highly curable lesions requires constant vigilance on the part of those working in head and neck tumor clinics or in dental clinics. These small inconspicuous tumors may often be handled with transoral surgery. Ill Defined Tumor Margins. The exact surface margins of the tumor may be delineated by the use of a supravital stain such as toluidine blue (Figures 1 and 2); it may often show the extent of the tumor to be greater than it appeared to be. Frequently the tumor of the palatine arch itself will be multicentric 181. Multicentricity. The problem of field cancerization in the aerodigestive tract is certainly a real one [9]. In this series of 130 patients, twenty-two presented initially with more than one primary tumor, and primary tumors developed in fifteen more during their follow-up periods, making a total of thirty-seven
The three year survival of patients presenting with or developing seci>nd primary lesions during the follow-up period was eight of thirty-seven or 21 per cent. An important finding was the number of patients in whom second primary lesions developed within the field of prior radiation; eight of seventyseven patients receiving radiation were found to have second primary lesions between one and five years after radiation. These eight patients represent 19 per cent of the forty-three patients who survived one year or more after therapy. The three year survival in this group was two of eight or 25 per cent. Contralateral Nodes. Carcinomas of the midline structures are more likely to produce contralateral nodal metastases. The palatine arch, which is so richly endowed with lymphatics, is very prone to exhibit this phenomenon when it gives rise to a primary tumor. Fletcher and Lindberg [11] have reported an incidence of 24 per cent of contralateral nodes in eighty-eight cases of carcinoma of the soft palate and tonsillar fossa. In this series we found seventeen cases of contralateral nodes in 130 patients (13 per cent). Only three of these patients survived three years. Failures. Failure to survive three years may be due to death from unrelated disease or a second primary lesion or to incomplete control of the primary lesion or metastatic disease. After surgical failure the use of postoperative radiation is inevitably considered. However, results are likely to be poor due to a reduced blood supply in the presence of scar tissue.
Figure 1. Pharynx viewed from above in head-down opefating position showing iii defined lesion of right anterior tonsiiiar piiiar and tonsiiiar fossa.
wih to/u/din; blue. Note muiticerkicity especiaiiy posterior pillar unnoticed prior to staining.
Comments
500
0;
The American Journal of Surgery
Carcinoma of Palatine Arch
Failure after radiation therapy may be due to relative radioresistence. An attempt to salvage these failures can often be made by prompt surgery. However, if the residual disease becomes evident six months or more after the completion of radiation or if a new primary lesion develops in the field of radiation, surgical management is more difficult and hazardous because of the difficulty in obtaining primary wound healing. Occasionally, cryosurgery or the surgical CO2 laser is helpful for palliation in patients who are no longer candidates for surgical resection. Distant Metastases. It is generally assumed that patients with head and neck cancer die of local disease; more recently it has been found that the incidence of distant metastases is much higher than formerly thought [12]. At the time of autopsy, fourteen of twenty-six patients or 54 per cent had evidence of distant metastases. Ten of sixteen patients with stage III disease and four of eight patients with stage IV disease demonstrated this finding. Selection of Treatment. The most difficult problem in the management of patients with carcinoma of the palatine arch is the selection of the optimal treatment for each patient. As in all types of cancer the best opportunity for cure is in the hands of the initial therapist. The traditional role of radiation in the management of these patients must be reevaluated [13-181. In this nonrandomized series, patients with all stages of disease treated by radiation had a three year survival rate of 17 per cent compared with 67 per cent in those treated by surgery (p
Vohinm 132, Oclobw 1979
Flgwe3.ShacWrq#onlndkatesareaofpalattnearchIrom which tumor may be resecfed kansorally.
Figure 4. LeMns that extend to dotted lines shodtl not be treated by transoral approach but by composite resection or radiation.
ceptable functional results. If the entire soft palate must be sacrificed, an upper denture with a nasopharyngeal obturator may be fitted in order to reduce the nasopharyngeal isthmus to the appropriate size. Immediate postoperative swelling of the oropharyngeal structures is not a problem if adequate intraoperative doses of corticosteroids are used to prevent edema, so that tracheostomy may often be avoided. The transoral approach is contraindicated (Figure 4) when the tumor of the palatine arch extends to or into the base of the tongue where good exposure is difficult to obtain. Local excision of tumors that extend to the retromolar area may not be satisfactory if the disease involves the periosteum of the mandible since incapacitating trismus is to be expected if the medial pterygoid is resected only partially. When the tumor extends onto the posterior pharyngeal wall, it should not be handled transorally because deep resection at the junction of the posterior wall and the posterior tonsillar pillar may expose the carotid ar-
501
Healy et al
tery to infection and possible rupture in certain patients in whom the vessel is medially situated. Tumors of the posterior pharyngeal wall, except the most superficial lesions, commonly involve the prevertebral fascia and thus should not be handled in this manner. Composite resection: Many primary cancerous lesions that are not amenable to transoral resection can be managed with composite resection of the primary tumor with segmental resection of the mandible and radical neck dissection. Usually the surgical defect can be sealed satisfactorily without the use of a free skin graft or local flap. After portions of the soft palate and upper part of the tonsillar fossa are removed, it is not necessary to provide complete mucosal coverage of this area. It may be left open and allowed to heal secondarily as would be the case in a tonsillectomy wound. However, one must take care to provide several layers of buttressing sutures between the cheek flap and the remaining pterygoid muscles to protect the carotid artery. It is our firm opinion that radical neck dissection is the method of choice in eradicating metastatic disease from cervical nodes in the N1 stage; this may be done discontinuously when the pharynx has healed after transoral resection. Patients who have fixed nodes should have a tumorcidal dose of radiation. If the nodes become mobile and amenable to radical neck dissection, the operation may be carried out. It appears, however, that radical neck dissection adds little, in terms of survival, to these unfortunate patients [20]. Radiation therapy: This can be an effective means of handling many of these cases and requires a dosage of 5,000 r or more. If high energy radiation is skillfully applied, little skin damage results. Radiation therapy
is less likely to be effective when lesions involve the base of the tongue and is less desirable in lesions that involve the retromolar trigone area. Postirradiation edema or ulceration with bone necrosis often makes it difficult to determine the presence or absence of residual disease. Although T1 and Tz tumors of the palatine arch are most responsive to radiation therapy, they are also amenable to surgical excision, so that the use of radiation in many of these cases represents a relative “overkill.” In addition, the management of second primary tumors that may appear in the field of radiation (19 per cent in this series) may be compromised. Treatment of the first tumor should be designed to make management of the second primary lesion as uncomplicated and certain as possible. Planned combined therapy of a less than tumortidal preoperative dose of radiation followed by appropriate surgery has been advocated on the basis of retrospective studies and theoretic considerations [21]. A prospective study is nearing completion and will confirm or negate the validity of this concept. Current Approach. It is true that both radiation therapy and surgery have advantages and limitations in the management of these tumors. It is mandatory that a thorough search be made for additional primary lesions. Direct laryngoscopy and upper esophagoscopy and accurate staging of the disease are required before the particular method of treatment can be decided upon. At present we treat carcinoma of the palatine arch as follows. Stage I, II, and III disease is treated by appropriate surgery except when the primary tumor involves the posterior pharyngeal wall or the pharyngomandibular space or when a second primary tumor demands radiation (such as a T1 tumor of the vocal cord
Figure 5. Surgkaimsect&n as viewedhvm above showing defect created by surgical CO2 laser.
Figure 6. Postoperatlve view In sitting hea&up position showing fully healed defect with minimal scarring.
502
The American Journal of Surgery
Carcinoma
of Palatine Arch
or a stage IV tumor elsewhere). The good functional results, the short convalescence, and the low morbidity that results in most cases make transoral local resection a satisfactory method of managing many T, and Tz tumors. Diathermy excision and more recently the surgical laser have been most satisfactory in this regard. (Figures 5 and 6.) Stage IV tumors are usually treated with a full tumorcidal dose of radiation and evaluated six weeks post therapy and appropriate surgery is considered when technically feasible. Our recent experience, however, in patients with fixed nodes seemed to indicate that surgery adds little to survival, and if the trend continues, secondary surgery of this type may be abandoned. Patients with carcinoma arising in the tonsillar crypts (carcinoma of the tonsil) are treated by radiation alone; in the presence of metastatic nodes, radical neck dissection is advised if the nodes do not vanish after radiation. Careful follow-up study must be undertaken and will often detect other primary lesions in the aerodigestive tract especially when the patient cannot be persuaded to stop smoking. These may be handled by either surgery or radiation depending on which seems most appropriate at the time. Patients presenting with incurable disease and those who fail to respond to surgery, to radiation, or to both should continue to receive understanding and supportive therapy during the terminal days of their illness.
chosen method of treatment by either the surgeon or the radiotherapist, and continuous follow-up study and supportive treatment for the rest of the patient’s life.
Summary
14.
1. Carcinoma of the palatine arch is part of a regional diathesis of carcinoma of the mucosa of the upper aerodigestive tract and this concept has a definite influence on the choice of treatment. 2. Surgery has animportant role in the management of both the primary tumors and the regional metastatic nodes. 3. Radiation therapy is indispensible in the management of carcinoma of the tonsillar crypts, stage IV tumors of the palatine arch, and primary tumors of the palatine arch with certain specific extensions. 4. Comprehensive management of carcinoma of the palatine arch requires careful evaluation of each patient and his disease, vigorous application of the
15.
Volume 135 October 1976
References 1. Strong MS, DiTroia JF, Vaughan CW: Carcinoma of the palatine arch. Trans Am AC@ Ophthalmol Otolaryngol 75: 957, 1971. 2. Seda HJ, Snow JB: Carcinoma of the tonsil. Arch Otolaryngol 69: 756, 1969. 3. Neal CL, Snow JB, Seda HJ: Analysis of therapy for carcinoma of the tonsil. Trans Am Acad Ophthe/mo/ Otolaryngol77: 97, 1973. 4. MacKenzie M: Diseases of the larynx, pharynx and trachea. New York, William Wood, 1660, p 62. 5. Stram JR: Topographical histologyof the oral cavity. Otolam/ C/in North Am 5: 201, 1972. 6. Daly JF: Cancer of the tonsil. Oto/aryngo/ C/in North Am 2: 595, 1969. 7. American Joint Committee for Cancer Staging and End-Results Reporting. Clinical staging system for carcinomaof the oral
cavity.9: 7, 1967. 6. 9. 10.
11.
12.
13.
16. 17. 16. 19. 20.
21.
22.
Strong MS, Vaughan CW, lncze JS: Toluidine blue in the management of carcinoma of the oral cavity. Arch Otolaryngol 67: 527, 1966. Slaughter DP, Southwick HW, Smejkel W: Field cancerization inoral stratified epithelium. Cancer 6: 963, 1953. Whicker JH, DeSanto LW, Devine KD: Surgical treatment of squamous cell carcinoma of the tonsil. Laryngoscope 64: 90, 1974. Fletcher GH, Lindberg RD: Squamous cell carcinoma of the tonsillar area and palatine arch. Am J Roentgenol96: 574, 1966. Probert JC, Thompson RW, Bagshaw MA: Patterns of spread of distant metastases in head and neck cancer. Cancer 33: 127, 1974. Seydel HG, Scholl H: Carcinoma of the soft palate and uvula. Am J Roentgenol20: 603, 1974. Fayos JV, Lampe I: Radiation therapy of carcinoma of the tonsillar region. Am J Roentgenol 111: 65, 1971. Calomel PM, Hoffmeister FS: Carcinoma of the tonsil: comparison of surgical and radiation therapy. Am J Surg 114: 582, 1967. Staple HW, Holtz S, Ogura J, Powers WE: Carcinoma of the tonsil. Missouri J Med 62: 909, 1965. Ratzer ER, Schweitzer RJ, Frazell EL: Epidermoid carcinoma of the palate. Am J Surg 119: 294, 1970. Schulz MD: Tonsil and palatine arch cancer: treatment by radiotherapy. Laryngoscope 75: 956, 1965. Strong MS, Jako GJ, Polanyi T, Wallace RA: Laser surgery in the aerodigestive tract. Am J Surg 126: 529, 1973. Santos VB, Strong MS, Vaughan CW, DiTroia JF: Role of surgery in head and neck cancer with fixed nodes. Arch Otolaryngol 101: 645, 1975. Rolander TL, Everts EC, Shumrick DA: Carcinoma of the tonsil: a planned combined therapy approach. Laryngoscope 61: 1199, 1971. American Joint Committee for Cancer Staging and End-Results Reporting. Reporting of cancer survival and end-results. 3: 10, July 1963.
503
Carcinoma of the mucosa of the’upper aerodigestive tract is a diathesis demonstrated by many patients and may involve the mucosa of the oral cavity, pharynx, or larynx. It occurs most often in male smokers with a history of heavy alcohol ingestion [I-3]. In this study the behavior of this disease in 130 patients with carcinoma of the palatine arch will be followed and methods of management will be compared. The traditional approach to this disease will be reviewed and current methods’of treatment will be described. Arbitrarily, the palatine arch includes the mucosa of the soft palate, uvula, the tonsillar pillars, the tonsillar fossa, and the mucosa of the tonsil, if it is present. Carcinoma of the palatine arch is a common variety of carcinoma of the aerodigestive tract and is far more common than carcinoma of the tonsillar crypts which, as pointed out many years ago by MacKenzie [4], is quite rare. The biologic behavior of carcinoma of the tonsil is quite different from that of carcinoma of the palatine arch and demands separate consideration. Hyams and others have shown that there exists deep within the tonsillar crypts a nonmaturing, poorly differentiated epithelial cell at the interface of mesenchymal and ectodermal tissue. Neither an ultrastructural basement membrane nor typical epithelial desmosomes can be demonstrated around these cells. This epithelium permits free migration of lymphocytes through it. It has been demonstrated that the neoplastic manifestation of this epithelial cell has the recognizable features of poorly differFrom the Department of Otolaryngology, Boston University School of Medicine, University Hospital, and the Departments of Dtolaryngology and Radiotherapy, Boston Veterans Administration Hospital, Boston, Massachusetts. Reprint requests should be addressed to Gerald 8. Healy, MD, 300 Longwood Avenue, Boston, Massachusetts 02115. Presented at the Joint Meeting of the Society of Head and Neck Surgeons and the American Society for Head and Neck Svgery, San Diego, California, April 11-15, 1976.
498
entiated squamous epithelium and in the presence of lymphoid tissue free migration of lymphocytes through it is seen [5]. Due to its junctional location between the oral cavity anteriorly and the laryngopharynx posteriorly, the palatine arch has been a neglected area. Perhaps this has caused apathy among surgeons, so that most patients have been treated arbitrarily with radiation therapy without being considered for surgery. This approach has been further fostered by recollection of former problems with anesthesia, blood replacement, and wound breakdown, which made postoperative morbidity and mortality unacceptable. This as well as the exposure of the surgeon to a large number of “late” cases has led surgeons to believe that surgery for these lesions was ill advised. Clinical Material In 1971 our group reported on seventy-three patients with carcinoma of the palatine arch [I]. Data are now available on 130 patients treated at the University Hospital and Boston Veterans Administration Hospital from 1955 to 1975. In addition to the 130 cases of carcinoma of the palatine arch, four cases of carcinoma arising in a tonsillar crypt (carcinoma of the tonsil) are reviewed. Three of these lesions occurred in nonsmoking, nondrinking women; the lesioxis had presented as infections of the tonsil with ulceration and had been treated as such prior ta the diagnosis of carcinoma. Two of the lesions were stage I whereas one was stage III; they responded to a high dose of orthovoltage radiation, and the patients survived three years or more. The fourth patient was a heavy smoking, heavy drinking man who presented with a neck mass and a nodule deep in the substance of the tonsil without ulceration. After receiving 4,400 r of orthovoltage radiation, he refused further treatment and was free of disease for one year; however, he died two and a half years later of recurrence at the primary and metastatic sites. In none of these patients did second primary tumors develop. Carcinoma of the tonsil is exquisitely sensitive to radiotherapy and does not appear to have anything in common with carcinoma of the aerodigestive tract mucosa.
The American
Journal of Surgery
Carcinoma
I
3 Year
Interval after Admission (years)
Alive at Beginning of interval
1
II
Interval after Admission (years)
1 2 3
3 Year
of all 77 Patients
Died of Cancer during Interval
Died of Other Causes during Interval
25
77 44 27
2 3
TABLE
End-Results
Lost to Follow-up Study during Interval
4 3 0
10 7
End-Results
Treated
Treated
Alive at Beginning of Interval
Died of Cancer during Interval
Died of Other Causes during Interval
Lost to Follow-up Study during Interval
48 36 30
8 4 3
2 2 2
0 0 0
Volume 132, October 1976
Treatment and Results Radiation therapy was the primary mode of treatment in seventy-seven patients and was delivered in doses of 5,000 r or more by 250 kv machines, by 2,000 kv machines, and by cobalt 60 apparatus. Among patients treated by radiation, there were fifty-three determinate cases admitted to the study prior to December 1972. The three year survival rate by stage is as follows [7]: stage I, two of five patients; stage II, five of eighteen; stage III, two of sixteen; stage IV, zero of fourteen. The three year survival was nine of fifty-three patients or 17 per cent. When all seventy-seven cases treated by radiation are evaluated by the actuarial method, the three year survival rate is 31 per cent. (Table I.) Surgery either by transoral local resection or a composite operation was the primary method of treatment in thirty-three patients. An additional fifteen patients required operation because of residual disease after the completion of radiation therapy. There were, therefore, forty-eight patients treated surgically. The three year determinate survival rate by stage is as follows: stage I, six of seven patients; stage II, twelve of eighteen; stage III, three of six; stage IV, one of two. Twenty-two of thirtythree patients (67 per cent) survived three years. Analysis of forty-eight patients by the actuarial method gives a three year survival of 55 per cent. (Table II.) by Radiation
P21
dzi Alive during Interval
Effective Number Exposed to Risk
2 4 0
75 42 27
2 0 0
of 48 Patients
Arch
years after their initial treatment. In eight patients second primary carcinomas developed within the field of their prior radiation.
These tumors appear to be more closely related to carcinoma of the nasopharynx and should be considered similar tumors in terms of their biologic behavior and response to treatment [6]. Of the 130 patients, 125 were male and 5 female. The mean age was fifty-seven years for the males and fifty-one for the females. Etiologic Factors. All patients with neoplasms of the palatine arch in this series were heavy users of tobacco and 118 had a history of excessive alcohol intake for many years; many of these patients presented with severe liver damage. Four males had had tuberculosis and one male and one female had had syphilis. Histology. All of these lesions were squamous cell carcinoma and four patients presented with adjacent areas of leukoplakia. The degree of differentiation varied widely from patient to patient and did not appear to have prognostic significance. Staging. All patients were staged on the basis of pretherapy findings according to the American Joint Committee Staging System for Carcinoma of the Pharynx (lateral wall of the oropharynx) rather than the oral cavity. It should be noted, however, that a Ts tumor of the soft palate or uvula almost always involves the base of the tongue and hence more properly belongs to the lateral wall of the oropharynx as is done in the UICC staging system. A T3 tumor was allocated to stage III only if regional nodes were clinically palpable. There were thirteen patients with stage I disease, fifty-one with stage II, thirty-one with stage III, and thirty-five with stage IV. Multicentricity. Twenty-two patients presented with two or more primary carcinomas in the upper aerodigestive tract at the time of their original diagnosis. Second primary tumors developed in the head and neck region in fifteen patients in the follow-up period of five TABLE
of Palatine
by Surgery Withdrawn Alive during Interval
2 0 0
Percentage Dying
38.7 31 25.9
Percentage Surviving in Interval
61.3 69 74.1
Cumulative Percentage of Survivors
61.3 42.3 31.4
1221 Effective Number Exposed to Risk
Percentage Dying
Percentage Surviving in interval
47 36 30
21.3 16.7 16.7
78.7 83.3 83.3
Cumulative Percentage of Survivors
78.7 65.5 54.6
499
Healy et al
Planned combined therapy was employed in five patients; two patients received 2,000 r of cobalt 60 preoperatively in five days followed by a composite resection (as part of a protocol). Of these, one patient died in one year of massive recurrence in the neck and one patient is alive and well eight years after surgery. Three patients received a full tumor dose of cobalt 60 preoperatively followed in four to six weeks by a composite resection. Of these, two died with recurrent disease in less than one year and one patient is alive without disease one year after treatment.
or 35 per cent. Many investigators have alluded to this problem, with the reported incidence of second primary tumors varying from 10 to 38 per cent [lU,ll].
Inconspicuous Lesions. Early tumors of the palatine arch may present as areas of erythroplasia and are often considered inflammatory. Thus, they may escape detection. Recognition of these highly curable lesions requires constant vigilance on the part of those working in head and neck tumor clinics or in dental clinics. These small inconspicuous tumors may often be handled with transoral surgery. Ill Defined Tumor Margins. The exact surface margins of the tumor may be delineated by the use of a supravital stain such as toluidine blue (Figures 1 and 2); it may often show the extent of the tumor to be greater than it appeared to be. Frequently the tumor of the palatine arch itself will be multicentric 181. Multicentricity. The problem of field cancerization in the aerodigestive tract is certainly a real one [9]. In this series of 130 patients, twenty-two presented initially with more than one primary tumor, and primary tumors developed in fifteen more during their follow-up periods, making a total of thirty-seven
The three year survival of patients presenting with or developing seci>nd primary lesions during the follow-up period was eight of thirty-seven or 21 per cent. An important finding was the number of patients in whom second primary lesions developed within the field of prior radiation; eight of seventyseven patients receiving radiation were found to have second primary lesions between one and five years after radiation. These eight patients represent 19 per cent of the forty-three patients who survived one year or more after therapy. The three year survival in this group was two of eight or 25 per cent. Contralateral Nodes. Carcinomas of the midline structures are more likely to produce contralateral nodal metastases. The palatine arch, which is so richly endowed with lymphatics, is very prone to exhibit this phenomenon when it gives rise to a primary tumor. Fletcher and Lindberg [11] have reported an incidence of 24 per cent of contralateral nodes in eighty-eight cases of carcinoma of the soft palate and tonsillar fossa. In this series we found seventeen cases of contralateral nodes in 130 patients (13 per cent). Only three of these patients survived three years. Failures. Failure to survive three years may be due to death from unrelated disease or a second primary lesion or to incomplete control of the primary lesion or metastatic disease. After surgical failure the use of postoperative radiation is inevitably considered. However, results are likely to be poor due to a reduced blood supply in the presence of scar tissue.
Figure 1. Pharynx viewed from above in head-down opefating position showing iii defined lesion of right anterior tonsiiiar piiiar and tonsiiiar fossa.
wih to/u/din; blue. Note muiticerkicity especiaiiy posterior pillar unnoticed prior to staining.
Comments
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0;
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Failure after radiation therapy may be due to relative radioresistence. An attempt to salvage these failures can often be made by prompt surgery. However, if the residual disease becomes evident six months or more after the completion of radiation or if a new primary lesion develops in the field of radiation, surgical management is more difficult and hazardous because of the difficulty in obtaining primary wound healing. Occasionally, cryosurgery or the surgical CO2 laser is helpful for palliation in patients who are no longer candidates for surgical resection. Distant Metastases. It is generally assumed that patients with head and neck cancer die of local disease; more recently it has been found that the incidence of distant metastases is much higher than formerly thought [12]. At the time of autopsy, fourteen of twenty-six patients or 54 per cent had evidence of distant metastases. Ten of sixteen patients with stage III disease and four of eight patients with stage IV disease demonstrated this finding. Selection of Treatment. The most difficult problem in the management of patients with carcinoma of the palatine arch is the selection of the optimal treatment for each patient. As in all types of cancer the best opportunity for cure is in the hands of the initial therapist. The traditional role of radiation in the management of these patients must be reevaluated [13-181. In this nonrandomized series, patients with all stages of disease treated by radiation had a three year survival rate of 17 per cent compared with 67 per cent in those treated by surgery (p
Vohinm 132, Oclobw 1979
Flgwe3.ShacWrq#onlndkatesareaofpalattnearchIrom which tumor may be resecfed kansorally.
Figure 4. LeMns that extend to dotted lines shodtl not be treated by transoral approach but by composite resection or radiation.
ceptable functional results. If the entire soft palate must be sacrificed, an upper denture with a nasopharyngeal obturator may be fitted in order to reduce the nasopharyngeal isthmus to the appropriate size. Immediate postoperative swelling of the oropharyngeal structures is not a problem if adequate intraoperative doses of corticosteroids are used to prevent edema, so that tracheostomy may often be avoided. The transoral approach is contraindicated (Figure 4) when the tumor of the palatine arch extends to or into the base of the tongue where good exposure is difficult to obtain. Local excision of tumors that extend to the retromolar area may not be satisfactory if the disease involves the periosteum of the mandible since incapacitating trismus is to be expected if the medial pterygoid is resected only partially. When the tumor extends onto the posterior pharyngeal wall, it should not be handled transorally because deep resection at the junction of the posterior wall and the posterior tonsillar pillar may expose the carotid ar-
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tery to infection and possible rupture in certain patients in whom the vessel is medially situated. Tumors of the posterior pharyngeal wall, except the most superficial lesions, commonly involve the prevertebral fascia and thus should not be handled in this manner. Composite resection: Many primary cancerous lesions that are not amenable to transoral resection can be managed with composite resection of the primary tumor with segmental resection of the mandible and radical neck dissection. Usually the surgical defect can be sealed satisfactorily without the use of a free skin graft or local flap. After portions of the soft palate and upper part of the tonsillar fossa are removed, it is not necessary to provide complete mucosal coverage of this area. It may be left open and allowed to heal secondarily as would be the case in a tonsillectomy wound. However, one must take care to provide several layers of buttressing sutures between the cheek flap and the remaining pterygoid muscles to protect the carotid artery. It is our firm opinion that radical neck dissection is the method of choice in eradicating metastatic disease from cervical nodes in the N1 stage; this may be done discontinuously when the pharynx has healed after transoral resection. Patients who have fixed nodes should have a tumorcidal dose of radiation. If the nodes become mobile and amenable to radical neck dissection, the operation may be carried out. It appears, however, that radical neck dissection adds little, in terms of survival, to these unfortunate patients [20]. Radiation therapy: This can be an effective means of handling many of these cases and requires a dosage of 5,000 r or more. If high energy radiation is skillfully applied, little skin damage results. Radiation therapy
is less likely to be effective when lesions involve the base of the tongue and is less desirable in lesions that involve the retromolar trigone area. Postirradiation edema or ulceration with bone necrosis often makes it difficult to determine the presence or absence of residual disease. Although T1 and Tz tumors of the palatine arch are most responsive to radiation therapy, they are also amenable to surgical excision, so that the use of radiation in many of these cases represents a relative “overkill.” In addition, the management of second primary tumors that may appear in the field of radiation (19 per cent in this series) may be compromised. Treatment of the first tumor should be designed to make management of the second primary lesion as uncomplicated and certain as possible. Planned combined therapy of a less than tumortidal preoperative dose of radiation followed by appropriate surgery has been advocated on the basis of retrospective studies and theoretic considerations [21]. A prospective study is nearing completion and will confirm or negate the validity of this concept. Current Approach. It is true that both radiation therapy and surgery have advantages and limitations in the management of these tumors. It is mandatory that a thorough search be made for additional primary lesions. Direct laryngoscopy and upper esophagoscopy and accurate staging of the disease are required before the particular method of treatment can be decided upon. At present we treat carcinoma of the palatine arch as follows. Stage I, II, and III disease is treated by appropriate surgery except when the primary tumor involves the posterior pharyngeal wall or the pharyngomandibular space or when a second primary tumor demands radiation (such as a T1 tumor of the vocal cord
Figure 5. Surgkaimsect&n as viewedhvm above showing defect created by surgical CO2 laser.
Figure 6. Postoperatlve view In sitting hea&up position showing fully healed defect with minimal scarring.
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or a stage IV tumor elsewhere). The good functional results, the short convalescence, and the low morbidity that results in most cases make transoral local resection a satisfactory method of managing many T, and Tz tumors. Diathermy excision and more recently the surgical laser have been most satisfactory in this regard. (Figures 5 and 6.) Stage IV tumors are usually treated with a full tumorcidal dose of radiation and evaluated six weeks post therapy and appropriate surgery is considered when technically feasible. Our recent experience, however, in patients with fixed nodes seemed to indicate that surgery adds little to survival, and if the trend continues, secondary surgery of this type may be abandoned. Patients with carcinoma arising in the tonsillar crypts (carcinoma of the tonsil) are treated by radiation alone; in the presence of metastatic nodes, radical neck dissection is advised if the nodes do not vanish after radiation. Careful follow-up study must be undertaken and will often detect other primary lesions in the aerodigestive tract especially when the patient cannot be persuaded to stop smoking. These may be handled by either surgery or radiation depending on which seems most appropriate at the time. Patients presenting with incurable disease and those who fail to respond to surgery, to radiation, or to both should continue to receive understanding and supportive therapy during the terminal days of their illness.
chosen method of treatment by either the surgeon or the radiotherapist, and continuous follow-up study and supportive treatment for the rest of the patient’s life.
Summary
14.
1. Carcinoma of the palatine arch is part of a regional diathesis of carcinoma of the mucosa of the upper aerodigestive tract and this concept has a definite influence on the choice of treatment. 2. Surgery has animportant role in the management of both the primary tumors and the regional metastatic nodes. 3. Radiation therapy is indispensible in the management of carcinoma of the tonsillar crypts, stage IV tumors of the palatine arch, and primary tumors of the palatine arch with certain specific extensions. 4. Comprehensive management of carcinoma of the palatine arch requires careful evaluation of each patient and his disease, vigorous application of the
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Volume 135 October 1976
References 1. Strong MS, DiTroia JF, Vaughan CW: Carcinoma of the palatine arch. Trans Am AC@ Ophthalmol Otolaryngol 75: 957, 1971. 2. Seda HJ, Snow JB: Carcinoma of the tonsil. Arch Otolaryngol 69: 756, 1969. 3. Neal CL, Snow JB, Seda HJ: Analysis of therapy for carcinoma of the tonsil. Trans Am Acad Ophthe/mo/ Otolaryngol77: 97, 1973. 4. MacKenzie M: Diseases of the larynx, pharynx and trachea. New York, William Wood, 1660, p 62. 5. Stram JR: Topographical histologyof the oral cavity. Otolam/ C/in North Am 5: 201, 1972. 6. Daly JF: Cancer of the tonsil. Oto/aryngo/ C/in North Am 2: 595, 1969. 7. American Joint Committee for Cancer Staging and End-Results Reporting. Clinical staging system for carcinomaof the oral
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Strong MS, Vaughan CW, lncze JS: Toluidine blue in the management of carcinoma of the oral cavity. Arch Otolaryngol 67: 527, 1966. Slaughter DP, Southwick HW, Smejkel W: Field cancerization inoral stratified epithelium. Cancer 6: 963, 1953. Whicker JH, DeSanto LW, Devine KD: Surgical treatment of squamous cell carcinoma of the tonsil. Laryngoscope 64: 90, 1974. Fletcher GH, Lindberg RD: Squamous cell carcinoma of the tonsillar area and palatine arch. Am J Roentgenol96: 574, 1966. Probert JC, Thompson RW, Bagshaw MA: Patterns of spread of distant metastases in head and neck cancer. Cancer 33: 127, 1974. Seydel HG, Scholl H: Carcinoma of the soft palate and uvula. Am J Roentgenol20: 603, 1974. Fayos JV, Lampe I: Radiation therapy of carcinoma of the tonsillar region. Am J Roentgenol 111: 65, 1971. Calomel PM, Hoffmeister FS: Carcinoma of the tonsil: comparison of surgical and radiation therapy. Am J Surg 114: 582, 1967. Staple HW, Holtz S, Ogura J, Powers WE: Carcinoma of the tonsil. Missouri J Med 62: 909, 1965. Ratzer ER, Schweitzer RJ, Frazell EL: Epidermoid carcinoma of the palate. Am J Surg 119: 294, 1970. Schulz MD: Tonsil and palatine arch cancer: treatment by radiotherapy. Laryngoscope 75: 956, 1965. Strong MS, Jako GJ, Polanyi T, Wallace RA: Laser surgery in the aerodigestive tract. Am J Surg 126: 529, 1973. Santos VB, Strong MS, Vaughan CW, DiTroia JF: Role of surgery in head and neck cancer with fixed nodes. Arch Otolaryngol 101: 645, 1975. Rolander TL, Everts EC, Shumrick DA: Carcinoma of the tonsil: a planned combined therapy approach. Laryngoscope 61: 1199, 1971. American Joint Committee for Cancer Staging and End-Results Reporting. Reporting of cancer survival and end-results. 3: 10, July 1963.
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