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An Evaluation of Radical “In-Continuity” Resection in Cancer of the Head and Neck
An Evaluation of Radical ~~In.Continuity" Resection in Cancer of the Head and Neck G. DAVID KING
THE use of radical "in-continuity" resection in dealing with head and neck cancer has been relatively recent. The term, in-continuity, refers to resection of a primary lesion together with all homolateral and, in some cases, contralateral cervical lymph nodes, all soft tissue between the nodes and the primary lesion and, if necessary, bone and skin. This approach has been utilized in place of the older method whereby local or transoral removal of a primary lesion was followed by conventional radical neck dissection at the same time or at a later date. That the composite in-continuity procedure is associated with higher mortality and is more disabling and technically more formidable cannot be disputed. This is especially true when the procedure is applied to composite jaw resections and, to a lesser extent, in composite laryngectomy which exposes the neck wound to infected pharyngeal secretions. In performing resection for tumors of the skin and salivary glands, the composite procedure is not appreciably more hazardous than radical neck dissection itself. An en bloc procedure, on the other hand, permits much better exposure of the primary lesion and a more extensive resection when necessary. We must consider whether or not this advantage results in a significantly higher rate of cure. With this thought in mind, a group of 55 consecutive patients treated at this clinic from 1949 to 1953 by incontinuity resection or by a "discontinuous" series of operations has been analyzed. All of these patients have had follow-up studies for five years or until death. In general, the in-continuity type of operation was utilized in dealing with the bulkier lesions, often in the presence of enlarged lymph nodes or invasion of the mandible, soft tissues or skin. The discontinuous procedure was usually employed in patients with smaller primary lesions, no palpable lymph nodes or uncomplicated skin and lip carcinomas; in such cases, in-continuity dissection is not usually considered. Discon655
G. David King
656
tinuous neck dissection was usually indicated when nodes became enlarged. The cases were classified according to the site of the primary lesion and these were divided into larynx, lip, tongue and general oral area (including the buccal mucous membrane, gingiva, floor of the mouth, palate and tonsils). A miscellaneous group included salivary gland tumors, one malignant melanoma, one metastatic pheochromocytoma from a previously resected primary lesion in the adrenal gland, and two cases in which radical neck dissection was carried out without discovery of a primary lesion (Table 1). Table 1 RELATION OF CONTROL TO TYPE OF OPERATION AND SITE OF MALIGNANT DISEASE IN-CONTINUITY
Control Lip .......................... Mouth (except tongue) ........ Tongue ............... Larynx ............... Miscellaneous ...
0 4 2 8 2 16
DISCONTINUOUS
Recurrence or Operative Death
Control
Recurrence or Operative Death
3* 1* 4* 6* 3 17
3 2 1 5 4 15
0 4 4 4 1 13
* See Table 2. For purposes of this study, it was considered that control had been established over a primary lesion if both the primary site and the resected area remained free of disease despite the subsequent appearance of metastases in other areas or the development of distant metastases. The former type usually appeared in the opposite side of the neck (six cases) and it was necessary to carry out the operation discontinuously from the primary site. Distant metastases developed in two instances. The two cases are included because the metastatic spread did not preclude a five year follow-up of control at the resected site. The discontinuous contralateral radical neck dissections following a homolateral incontinuity procedure were evaluated with regard to their effectiveness in controlling metastatic disease. ANALYSIS OF DATA
A total of 61 operations were performed on 55 patients; 33 of these procedures consisted of en bloc dissection of the primary tumor together with intervening tissue, including the mandible and skin when necessary and the cervical lymph nodes. All neck dissections were complete. Twenty-eight discontinuous procedures were carried out; radical neck
Resection in Cancer of the Head and Neck
657
dissection alone was performed when the disease had previously been controlled by surgery, radiation, or both. The control rates for both methods were approximately the same-nearly 50 per cent in each group. Four operative deaths occurred in the group of 33 in-continuity procedures (Table 2). The in-continuity procedures for lip cancer were massive; mandible resection was required in all cases because of invasion, and treatment was of no avail. That control was established in the three patients with cervical lymph node metastases from previously controlled primary lip lesions serves to substantiate the opinion that prophylactic neck dissecTable 2
MORTALITY: ANALYSIS OF FOUR DEATHS IN 33 CASES
CASE
AGE AND SEX
1
50 M
2
80 M
3
50 F
4
64 M
DISEASE
PROCEDURE
CAUSE OF DEATH
DAYS AFTER OPERATION
Carcinoma of pyri- Laryngopharyngecform sinus with tomy; left radical metastases neck dissection
13
Carcinoma of lip with invasion of mandible
12
Carcinoma of floor of mouth, with invasion of mandible and metastases Carcinoma of base of tongue
Massive wound infection; carotid rupture Tracheotomy; re- Aspiration section of lip, pneumonmandible and left itis neck dissection Tongue-jaw-neck Cardiac failure dissection; (previous tracheotomy severe right heart disease) Tongue-jaw-neck Staphylococcic dissection; enterocolitis tracheotomy
2
28*
* Two weeks after hospital discharge. tion is unnecessary in these patients since they represent only a small percentage of the group in which primary lesions of the lip were treated without development of metastases. Prophylactic radical neck dissection would not have helped any of the patients in whom subsequent jaw invasion required the performance of composite operations. Our experience in the treatment of oral lesions indicates the definite superiority of the in-continuity approach to these problems. A wide transoral excision is difficult, and division of the mandible (with or without resection) provides excellent exposure and allows satisfactory repair. One patient survived in satisfactory condition after marginal resection of the mandible, excision of the floor of the mouth, partial glossectomy and bilateral radical neck dissection in continuity; the internal jugular
658
G. David King
vein on the contralateral side was preserved. The discontinuous operations within the mouth were generally carried out for carcinoma of the palate or of the buccal mucosa; the technical difficulties of performing an in-continuity resection under such circumstances may be appreciated. In view of the less effective control following discontinuous surgery, it has more recently been our practice to remove a portion of the mandible (and maxilla if necessary) and the buccal mucous membrane widely in continuity with the contents of the neck; the defect between the upper buccal sulcus and the lingual mucosa is bridged with a split-thickness skin graft rather than attempting to bring these two widely separated structures together. In cases of tongue carcinoma, closure is much easier and healing is usually satisfactory. The intrinsically malignant nature of these lesions makes it difficult to obtain good results by any method, however. CARCINOMA OF THE LARYNX
It seems of special interest to point out the good results in the group of patients with laryngeal cancer since, as stated above, bulky extraglottic disease was present in most of the patients treated by composite operation and obvious cervical metastases were found in some cases. Results in this group were comparable to those obtained in the group with localized supraglottic or glottic carcinomas without obvious metastases at the time of laryngectomy. It is our opinion that in all cases of extraglottic carcinomas treated surgically, complete radical neck dissection should be carried out simultaneously in continuity with resection of the primary tumor. We believe that the four patients who died after discontinuous surgery could have been cured by application of this method. In the miscellaneous group, all in-continuity resections included large amounts of skin, or skin plus total parotidectomy and neck contents. The patients submitted to discontinuous operation, on the other hand, usually had cervical metastases from low grade salivary gland carcinomas appearing years after the initial excisions. In one case in which radical neck dissection was carried out, however, no primary tumor had been found preoperatively or was found at operation, and the patient is still well five years later. MORTALITY
The mortality rate for the in-continuity procedure was high-four deaths in 33 operations, or 12 per cent (Table 2). Jaw resection causes paralysis of deglutition and aspiration of mouth secretions, and _allows mouth organisms to reach the neck wound. In these large procedures iatrogenic diseases caused by massive blood transfusions, antibiotics and other drugs, surgical wound infections, and the sometimes devastating effects of repeated tracheal suction must be considered. This state of
Resection in Cancer of the Head and Neck
659
affairs leads to morbidity and mortality, and for this reason in-continuity procedures should not necessarily be carried out in all of these cases, even though such an operation may be technically feasible. The elderly patient (Case 2) and the cardiac patient (Case 4) might have been treated palliatively by radiation. The morbidity and mortality rates also lead us to the conclusion that in-continuity operations of major stature should never be intentionally carried out as palliative procedures, although the operative exploration may reveal that this is necessary. These patients require a long period of rehabilitation and it is no comfort to the patient to know that an operation carried out a few weeks or months before for removal of a fungating or foul-smelling tumor has only postponed its reappearance until a later date. In the interim the patient must be fed by a nasogastric tube, undergo tracheotomy and use a suction apparatus after hospital discharge, and is now minus part of his mouth and face and usually a considerable sum of money, without ever having enjoyed any comfort from this so-called palliative procedure. SUMMARY
A series of 55 consecutive patients submitted to in-continuity or discontinuous dissection for various types of head and neck cancer has been studied to determine whether or not the additional morbidity and mortality associated with in-continuity operations is justifiable because of better results. In dealing with carcinoma of the floor of the mouth and of the larynx, this procedure has proved definitely superior to discontinuous procedures. It is hoped that application of this operation to carcinomas of the palate and buccal mucosa will, in the future, elicit better results than those obtained at present by the discontinuous method. The benefits in cases of tongue carcinoma are more questionable because of their intrinsically higher level of biological activity. A substantial morbidity and mortality are associated with the in-continuity procedure, and for this reason it should not be employed routinely. This is not to imply that only a few patients should be treated by this method, but rather that a few patients should be omitted from the group in which in-continuity surgery would normally be indicated. Only in this way will we be able to produce maximal benefits with the procedure.
THE use of radical "in-continuity" resection in dealing with head and neck cancer has been relatively recent. The term, in-continuity, refers to resection of a primary lesion together with all homolateral and, in some cases, contralateral cervical lymph nodes, all soft tissue between the nodes and the primary lesion and, if necessary, bone and skin. This approach has been utilized in place of the older method whereby local or transoral removal of a primary lesion was followed by conventional radical neck dissection at the same time or at a later date. That the composite in-continuity procedure is associated with higher mortality and is more disabling and technically more formidable cannot be disputed. This is especially true when the procedure is applied to composite jaw resections and, to a lesser extent, in composite laryngectomy which exposes the neck wound to infected pharyngeal secretions. In performing resection for tumors of the skin and salivary glands, the composite procedure is not appreciably more hazardous than radical neck dissection itself. An en bloc procedure, on the other hand, permits much better exposure of the primary lesion and a more extensive resection when necessary. We must consider whether or not this advantage results in a significantly higher rate of cure. With this thought in mind, a group of 55 consecutive patients treated at this clinic from 1949 to 1953 by incontinuity resection or by a "discontinuous" series of operations has been analyzed. All of these patients have had follow-up studies for five years or until death. In general, the in-continuity type of operation was utilized in dealing with the bulkier lesions, often in the presence of enlarged lymph nodes or invasion of the mandible, soft tissues or skin. The discontinuous procedure was usually employed in patients with smaller primary lesions, no palpable lymph nodes or uncomplicated skin and lip carcinomas; in such cases, in-continuity dissection is not usually considered. Discon655
G. David King
656
tinuous neck dissection was usually indicated when nodes became enlarged. The cases were classified according to the site of the primary lesion and these were divided into larynx, lip, tongue and general oral area (including the buccal mucous membrane, gingiva, floor of the mouth, palate and tonsils). A miscellaneous group included salivary gland tumors, one malignant melanoma, one metastatic pheochromocytoma from a previously resected primary lesion in the adrenal gland, and two cases in which radical neck dissection was carried out without discovery of a primary lesion (Table 1). Table 1 RELATION OF CONTROL TO TYPE OF OPERATION AND SITE OF MALIGNANT DISEASE IN-CONTINUITY
Control Lip .......................... Mouth (except tongue) ........ Tongue ............... Larynx ............... Miscellaneous ...
0 4 2 8 2 16
DISCONTINUOUS
Recurrence or Operative Death
Control
Recurrence or Operative Death
3* 1* 4* 6* 3 17
3 2 1 5 4 15
0 4 4 4 1 13
* See Table 2. For purposes of this study, it was considered that control had been established over a primary lesion if both the primary site and the resected area remained free of disease despite the subsequent appearance of metastases in other areas or the development of distant metastases. The former type usually appeared in the opposite side of the neck (six cases) and it was necessary to carry out the operation discontinuously from the primary site. Distant metastases developed in two instances. The two cases are included because the metastatic spread did not preclude a five year follow-up of control at the resected site. The discontinuous contralateral radical neck dissections following a homolateral incontinuity procedure were evaluated with regard to their effectiveness in controlling metastatic disease. ANALYSIS OF DATA
A total of 61 operations were performed on 55 patients; 33 of these procedures consisted of en bloc dissection of the primary tumor together with intervening tissue, including the mandible and skin when necessary and the cervical lymph nodes. All neck dissections were complete. Twenty-eight discontinuous procedures were carried out; radical neck
Resection in Cancer of the Head and Neck
657
dissection alone was performed when the disease had previously been controlled by surgery, radiation, or both. The control rates for both methods were approximately the same-nearly 50 per cent in each group. Four operative deaths occurred in the group of 33 in-continuity procedures (Table 2). The in-continuity procedures for lip cancer were massive; mandible resection was required in all cases because of invasion, and treatment was of no avail. That control was established in the three patients with cervical lymph node metastases from previously controlled primary lip lesions serves to substantiate the opinion that prophylactic neck dissecTable 2
MORTALITY: ANALYSIS OF FOUR DEATHS IN 33 CASES
CASE
AGE AND SEX
1
50 M
2
80 M
3
50 F
4
64 M
DISEASE
PROCEDURE
CAUSE OF DEATH
DAYS AFTER OPERATION
Carcinoma of pyri- Laryngopharyngecform sinus with tomy; left radical metastases neck dissection
13
Carcinoma of lip with invasion of mandible
12
Carcinoma of floor of mouth, with invasion of mandible and metastases Carcinoma of base of tongue
Massive wound infection; carotid rupture Tracheotomy; re- Aspiration section of lip, pneumonmandible and left itis neck dissection Tongue-jaw-neck Cardiac failure dissection; (previous tracheotomy severe right heart disease) Tongue-jaw-neck Staphylococcic dissection; enterocolitis tracheotomy
2
28*
* Two weeks after hospital discharge. tion is unnecessary in these patients since they represent only a small percentage of the group in which primary lesions of the lip were treated without development of metastases. Prophylactic radical neck dissection would not have helped any of the patients in whom subsequent jaw invasion required the performance of composite operations. Our experience in the treatment of oral lesions indicates the definite superiority of the in-continuity approach to these problems. A wide transoral excision is difficult, and division of the mandible (with or without resection) provides excellent exposure and allows satisfactory repair. One patient survived in satisfactory condition after marginal resection of the mandible, excision of the floor of the mouth, partial glossectomy and bilateral radical neck dissection in continuity; the internal jugular
658
G. David King
vein on the contralateral side was preserved. The discontinuous operations within the mouth were generally carried out for carcinoma of the palate or of the buccal mucosa; the technical difficulties of performing an in-continuity resection under such circumstances may be appreciated. In view of the less effective control following discontinuous surgery, it has more recently been our practice to remove a portion of the mandible (and maxilla if necessary) and the buccal mucous membrane widely in continuity with the contents of the neck; the defect between the upper buccal sulcus and the lingual mucosa is bridged with a split-thickness skin graft rather than attempting to bring these two widely separated structures together. In cases of tongue carcinoma, closure is much easier and healing is usually satisfactory. The intrinsically malignant nature of these lesions makes it difficult to obtain good results by any method, however. CARCINOMA OF THE LARYNX
It seems of special interest to point out the good results in the group of patients with laryngeal cancer since, as stated above, bulky extraglottic disease was present in most of the patients treated by composite operation and obvious cervical metastases were found in some cases. Results in this group were comparable to those obtained in the group with localized supraglottic or glottic carcinomas without obvious metastases at the time of laryngectomy. It is our opinion that in all cases of extraglottic carcinomas treated surgically, complete radical neck dissection should be carried out simultaneously in continuity with resection of the primary tumor. We believe that the four patients who died after discontinuous surgery could have been cured by application of this method. In the miscellaneous group, all in-continuity resections included large amounts of skin, or skin plus total parotidectomy and neck contents. The patients submitted to discontinuous operation, on the other hand, usually had cervical metastases from low grade salivary gland carcinomas appearing years after the initial excisions. In one case in which radical neck dissection was carried out, however, no primary tumor had been found preoperatively or was found at operation, and the patient is still well five years later. MORTALITY
The mortality rate for the in-continuity procedure was high-four deaths in 33 operations, or 12 per cent (Table 2). Jaw resection causes paralysis of deglutition and aspiration of mouth secretions, and _allows mouth organisms to reach the neck wound. In these large procedures iatrogenic diseases caused by massive blood transfusions, antibiotics and other drugs, surgical wound infections, and the sometimes devastating effects of repeated tracheal suction must be considered. This state of
Resection in Cancer of the Head and Neck
659
affairs leads to morbidity and mortality, and for this reason in-continuity procedures should not necessarily be carried out in all of these cases, even though such an operation may be technically feasible. The elderly patient (Case 2) and the cardiac patient (Case 4) might have been treated palliatively by radiation. The morbidity and mortality rates also lead us to the conclusion that in-continuity operations of major stature should never be intentionally carried out as palliative procedures, although the operative exploration may reveal that this is necessary. These patients require a long period of rehabilitation and it is no comfort to the patient to know that an operation carried out a few weeks or months before for removal of a fungating or foul-smelling tumor has only postponed its reappearance until a later date. In the interim the patient must be fed by a nasogastric tube, undergo tracheotomy and use a suction apparatus after hospital discharge, and is now minus part of his mouth and face and usually a considerable sum of money, without ever having enjoyed any comfort from this so-called palliative procedure. SUMMARY
A series of 55 consecutive patients submitted to in-continuity or discontinuous dissection for various types of head and neck cancer has been studied to determine whether or not the additional morbidity and mortality associated with in-continuity operations is justifiable because of better results. In dealing with carcinoma of the floor of the mouth and of the larynx, this procedure has proved definitely superior to discontinuous procedures. It is hoped that application of this operation to carcinomas of the palate and buccal mucosa will, in the future, elicit better results than those obtained at present by the discontinuous method. The benefits in cases of tongue carcinoma are more questionable because of their intrinsically higher level of biological activity. A substantial morbidity and mortality are associated with the in-continuity procedure, and for this reason it should not be employed routinely. This is not to imply that only a few patients should be treated by this method, but rather that a few patients should be omitted from the group in which in-continuity surgery would normally be indicated. Only in this way will we be able to produce maximal benefits with the procedure.