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Cancer in and about the mouth A study of two hundred and eleven cases
DEPARTMENT
OF
ORAL SURGERY, ORAL PATHOLOGY ANDSURGICAL ORTHODONTIA g
E z
Under
= E= s eE E E= E z sI g E= ==
Editorial
Supervision
of
Sterling V. Mead, D.D.S., Washington, DC., Director M. N. Pederspiel, D.D.S., M.D., F.A.C.S., Milwaukee.-Vilray P. Blair, M.D., F.A.C.S., St.Louis,Mo.-Theodor Blum, D.D.S., M.D., F.A.C.D., NewYork.-Leroy M. S. Miner, M.D., D.M.D., Boston.-Wm. L. Shearer, M.D.,D.D.S.,Omaha.Frederick F. Molt, D.D.S., Chicago.-Robert H. Ivy, M.D., D.D.S., Philadelphia. -Edward L. Miloslavich, M.D., Milwaukee.-French K. Hansel, M.D., M.S., St. Louis, MO.-W. M. Reppeto, D.D.S., Dallas, Texas
~~llllllllllllllllllllllllllllllllllllillllllllllllllllllllilllllllll~ll
lllilllllll1lllllllllllllllllllllllllllllllllMl
CANCER A BY
VILRAY
PAPIK
STUDY
II II II Illll!llilllllllllllllllllllllllllllllllll~lllllllll[~lllllllli~l~ll
IN AND ABOUT OF
Two
HUNDRED
lllllillilllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll~~lllll~ll~
TIIE AND
MOUTH*
ELEVEN
M.D., F.A.C.S., JAI,IE~ IMzRhTT A. WOMACK, M.D., ST. LOUIS,
BLAIR, BATIIAN
EE =E z i ; E ; I g= I
CASFX
BROWN, M.D., AND 110.
T
HIS survey was not undertaken as a basis for any broad conclusions, but rather to check our own work and results. We do not speak of cures, but believe that if we can add one year of healthful, comparatively comfortable activity to the life of a useful man we have made a real accomplishment. If a patient dies as the result of a sincere attempt to eradicate cancer, it is a bad mark against surgery, but economically it is no disaster. If after complete relief from a mouth cancer, the patient is later carried off by a recurrence in some vital organ, he not only has had the benefit of the extra span of life, but has also been spared a much worse form of death, namely, from uncontrolled cancer of the mouth. This presentation is facilitated by assuming the following growth sites, but these regional distinctions were noted chiefly because of their relation to treatment, plan of operative attack and prognosis. Cancer does not love rules, but it has preferences of location which in turn seem to influence direction of growth and, to some extent, quality of malignancy. Extension will occur from one area to another, but the site of the primary appearance here defines the location. There seem to be some general tendencies as to the direction in which the extension will occur. The anatomic locations are (1) buccal cavity mucosa, (2) lip, (3) tongue and floor of the mouth, (4) face, (5) pharynx and tonsil, (6) neck, and (7) accessory nasal sinuses and nasal passages. *From the Department MO. Presented by Dr. Blair C.. May. 1928. Reprfnted Prom Annals
Lalls. D.
of at the
Surgery meeting
oP Surgery
of
Washington of the American
RI%: 705, 188
1928.
UnIversIty Surgical
School Association.
of
Medicine. Waahlngton,
St.
(1) The lwccal cwity mucosa group includes growths of the gums and Palate, often classed as cancer of the jaw, a classification that we disregard because of bone involvement is accidental and only incident.ally influenres the plan of attack.’ Metastatic carcinoma of the j;tw has been noted thm~ times, once from the rectum and twice from the breast. This buccal cavity mucosa division also includes those growths which have originated from within but have perforat.ed the cheek.
rIl i hih
(2) The true Zip cancers arise from the exposed vermilion border. group are included those cases which came to us wit.h healed lips, t.he result, of operation, radiation or pastes, but with metastatic growths in the neck. These have been fairly frequent, and there have been some patients who. whtrn questioned, at first failed to remember that they had had a sore on the lip treated years previous to the appearance of the growth in the neck. (3) Tongue, both oral and pharyngeal parts, and floor of fhe ,nzoufh. Growths of the floor of the mouth are grouped with the tongue, on account of both the frequency of the double involvement and the therapeutic indications. The floor of the mouth is less frequently involved from the gums than from the tongue; and further, a growt.h on the gum is usually destroyed with a soldering iron, while the tissues of the involved floor of the mouth or tongue demand deep removal or radiat.ion. From the tongue a growth may (1xfvud widely into the cheek, fauces or pharynx, usually invading these Cssnes h+ hind the alveolar process. (4) FWC, squamous-cell carcinomata arising from the skin, not including growths perforating from the deep structures. (5) Pharynx and tonsil, growths arising in the oral pharynx. (6) Neck, including tumors arising deep in the neck in pat.ients in whom no primary site could be found. Treves pointed out the possibility of primary neck growths arising from epithelial remnants, but our observations are leading us to an increasingly strong belief that the majority of them are metastat.ic from unrecognized growths in the upper alimentary or respiratory tracts. (7) riccessoq nasal sinuses rind nasal possn~es. together with the nasnpharynx. We have also found it convenient to distinguish four arbitrary stages of growth as noted at the first examination. (1) Early: Growths of relatively short duration and where there is no gross evidence of glandular involvement. These are frequently small enough for apparently complete excision for the biopsy. There were only ten in this stage out of a total of two hundred and eleven cases. (2) Nedium: More active growths, still not of great size nor involving tissues difficult to eradicate. Many of these patients have enlarged regional glands. Grades I and II are regarded as belonging to the likely curable class. There were thirty-five in this stage. (3) Advanced: This stage includes growths which from their size or from the tissues involved render the treatment more hazardous and the prognosis distinctly less promising. There (4) Inoperable: Growths too were one hundred and seventeen in this stage. far advanced for any prolonged relief to be expected, regardless of the t.ype of lx&e
*The paradental starting point
eplthelial cell OP some malignant
remnants growths,
(patMental but
WQ have
clbbris found
of .Malassez) no deflnlte
may wfdencc
~wselbl~ ou this
treatment. A few are included in this stage bccansc of physical disability! aside from the carcinoma. Radiation in som(~ form was usc~l on mnst. of these patients. There were forty-ninc& in this stage. Although there can br no fixed lines tlemarcating ally two stages, this classification has proved of pract.ical use. as it gives a basis for prognosis from clinical findings. The size, the duration. the rate of growth, the histology, and the condition of the patient are all given consideration in summing up the prognosis and in planning treatment. No one criterion has been found to offer a basis of prognosis accurate enough t,o present a percentage plan to the patient of’his chances of life. Some of the advanced and inoperable cases have not had biopsies; and in a few others, the microscopic sections were not available. An attempt has been made to grade these growths according to Rroder’s classification (Figs. 20, 21, 22, 23). In some cases several slides have been studied; the ones from the biopsy, those from the specimen at the operation and those from the regional glands. In some of the earlier cases, biopsy was rather avoided for fear of spreading the disease, but WC now feel sbrongly that there are advantages in the pret.reatment microscopic study that outweigh the dangers. By the total removal of small growths, or by the use of t.he cutting cautery for biopsy combined with radiation, the dangers of implantation must be materially re.duced. Throughout this series, an attempt has been made to correlate histology with the other factors, t.aking into account cellular differentiation, mitoses and the distribution of the cancer cells; but individual ideas influence microscopic grading perhaps much as they do in determining clinical stages. While it may be claimed that one cell or a small group of cells may prove malignancy, various stages of differentiation may often be demonstrated in a single section. This necessitates a fairly thorough examination and final balance of the differentiated and undifferentiated cells in det.ermining the group. In spite of these uncertainties, it would appear quite certain that there is a definite relationship between the stage of cellular different.iation and the virulence of t.he individual growth. Therefore, this latter has a bearing on the prognosis and on the character and extent of the treatment. Our clinical observations over a much larger series have led to the rather definite conclusion that many growths are for a time held in relative abeyance but later take on much more rapid growth, if not a real increase in malignancy. The opportunities to make early and late microscopic examinations on the same growth are relatively rare, but this series shows a higher percentage of growths of Grades III and IV in the advanced and inoperable cases than in the early and medium cases. In drawing this conclusion, changes of only one degree were not considered of worthy note (Table I). We have observed a type of growth that occurs in the mouth that very closely resembles cancer in its clinical progress and its outcome, but in which repeated microscopic examinations do not show the typical breaking through of the epithelial cells, which is considered necessary in the definition of cancer. These might rightly be considered as a precancerous stage, and in several a brea#ing through of t.he cells has been demonstrated in a very small area of
a relativelylarge growth. However,severalhavegrown for long periods of time, haveattainedlarge sizeand haveaccomplished great dest.ructiou nit,hout any breaking-through
being demonstrated.
(Case ‘I.)
%‘hen carcinoma could be demonstrated in thr glands, the tieprc~~ of malignancp nearly always approximated that. of t.he primary growth. l’hc glands were graded one grade lower seven times, one grad(> higher four times. and two grades higher one time. (+landular mctastases appearing long after the appartbnt eradication of the primary growth were practically always of the third or fourth grades and, where the data was available, were founti tcl have come from growt.hs of original high malignancy. So malignancy WAS found in forty-nine out of one hundred and thirteen gland examinations; but this tlof~s not. necessarily mean that thr~ pla~tls w(‘r(’ not aft’ectetl. ~Vh~rl
~
._ -----=
T-I-.
STz\GE
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STAGE
-__ Hut.
-
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._ -
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.
.MEDlLrJI -
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-_-
-
-.
-
-.
EARLY
- ____
-
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.-
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INf~PEKAHLR .
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1 - 3.7 -
lli -.. .--..
.-..-
.-. .-. .- _.-
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ADV.\Yt’FI) 1 ,
car.
Lip Tongue Face Pharynx Neck Antrum -.-
-
bXKLT
_ ._ _
_
Total-21 _- ,- -..
-.-
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1 6 .Li I! -l!i -. ---...
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cancer was microscopically demonstraM in the glands, there were seven Grade I. nine Grade II, fourteen Grade III, and t,hirty Grade IV. Of fivt’ that were not graded, one was a very malignant adthnocarcinoma from tbl> orlly adenocarcinorna of the tongue in the series. (Table II.) In most cases. the glands were removed by radical block dissection. The failure to demonstrate metast,ases microscopically does not mean necessarily that there was no glandular involvement. Results are. of .course, better in the group n-here no carcinoma was demonstrated. but there are cases in the series which show that. undifferentiated carcinoma, ereu affecting the glands of the neck, is not an absolutely hopeless situation. However, these cases call for the most. extensive removal. See Cases 2 and 10. ‘Inhere were seven Grade TTT cases that had glandular metastases still alive three, four, seven, seven, eight. eleven and twelve years after treatment ; six Grade 1.V after
Rlair,
192
Brown, TABLE
and Womack II
The grade of the metastatic growth rather closely followed that of the primary tumor. Of 114 gland examinations, 65 were found to be carcinomatous. Of 65 glands with positive carcinoma, 60 were graded. Of the 60 graded metastases: 6 came from Grade I primary growths; 7 were Grade I-Of these: 1 from a Grade II growth. 7 came from Grade II primary growths; 9 were Grade II-Of these: 2 from Grade III growths. 1 came from an ungraded primary growth; 14 were Grade III-Of these: 1 from a Grade II growth; 8 from Grade III growths; 4 from Grade IV growths. 30 were Grade IV-Of these: 8 came from ungraded primary growths; 1 from a Grade II growth; 3 from Grade III growths; 18 from Grade IV growths. 1 undifferentiated growth in a lymph node came from a primary adenocarcinoma of the tongue. 4 were not graded-2 from ungraded growths; 2 from Grade II growths. In 49 glands, 1 was 7 were 9 were 15 were 8 were 9 were
no carcinoma was found. Of these: from an adenocarcinoma of the check; from ungraded growths; from Grade I growths; from Grade II growths; from Grade III growths; from Grade IV growths. TABLE III LONGEVITY REI~ATWE TO LYMPH ORADES
Alive l-5 years Alive 5-12 years Poetoperative deaths Treated cases, dead later Treated cases not traced
SODE
INFECTIOE
NO CABCINOMAl
10
*One suldde.
one, one, two, three and a half, four and seven years; and one Grade IV case that lived three years before a recurrence. (See Cases 2, 3, 4, 5, 6, 7, 8, 9. Tables III and IV.) The results of treatment’can best be shown in tabulations. There is a very high operative mortality, an average of 21.5 per cent according to the number of patients. In this series, one hundred and eighty-nine major operations were done on one hundred and ‘thirty patients. All but one of the postoperative deaths occurred in advanced cases where very radical operations were done, and the growths in nearly all of the cases were poorly differentiated ones. It seems that the farther back in the mouth and pharynx the operation is carried, the higher the mortality. This may be due in part to the increased inability to get rid of mouth secretions, either externally or
means, including suction. Radiation tc~tttpot2trily to stop tltc salivary NOW has been considered but not tried so far; bwause. in spitfl of thca annoyante of it, it often swnts to bc the one thing that lifv~ps t.he total secretion movabh~ so that it cart be got,ten rid of. I)tvtth occutwd ttinc~twtt times Erom pulmonary complications, thrw times front ctartli;tca c:otnl)licc;ttions, threr tinws from hemorrhage. Of four cases in wlticlt thr cott~mott or intwnal carotid artery was tied, four died. Two of’ fh(w. Itowc~vw. ;lppfirrntl~~ died of pnvttmonia. (Table 17.) Of thv treated early cases. liti per writ arv supposrtl to be currtl. Of t!~tt treated ntc~dium cases, 72.4 per cvttt aw ;tliv(h; antI of tlte t,rcated H(~VRIIC~(I cases, 32 per cent arcA known to be alive atrtl without known recurrenct’. ot thaw ad~attced o~sw t.hat survivtvl opvrntiott, 43 pvr ccsttt(6arc still aliw. The pcrcentaKes of liyinp patiwts without ktww~t r~~~llrrence, with growths of Grades I, I I, 1 II and II?, are 50 per wilt, 43 peg cent, 40.7 pvr ccttt and P:I per cent, rCspectiurl>-. I~ntreatcd cases do not fipurc in these ~wrcentapes, bnt those lost track of arc counted. So reports could hfl obtained on forty-ot!(* aw iwspatients. Of tltvs?, t.n-rntg-eight are J~rObilbl~ tlP;\d i~titl t Itirtwti sibly alirv. There are swent~- known deaths othw than the postolwratiw ontbs. Of these, thirty-four had been t.reated by operation att(I radiation and tbirtwrl by radiation ; sixtwrt tyftzvtl treatmettt or wvt*c sent. home for radiation, st’yett Subscquettt dcbatlt front eittt(!(‘t is wcortltvl in twcalve or were ttntreatcd. fiftrpn cases. All but three of these cast’s w?rv itdvattc*rd or inoperable, and t)lprp wprp fo~tr Gradr 1 growths, lert Grade II. svvvtt Grade III. attd twelIt?‘one Grad12 IV. _--surgical
*Most c,f the wrvicc.
t:tt.,,
rchpol‘ts
on
thus I):lti+,nt-;
11.1v1, I),Y~II saht:linc+l
bx’ tile. ..c,r:i:il
work,.!
on
tlla
___-------
--------------
- -.-
- ---._--
-.
-. . --
- -- - __---_----.--.- ---
--
Postoperative deaths stng” of growth Grades
Cause
:
Grade Grade Grade Grade Ungraded
-----.-.--
2.9 “8 ndv:rnretl
1 3 3 8 11 4
I TT III IV
of death: Pulmonary complications Cardiac complications Secondary hemorrhage Common or internal carotid Death occurred Average time
of
ligntion
from 1 to death-10%
(2 from
42 days days
early cases cases cases cases cases 19 3 3 -!
pneumonin)
after after
operation. operation. TOTAL OPER.
Buccal Lip Tongue Face Pharynx Neck Antrum m-------J---
than
X0. AT
cavity
_ --
I postoperative
*The that
according
--Lb to
------___
death rate according the number of patients.
to
CASE I-Male, fifty-nine years old, white. lips became painful and reddened, and hca noted growth on right cheek became worse. He was “electric destruction ” three times. Upon cracked and far back as in diameter. The process in the cheek, dome-shaped deep within
the
number
.)I
Three years a lump in his gi& rlsewhere
operations
before chock. four
is,
of
course
lowet
admission the patient’s One year ago, lips and rndium treatments and
admission, the epithelium of the lip was found to be reddened, thinned-out, painful. There was a widespread, smooth lcucoplakin over the right cheek ns the molar rtrgion. In the molar region, there wns a papillomatous ulcer 1.5 cm. The edges were firm and everted, but not as hard as art’ usually seen in cancer. extended hto the upper fornix, and becausr of t,hickcning and an abscess deep the mouth could not be opcncd more than 1.5 cm. On the outside, there was a induration over the center of the cheek with a small opckning draining pus from the cheek.
The specimen removed showed a verrucous growth 1.5 cm. in diameter. The borders were fairly well demarcated, but were found to extend down into the ulcerated area in the cheek. The microscopic picture resembled a benign papillomatous growth rather than a true cancer, as may be seen in the microphotograph. It was because of this picture that three biopsies were done before radical operation was instituted. (Fig. I,) CASE
floor of treatment. more
the
2.-Male, mouth
Examination than 1 cm.
forty-six thrvc
months
years
old,
brfore
showed a smooth, flat in diameter. No enlarged
white. his
The
admission
pntient
noticed
a small
to
hospital.
1Ie
ulcrr in the left rc~ginnal lymph
the
sidr of the notl(~s were
floor felt.
tumor had
in
received
the no
of thr mouth, not Without previous
Fig.
I.-Case
I..
III Fig. 4, taken from OIIC of the regionnl glands. thvrr has been giveu a Group 4 grading. are two areas distended with cancer cells and surrouutlrd 1)~ adenoid tissue. Mitoses are not ns frequent ns in tho initial lesion, but even here differentiation is not especially good. From a study of this and other arcas, the gland mrtnstnses hare ~WII given a CIroup 3 grading. CASE 3.-Malt, fifty-one pears old, white. One \-wr before the pntient vm sew, he noticed :L bliatcr at thr oIII(‘,~-cUt:Llleol1Y border of the right lower lip near the angle. Four month8 later ii ~:LNS appeared beneath the right jaw.
Examin:itiou showed an ulcer at the cornw wns shallow, with a dry, gray bnw and with h:lrd node was very large, hard and mor:~hle.
of the rwrted
right lowcar lip 2 s I bin. cdpc3. A right sulmwxillary
The
ulcer lymph
Pathology.-Fig. 3 is tuken from the prinmry growth. ‘l’hc~r~ is abund;lnt kcr:itiniz:ltion present. The marked inflammatory rwction 1)rracnt is ~wrhapy due to the proximity of the ulcer, Grndt III. Fig. 0 is from one of thr regional lymph glnnds. Thcb normal nwhitcr-
ture of the gland has given way to the extensive carcinomatous proliferation. Diffcrcntiation is not as complete as in the primary lesion. There is practically no hyalinization and numrrous mitosee may be seen. Fairly extensive fibrous tissue proliferation is present. This gland has been graded III. CASE
the hospital, locally aud a recurrenco wnsidcmhle
4.-Male, fifty-six years old, white. Three and a half years before admission into the patient noted a small ulcer beneath the tip of the tongue. This was excised was said to have bern diagnosed microscopically as a benign lesion. There Was within two months. For th? last nine months before ndmission, there 11nd lwn bleeding and pain.
FOE. .5.--C *ia s,’ :i
Hlflir,
m3
Casx tongue fire recurrence.
5.--Malt, years
forty-eight previously
lJWlf~ll,
years which
was
(!?I(1
I\v(lrllf/Cli
old, white. The then excised.
patient He
had sought.
noticed tl.e:itment
a lump on the for a rcccnt
arca involving most of the Examination upon admission sho~vctd a hard, red, ulcrrntcd The edges \vere cvcrted and showrtl a tendency to hlecd. The surface of the tonguc~. There wcrc ~u~lpabh~ glands in both subniaxillar~ tongue was hard, swollen snd tender. triangles. upper
Fig.
‘i.-Case
‘4.
3%.
8.-C!ase
4.
A tracheotomy was done followed by a complete removal of the tongue with an np~)er The patient returned at later dates for lower neck dissections neck dissection on both sidos. on both sides, and for excision of a small nodule just above the clavicle that proved to be inflammatory in origin. The patient is well no\v and able to continne his profession as a physician twelve years after the operation. Pathdogy.--Fig. cinoma with tendency due, no doubt, to the
9, from the primary growth, toward pearl format.ion. There proximity of the area seen hero
good differentiation is a widespread inflammatory to the ulcer. Grade II.
showa
of
the carreaction
~sellt. of
:I
syncytial primary
Grade
arrangemenf.
excision
of
the
TV.
tumor,
four
This years
paticut
has
11:1(1 no
rwurreuw
7.-M&, forty-fire years old, nhite. Ousct our year before Srwrnl plasters uerc nodule back of car. This soon ulcer:ltctl. rapidly in size. X-ray therapy was givcu. Siurc then, there
admission, applied.
CASE
painless increased
following
ihe
ngo.
has
bcru
with hard, The growth c~onsiderablr
pain.
Upon
examination
rolled, hard aides of the The is well
tissuo
now,
border neck.
patient three
an
oval
and about There was
ulcer
12.-Case
2r,5
x 2 cm.
7. was
5 mm. in depth. There a generalized hyperkeratosis
had a complete and a half years
Pathozogy.-Fig. stroma. Here
Fig.
left neck dissection after the operation.
12. There are masses and there spindle cells
with
noted were
back
of
the
left
palpable lymph of the skin.
removal
of the
parotid
ear
nodes
nith
a
on both gland,
and
of carcinoma cells surrounded by a dense fibrous may be scen, but from a study of the section
Fig.
.l:i..-L':l.~~~
.
202
Blair,
Brown,
and Womack
A
B
Fig.
16--A,
Csse
Fig.
10. B, Case
16.-Case
11.
10.
FI,n.
17.-Case
Il.
Fig.
lR.-Cast
1%
IO.--Malr, fifty-fire years old, \yhite. The pxticnt noted n sm:ill papule on the two yrnrs before admission. 110 consulted n physici:in \vho gave him radium trcxtLater, a mass appeared in the neck. Examination showed an ulcer 23’2 s l$‘~ cm. in diamrter with hard, raised edges occupythe position of the vaIlate papillae and going backward for attachment to the posteriol CASE
tongue ment. ing
Fig.
EYg. formatton
Grade faucial carotid
I.
ZO.-The
is
present
section
and
pillar of the right on the right side.
shows
cell
side.
eplthelial
I?.
Proliferation
differentiation
There
19.-Case:
is
was
one
complete
large
In
a fairly
enough
lymph
node
dense fibrous group this
to
at
the
area. tumor
bifurcation
Pearl as a
of
the
A preliminary tracheotomy was done followed two weeks later hy complete excision of the tongue with an upper neck dissection on both sides. Later, a lower right neck die. section was done. Several weeks after this, a lower left neck dissection was performed. Fig. 15-8 and B, taken three years after the operation, show the neck following the block d&ec-
;1 v:lIItc!ry
of
exriaion
tlIc* m:Ixill:I,
and
:III
uf
the
gruwth
upper
right
with nrrk
rcnIov:rl
Of most
nf
the
TW ~0s 401~. time Of tlisrh:irgt*
dissection At the
right.
m:Mihlc
r\veks
later.
:~Ibl
lxtrt
r:atlium
WIS
from tlw IIqGtal, and neck. The patient died two months I:der. ‘l’hc metastntwe mnnnrg mc!tnstascs wc’rc notf4 111 spite Of thv unrecugnixed, at the time of operation. probably prcbsmt, though deetrwtion and the outcome, the prtivnt and his family w&~~~I~d the rvlivf front pain opemt iuu gave. (Fig. lti.)
:rpplird
tn
thv
wnund
P~ltkolo~~~.--Pig. but
mcvrly
arw
17. tihrous
deme
:Iround
~tlges
Tissue tiaaur. The
s&ion
stroIn:I
is
r:rdhtion.
the m:tndiblc. The c;ItIcvr rella
RIIOW n
&4~wn
them
hII* h,v:4 linixation.
IIWC
110 cvidrucv lwtnratlt of
thv
of tllv
mylohyoid
cuncrr C.\SE
Inittsd
to
ia cnusidvra airrirtoni:itOi~s
crlls I?.-
the
.\1:1Iv, hospitul,
lifL.v.sis II0 noticed
It
Whrthrr
i?c :I roujrrturr,
ns WV ymra
thwse
014,
0 smull
the
Tlw
abundant, of
or
not
r:rdi:ition
do
not
knnw
ahitc.
I.vmph to
hns tlu*
l’llrrc~ in
the
nntc
elwrk.
pictttrr cvcvks
no the
[n ghinds
in this
th:l t (*:iti89~r iufluoucrd uf IIcafor**
the thr
othrr
I IIC
wc*lerO! iv rruult
nf
:arr:Lo
nol
cua*:
cells
i\vrc aSIr
cnrcinomu.
hard
prcwmably
~liffcrc,,ltiltiol,.
rOgi0nill
is intcrcsting
lump
edgv ahowed taken frnm :I
ulrcr
US
here
nucl
degree
mods-r:de
invnsian.
muscle.
from around slmwn
roaavc~d ‘Phc
pul
show4
rl~~~tti
werr
iliffrruntint
prim:rrv
growc’th.
111~ patient
~0s
hw
:II~.
206 Examination showed on the 2.5 cm, in diameter, poorl.~ the right clavicle. A wide excision of this mass, done v;ith the actual cautcry and was performed. Following this he after the first operation. about above
FIR. 22.-There of the cells. is very little III.
shape There Grade
Fig. spuamous siderable IymDh Grade
2X-From cancer.
variation channels
is very Mltoses Abrosls
the
inner drfincd
side of the right and very hard.
cheek a granular ulcerated A few hard glands were
including removal of the full thickness several months later :I neck dissection llud :I rrpair of the cheek. IIc is now
little keratinization. There Is a marked are easily demonstrated and giant-cell nrcsent. The poor differentiation has
structure
Cell outline in the size may be seen
of
the
above
section,
It
is dif%ult
felt
tumor just
of the check, was on the right. side well, twelve years
variation in the size and formation may be seen. placed this carcinoma In
to
say
is indistinct and the nuclei are hyperchromatic. and shape of the nuclei. Mltoses are abundant. studded with the cancer cells. This tumor has
that this 1s a There IS conMany small been given a
IV.
18 and 19. This is apparently a true adenocarcinoma, papillary in one in this series arising in the buccal mucosa. Fig. 19 is a higher magnification of an area shown in Fig. 18. One sees villi containing a delicate fibrous tissue There were no demonstrable stroms and lined by well differentiated, low columnar cpithclium. metaatases to the regional lymph nodes. type,
Pathology.-Figs. and is the only
1. Cases are grouped into fairly definite anatomic sites chiefly because of their relation to treatment and prognosis, and to facilitate classification. history-taking and presentation. 2. The term “carcinoma of the jaw” is uot used because bono iu\nlvement is secondary and only incidentally influences treatment. 3. Growths u-it.h wide extension or metastases arc put in the group corresponding to the pAmar>’ growth site. Xeck tumors do occur in which no primary growth site can be determinetl, but the majority of them are mctastatic from some nnrecogni;sed ul)per respirator>* or digestive tract growlh. 4. Four arbitrary clinical stages are distinguished and are of I)rat:tical use in giving a basis for t.reatment and prognosis from calinical findings. 5. Biopsies are done in most. cases before treatment, is begun, both for (*onfirmation of diagnosis and for studying the relative degree of malignanq~ of the growth. 6. ‘In arrivin&: at a plan of treatment and prognosis, clinical and mic*roscopic findings arc considered together. So one criterion has been found to offer a basis of prognosis accurate enouph t.o prcscnt a percentage plan to tllc patient of his chances of life. 7. Growths may for a time be held in rcalativtt abeyance, but later take on much more rapid growth if not a real increase in malignancy. In this series t.here is a higher percentage of undifferentiated growths in thc~ late than in the early stages. 8. There has been observed a type of growth that in clinical aspects is cancer, but in which the microscopic picture does not show the typical drfinition of cancer. These growths may cause great destruction if not treated at least locally as cancer. 9. The degree of malignancy of metastatic gland rarcinoma followed fairly closely that of the primary growth. There may be no microscopic evidence of malignancy in the regional glands? but this dacs not. necessarily mean that. the glands are not affected. 10. Though results arc, of course, best in the ceaseswhere no carcinoma was found in the glands, there are cases in the series that show t.hat undifferentiated carcinoma even in the glands of the neck is not an absolutr4y hopcless situation. 21.5 per cent: all but. one of the 11. Thcrct is a high operative mortality, deaths occurred in advanced cases where very radical operations had been done. 12. The farther back in the mouth am1 pharynx the operation is carried, the higher the mortality. This is probably duo to increased liability to rcsp!ratory infection. 13. Rrsults of trcatnlcvlt aw tabulated.
Dr. Kobert R. that the Icork Doctor cancer of the mouth
(r;rr~cowgh, BC&WZ, Afa.~.~., said that there was no questiou in his mind Blair has been doing in tho plastic repair of wry extensivo excisions in has opened up a field of useful surgical treatment in a group of paticlnts
Hc was thorouatily in accord with that have been left very much without help iu the past. the statement that if we can only rid a man of a sloughing, offensive local lesion within the that hc dies of more rrmoto metustasis, \Yt* mouth for as much as a year’s tim?, ewn if after have accomplished a great tlral for that p:\rticulnr man’s good. These extensive oprrations ran only tn. tlonc by making use of thcx principles of plastic surgery.
As to the grading of the degree of m:~lignancy of the just what is to’be done in the individual cusc, hc had been very There ij no this principle would be more widely accepted. in a tumor case of low grade malignancy may be I)ad judgment The two following tables sho\v the results of opc~ration of the lip and cancer of thr bucral mu~sa which wcrc graded of malignancy according to the amount of differentiation of themselves. TANLE I __-_--------
-----.-.LIVING CASES Group
1
Group
II
Group Simmons
and
-----.---
Dal;lmi
-l
(Surg..
1tFSl‘LTS ,L
Ggnec.
----__
(Surp..
Cvnec.
:~ntl
ant1
;
17 11 17 11 - ----
Obst.
15:
-.-
PEK (‘KS’P .- - -.-
-
--
22.0 -.-
Obst.
.----CASES --.--.-----.----
Group I Group II Group III Group ____----- IP
- -
---
OF OPIX<.\TlOX
--------
__-__------
--
93 11
III -----_-.-.---
___.___
Simmons
tumors in thr decision as to confident that as time went on doubt that what can be dons in one of higher gradr. in a series of CRSCS of canrcr into ihree and four group? the ~11s. The tables c~xplaiu
35:
TW,
PATHOLOGIC
DEAD (‘ASES ---. ------
I”
G -.---192).
14 -.
C;KOL!PlNti - --.----.
----.---.--.--.-----~z~--~~ C(YRES
- .-.----. 377.
hl..i 70.0
.- -
12 3 1 0
PER CENT
- - -
68 21 6 0
--__--.
-
IWG).
These cases were observed at the Massachusetts General Hospital and the Collis I’. The living cases were aliro without cridence of disease Huntington Memorial Hospital. three or more years after operation. Doctor Blair had sent on to Boston a few sample slides from this series of cases that he has reported. Three different observers, Dr. Chonning C. Simmons, Dr. H. F. Hartwell, surgical pathologist at the .Massachusetts General Hospital, and the speaker had reviewed these independently. As a result of the examination of these fourteen specimens of different grades of malignancy, following the Rroders classification of four grades, in only two instances did the estimates fall more than one grade apart. In other words, they were practically all agreed upon the cases of high malignancy,, and of low malignancy; and only in the middle groups were there differences of opinion as between Grade I and Grade II, and these differences were virtually insignificant. This would seem to demonstrate that in general the method of applying this gradation principle to cancer cases was being done in a reasonably uniform manner. There will always be some differences of opinion, since the personal equation enters so largely in the eetimatc. In one respect. their principles in Boston had been a little different from those suggested originally by Doctor Droders. Ln classifying the squamous cell tumors of the skin and mouth he attempted to estimate the percentage value of differentiation in the whole tumor. Supposing there was three-quarters of the tumor that was well differentiated, and one-quarter of the mass that was less differcmtiat4, Doctor Hroders would grade the tumor at a lower degree of malignancy thau in one where those percentages were reversed. With US, we have taken the position that the most malignant bit of tumor tissue that could bc observed in the whole tumor was the one which was to be considered, so far :is th(;
prognosis was concerned, if areas were found that malignancy. Dr. squamous
and therefore, were distinctly
in a tumor of a high
which grade,
~3 generally of ~1 low nmlignanc~~ t.llc C:IW is clnssed :LW one t;t’ high
Charming C. Simmons, Boston, Jiass., remarked that it is much easier to pads If the cell carcinoma p:rthologic:~lly thau the cdcwlatous forms, wch 3s c:~nccr wctum or of the breast, althougll this has betw easier to grade squamous cell carciuoma I~:ithologic:llly than the edematous ~anccr. The clinical ;8pl~lic:rtiou of this is not yet entirely clear. It. certainly is of great ralr~e iu the prognosis of cancer of the buccal mwosa aud lip. :~nd has a distinct rebctiou to the fowl of rrcatmeut which shc~uld be employed. For esample. an extremely radical operation in this form of caucer i3 unnecessary if the tumor is of lowgrade malignancy and small, while it should be done in cwry inst:~nce if the tllmor !)rov(a~ to hc of high-grade malignanay. The term ( ccancer’f applied to all the metastasizing epithclial tumors is in some ways unfortun:ltc--carleer should bc considrwd as a regional diseasc~. There is nothing iu common bctxcc~n cancer of the skin and c:rncer of that tougur and ewris. A tumor that would bl, of low-grade malignancy in cancer of the touguc, Grncie T. is ~*ompnrabI~~ to Grade III mnligmrncy of the lip.
OF
ORAL SURGERY, ORAL PATHOLOGY ANDSURGICAL ORTHODONTIA g
E z
Under
= E= s eE E E= E z sI g E= ==
Editorial
Supervision
of
Sterling V. Mead, D.D.S., Washington, DC., Director M. N. Pederspiel, D.D.S., M.D., F.A.C.S., Milwaukee.-Vilray P. Blair, M.D., F.A.C.S., St.Louis,Mo.-Theodor Blum, D.D.S., M.D., F.A.C.D., NewYork.-Leroy M. S. Miner, M.D., D.M.D., Boston.-Wm. L. Shearer, M.D.,D.D.S.,Omaha.Frederick F. Molt, D.D.S., Chicago.-Robert H. Ivy, M.D., D.D.S., Philadelphia. -Edward L. Miloslavich, M.D., Milwaukee.-French K. Hansel, M.D., M.S., St. Louis, MO.-W. M. Reppeto, D.D.S., Dallas, Texas
~~llllllllllllllllllllllllllllllllllllillllllllllllllllllllilllllllll~ll
lllilllllll1lllllllllllllllllllllllllllllllllMl
CANCER A BY
VILRAY
PAPIK
STUDY
II II II Illll!llilllllllllllllllllllllllllllllllll~lllllllll[~lllllllli~l~ll
IN AND ABOUT OF
Two
HUNDRED
lllllillilllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll~~lllll~ll~
TIIE AND
MOUTH*
ELEVEN
M.D., F.A.C.S., JAI,IE~ IMzRhTT A. WOMACK, M.D., ST. LOUIS,
BLAIR, BATIIAN
EE =E z i ; E ; I g= I
CASFX
BROWN, M.D., AND 110.
T
HIS survey was not undertaken as a basis for any broad conclusions, but rather to check our own work and results. We do not speak of cures, but believe that if we can add one year of healthful, comparatively comfortable activity to the life of a useful man we have made a real accomplishment. If a patient dies as the result of a sincere attempt to eradicate cancer, it is a bad mark against surgery, but economically it is no disaster. If after complete relief from a mouth cancer, the patient is later carried off by a recurrence in some vital organ, he not only has had the benefit of the extra span of life, but has also been spared a much worse form of death, namely, from uncontrolled cancer of the mouth. This presentation is facilitated by assuming the following growth sites, but these regional distinctions were noted chiefly because of their relation to treatment, plan of operative attack and prognosis. Cancer does not love rules, but it has preferences of location which in turn seem to influence direction of growth and, to some extent, quality of malignancy. Extension will occur from one area to another, but the site of the primary appearance here defines the location. There seem to be some general tendencies as to the direction in which the extension will occur. The anatomic locations are (1) buccal cavity mucosa, (2) lip, (3) tongue and floor of the mouth, (4) face, (5) pharynx and tonsil, (6) neck, and (7) accessory nasal sinuses and nasal passages. *From the Department MO. Presented by Dr. Blair C.. May. 1928. Reprfnted Prom Annals
Lalls. D.
of at the
Surgery meeting
oP Surgery
of
Washington of the American
RI%: 705, 188
1928.
UnIversIty Surgical
School Association.
of
Medicine. Waahlngton,
St.
(1) The lwccal cwity mucosa group includes growths of the gums and Palate, often classed as cancer of the jaw, a classification that we disregard because of bone involvement is accidental and only incident.ally influenres the plan of attack.’ Metastatic carcinoma of the j;tw has been noted thm~ times, once from the rectum and twice from the breast. This buccal cavity mucosa division also includes those growths which have originated from within but have perforat.ed the cheek.
rIl i hih
(2) The true Zip cancers arise from the exposed vermilion border. group are included those cases which came to us wit.h healed lips, t.he result, of operation, radiation or pastes, but with metastatic growths in the neck. These have been fairly frequent, and there have been some patients who. whtrn questioned, at first failed to remember that they had had a sore on the lip treated years previous to the appearance of the growth in the neck. (3) Tongue, both oral and pharyngeal parts, and floor of fhe ,nzoufh. Growths of the floor of the mouth are grouped with the tongue, on account of both the frequency of the double involvement and the therapeutic indications. The floor of the mouth is less frequently involved from the gums than from the tongue; and further, a growt.h on the gum is usually destroyed with a soldering iron, while the tissues of the involved floor of the mouth or tongue demand deep removal or radiat.ion. From the tongue a growth may (1xfvud widely into the cheek, fauces or pharynx, usually invading these Cssnes h+ hind the alveolar process. (4) FWC, squamous-cell carcinomata arising from the skin, not including growths perforating from the deep structures. (5) Pharynx and tonsil, growths arising in the oral pharynx. (6) Neck, including tumors arising deep in the neck in pat.ients in whom no primary site could be found. Treves pointed out the possibility of primary neck growths arising from epithelial remnants, but our observations are leading us to an increasingly strong belief that the majority of them are metastat.ic from unrecognized growths in the upper alimentary or respiratory tracts. (7) riccessoq nasal sinuses rind nasal possn~es. together with the nasnpharynx. We have also found it convenient to distinguish four arbitrary stages of growth as noted at the first examination. (1) Early: Growths of relatively short duration and where there is no gross evidence of glandular involvement. These are frequently small enough for apparently complete excision for the biopsy. There were only ten in this stage out of a total of two hundred and eleven cases. (2) Nedium: More active growths, still not of great size nor involving tissues difficult to eradicate. Many of these patients have enlarged regional glands. Grades I and II are regarded as belonging to the likely curable class. There were thirty-five in this stage. (3) Advanced: This stage includes growths which from their size or from the tissues involved render the treatment more hazardous and the prognosis distinctly less promising. There (4) Inoperable: Growths too were one hundred and seventeen in this stage. far advanced for any prolonged relief to be expected, regardless of the t.ype of lx&e
*The paradental starting point
eplthelial cell OP some malignant
remnants growths,
(patMental but
WQ have
clbbris found
of .Malassez) no deflnlte
may wfdencc
~wselbl~ ou this
treatment. A few are included in this stage bccansc of physical disability! aside from the carcinoma. Radiation in som(~ form was usc~l on mnst. of these patients. There were forty-ninc& in this stage. Although there can br no fixed lines tlemarcating ally two stages, this classification has proved of pract.ical use. as it gives a basis for prognosis from clinical findings. The size, the duration. the rate of growth, the histology, and the condition of the patient are all given consideration in summing up the prognosis and in planning treatment. No one criterion has been found to offer a basis of prognosis accurate enough t,o present a percentage plan to the patient of’his chances of life. Some of the advanced and inoperable cases have not had biopsies; and in a few others, the microscopic sections were not available. An attempt has been made to grade these growths according to Rroder’s classification (Figs. 20, 21, 22, 23). In some cases several slides have been studied; the ones from the biopsy, those from the specimen at the operation and those from the regional glands. In some of the earlier cases, biopsy was rather avoided for fear of spreading the disease, but WC now feel sbrongly that there are advantages in the pret.reatment microscopic study that outweigh the dangers. By the total removal of small growths, or by the use of t.he cutting cautery for biopsy combined with radiation, the dangers of implantation must be materially re.duced. Throughout this series, an attempt has been made to correlate histology with the other factors, t.aking into account cellular differentiation, mitoses and the distribution of the cancer cells; but individual ideas influence microscopic grading perhaps much as they do in determining clinical stages. While it may be claimed that one cell or a small group of cells may prove malignancy, various stages of differentiation may often be demonstrated in a single section. This necessitates a fairly thorough examination and final balance of the differentiated and undifferentiated cells in det.ermining the group. In spite of these uncertainties, it would appear quite certain that there is a definite relationship between the stage of cellular different.iation and the virulence of t.he individual growth. Therefore, this latter has a bearing on the prognosis and on the character and extent of the treatment. Our clinical observations over a much larger series have led to the rather definite conclusion that many growths are for a time held in relative abeyance but later take on much more rapid growth, if not a real increase in malignancy. The opportunities to make early and late microscopic examinations on the same growth are relatively rare, but this series shows a higher percentage of growths of Grades III and IV in the advanced and inoperable cases than in the early and medium cases. In drawing this conclusion, changes of only one degree were not considered of worthy note (Table I). We have observed a type of growth that occurs in the mouth that very closely resembles cancer in its clinical progress and its outcome, but in which repeated microscopic examinations do not show the typical breaking through of the epithelial cells, which is considered necessary in the definition of cancer. These might rightly be considered as a precancerous stage, and in several a brea#ing through of t.he cells has been demonstrated in a very small area of
a relativelylarge growth. However,severalhavegrown for long periods of time, haveattainedlarge sizeand haveaccomplished great dest.ructiou nit,hout any breaking-through
being demonstrated.
(Case ‘I.)
%‘hen carcinoma could be demonstrated in thr glands, the tieprc~~ of malignancp nearly always approximated that. of t.he primary growth. l’hc glands were graded one grade lower seven times, one grad(> higher four times. and two grades higher one time. (+landular mctastases appearing long after the appartbnt eradication of the primary growth were practically always of the third or fourth grades and, where the data was available, were founti tcl have come from growt.hs of original high malignancy. So malignancy WAS found in forty-nine out of one hundred and thirteen gland examinations; but this tlof~s not. necessarily mean that thr~ pla~tls w(‘r(’ not aft’ectetl. ~Vh~rl
~
._ -----=
T-I-.
STz\GE
_
-
-
I
- .----
-
----
.- ..-.---.-Y.-L
-
--
---.-.
---..-
STAGE
-__ Hut.
-
.
._ -
_
.
.MEDlLrJI -
_.
-_-
-
-.
-
-.
EARLY
- ____
-
._-
i.
.-
_
INf~PEKAHLR .
_
.
-.-
.----
^
?IEDII~.M
.-
-Ifi ti
7 4
I
1
I--
--lo
-_--1
I
.-
.._.
1 - 3.7 -
lli -.. .--..
.-..-
.-. .-. .- _.-
_
_
ADV.\Yt’FI) 1 ,
car.
Lip Tongue Face Pharynx Neck Antrum -.-
-
bXKLT
_ ._ _
_
Total-21 _- ,- -..
-.-
..-I-.-.
1 6 .Li I! -l!i -. ---...
..-
1 -. - --
cancer was microscopically demonstraM in the glands, there were seven Grade I. nine Grade II, fourteen Grade III, and t,hirty Grade IV. Of fivt’ that were not graded, one was a very malignant adthnocarcinoma from tbl> orlly adenocarcinorna of the tongue in the series. (Table II.) In most cases. the glands were removed by radical block dissection. The failure to demonstrate metast,ases microscopically does not mean necessarily that there was no glandular involvement. Results are. of .course, better in the group n-here no carcinoma was demonstrated. but there are cases in the series which show that. undifferentiated carcinoma, ereu affecting the glands of the neck, is not an absolutely hopeless situation. However, these cases call for the most. extensive removal. See Cases 2 and 10. ‘Inhere were seven Grade TTT cases that had glandular metastases still alive three, four, seven, seven, eight. eleven and twelve years after treatment ; six Grade 1.V after
Rlair,
192
Brown, TABLE
and Womack II
The grade of the metastatic growth rather closely followed that of the primary tumor. Of 114 gland examinations, 65 were found to be carcinomatous. Of 65 glands with positive carcinoma, 60 were graded. Of the 60 graded metastases: 6 came from Grade I primary growths; 7 were Grade I-Of these: 1 from a Grade II growth. 7 came from Grade II primary growths; 9 were Grade II-Of these: 2 from Grade III growths. 1 came from an ungraded primary growth; 14 were Grade III-Of these: 1 from a Grade II growth; 8 from Grade III growths; 4 from Grade IV growths. 30 were Grade IV-Of these: 8 came from ungraded primary growths; 1 from a Grade II growth; 3 from Grade III growths; 18 from Grade IV growths. 1 undifferentiated growth in a lymph node came from a primary adenocarcinoma of the tongue. 4 were not graded-2 from ungraded growths; 2 from Grade II growths. In 49 glands, 1 was 7 were 9 were 15 were 8 were 9 were
no carcinoma was found. Of these: from an adenocarcinoma of the check; from ungraded growths; from Grade I growths; from Grade II growths; from Grade III growths; from Grade IV growths. TABLE III LONGEVITY REI~ATWE TO LYMPH ORADES
Alive l-5 years Alive 5-12 years Poetoperative deaths Treated cases, dead later Treated cases not traced
SODE
INFECTIOE
NO CABCINOMAl
10
*One suldde.
one, one, two, three and a half, four and seven years; and one Grade IV case that lived three years before a recurrence. (See Cases 2, 3, 4, 5, 6, 7, 8, 9. Tables III and IV.) The results of treatment’can best be shown in tabulations. There is a very high operative mortality, an average of 21.5 per cent according to the number of patients. In this series, one hundred and eighty-nine major operations were done on one hundred and ‘thirty patients. All but one of the postoperative deaths occurred in advanced cases where very radical operations were done, and the growths in nearly all of the cases were poorly differentiated ones. It seems that the farther back in the mouth and pharynx the operation is carried, the higher the mortality. This may be due in part to the increased inability to get rid of mouth secretions, either externally or
means, including suction. Radiation tc~tttpot2trily to stop tltc salivary NOW has been considered but not tried so far; bwause. in spitfl of thca annoyante of it, it often swnts to bc the one thing that lifv~ps t.he total secretion movabh~ so that it cart be got,ten rid of. I)tvtth occutwd ttinc~twtt times Erom pulmonary complications, thrw times front ctartli;tca c:otnl)licc;ttions, threr tinws from hemorrhage. Of four cases in wlticlt thr cott~mott or intwnal carotid artery was tied, four died. Two of’ fh(w. Itowc~vw. ;lppfirrntl~~ died of pnvttmonia. (Table 17.) Of thv treated early cases. liti per writ arv supposrtl to be currtl. Of t!~tt treated ntc~dium cases, 72.4 per cvttt aw ;tliv(h; antI of tlte t,rcated H(~VRIIC~(I cases, 32 per cent arcA known to be alive atrtl without known recurrenct’. ot thaw ad~attced o~sw t.hat survivtvl opvrntiott, 43 pvr ccsttt(6arc still aliw. The pcrcentaKes of liyinp patiwts without ktww~t r~~~llrrence, with growths of Grades I, I I, 1 II and II?, are 50 per wilt, 43 peg cent, 40.7 pvr ccttt and P:I per cent, rCspectiurl>-. I~ntreatcd cases do not fipurc in these ~wrcentapes, bnt those lost track of arc counted. So reports could hfl obtained on forty-ot!(* aw iwspatients. Of tltvs?, t.n-rntg-eight are J~rObilbl~ tlP;\d i~titl t Itirtwti sibly alirv. There are swent~- known deaths othw than the postolwratiw ontbs. Of these, thirty-four had been t.reated by operation att(I radiation and tbirtwrl by radiation ; sixtwrt tyftzvtl treatmettt or wvt*c sent. home for radiation, st’yett Subscquettt dcbatlt front eittt(!(‘t is wcortltvl in twcalve or were ttntreatcd. fiftrpn cases. All but three of these cast’s w?rv itdvattc*rd or inoperable, and t)lprp wprp fo~tr Gradr 1 growths, lert Grade II. svvvtt Grade III. attd twelIt?‘one Grad12 IV. _--surgical
*Most c,f the wrvicc.
t:tt.,,
rchpol‘ts
on
thus I):lti+,nt-;
11.1v1, I),Y~II saht:linc+l
bx’ tile. ..c,r:i:il
work,.!
on
tlla
___-------
--------------
- -.-
- ---._--
-.
-. . --
- -- - __---_----.--.- ---
--
Postoperative deaths stng” of growth Grades
Cause
:
Grade Grade Grade Grade Ungraded
-----.-.--
2.9 “8 ndv:rnretl
1 3 3 8 11 4
I TT III IV
of death: Pulmonary complications Cardiac complications Secondary hemorrhage Common or internal carotid Death occurred Average time
of
ligntion
from 1 to death-10%
(2 from
42 days days
early cases cases cases cases cases 19 3 3 -!
pneumonin)
after after
operation. operation. TOTAL OPER.
Buccal Lip Tongue Face Pharynx Neck Antrum m-------J---
than
X0. AT
cavity
_ --
I postoperative
*The that
according
--Lb to
------___
death rate according the number of patients.
to
CASE I-Male, fifty-nine years old, white. lips became painful and reddened, and hca noted growth on right cheek became worse. He was “electric destruction ” three times. Upon cracked and far back as in diameter. The process in the cheek, dome-shaped deep within
the
number
.)I
Three years a lump in his gi& rlsewhere
operations
before chock. four
is,
of
course
lowet
admission the patient’s One year ago, lips and rndium treatments and
admission, the epithelium of the lip was found to be reddened, thinned-out, painful. There was a widespread, smooth lcucoplakin over the right cheek ns the molar rtrgion. In the molar region, there wns a papillomatous ulcer 1.5 cm. The edges were firm and everted, but not as hard as art’ usually seen in cancer. extended hto the upper fornix, and becausr of t,hickcning and an abscess deep the mouth could not be opcncd more than 1.5 cm. On the outside, there was a induration over the center of the cheek with a small opckning draining pus from the cheek.
The specimen removed showed a verrucous growth 1.5 cm. in diameter. The borders were fairly well demarcated, but were found to extend down into the ulcerated area in the cheek. The microscopic picture resembled a benign papillomatous growth rather than a true cancer, as may be seen in the microphotograph. It was because of this picture that three biopsies were done before radical operation was instituted. (Fig. I,) CASE
floor of treatment. more
the
2.-Male, mouth
Examination than 1 cm.
forty-six thrvc
months
years
old,
brfore
showed a smooth, flat in diameter. No enlarged
white. his
The
admission
pntient
noticed
a small
to
hospital.
1Ie
ulcrr in the left rc~ginnal lymph
the
sidr of the notl(~s were
floor felt.
tumor had
in
received
the no
of thr mouth, not Without previous
Fig.
I.-Case
I..
III Fig. 4, taken from OIIC of the regionnl glands. thvrr has been giveu a Group 4 grading. are two areas distended with cancer cells and surrouutlrd 1)~ adenoid tissue. Mitoses are not ns frequent ns in tho initial lesion, but even here differentiation is not especially good. From a study of this and other arcas, the gland mrtnstnses hare ~WII given a CIroup 3 grading. CASE 3.-Malt, fifty-one pears old, white. One \-wr before the pntient vm sew, he noticed :L bliatcr at thr oIII(‘,~-cUt:Llleol1Y border of the right lower lip near the angle. Four month8 later ii ~:LNS appeared beneath the right jaw.
Examin:itiou showed an ulcer at the cornw wns shallow, with a dry, gray bnw and with h:lrd node was very large, hard and mor:~hle.
of the rwrted
right lowcar lip 2 s I bin. cdpc3. A right sulmwxillary
The
ulcer lymph
Pathology.-Fig. 3 is tuken from the prinmry growth. ‘l’hc~r~ is abund;lnt kcr:itiniz:ltion present. The marked inflammatory rwction 1)rracnt is ~wrhapy due to the proximity of the ulcer, Grndt III. Fig. 0 is from one of thr regional lymph glnnds. Thcb normal nwhitcr-
ture of the gland has given way to the extensive carcinomatous proliferation. Diffcrcntiation is not as complete as in the primary lesion. There is practically no hyalinization and numrrous mitosee may be seen. Fairly extensive fibrous tissue proliferation is present. This gland has been graded III. CASE
the hospital, locally aud a recurrenco wnsidcmhle
4.-Male, fifty-six years old, white. Three and a half years before admission into the patient noted a small ulcer beneath the tip of the tongue. This was excised was said to have bern diagnosed microscopically as a benign lesion. There Was within two months. For th? last nine months before ndmission, there 11nd lwn bleeding and pain.
FOE. .5.--C *ia s,’ :i
Hlflir,
m3
Casx tongue fire recurrence.
5.--Malt, years
forty-eight previously
lJWlf~ll,
years which
was
(!?I(1
I\v(lrllf/Cli
old, white. The then excised.
patient He
had sought.
noticed tl.e:itment
a lump on the for a rcccnt
arca involving most of the Examination upon admission sho~vctd a hard, red, ulcrrntcd The edges \vere cvcrted and showrtl a tendency to hlecd. The surface of the tonguc~. There wcrc ~u~lpabh~ glands in both subniaxillar~ tongue was hard, swollen snd tender. triangles. upper
Fig.
‘i.-Case
‘4.
3%.
8.-C!ase
4.
A tracheotomy was done followed by a complete removal of the tongue with an np~)er The patient returned at later dates for lower neck dissections neck dissection on both sidos. on both sides, and for excision of a small nodule just above the clavicle that proved to be inflammatory in origin. The patient is well no\v and able to continne his profession as a physician twelve years after the operation. Pathdogy.--Fig. cinoma with tendency due, no doubt, to the
9, from the primary growth, toward pearl format.ion. There proximity of the area seen hero
good differentiation is a widespread inflammatory to the ulcer. Grade II.
showa
of
the carreaction
~sellt. of
:I
syncytial primary
Grade
arrangemenf.
excision
of
the
TV.
tumor,
four
This years
paticut
has
11:1(1 no
rwurreuw
7.-M&, forty-fire years old, nhite. Ousct our year before Srwrnl plasters uerc nodule back of car. This soon ulcer:ltctl. rapidly in size. X-ray therapy was givcu. Siurc then, there
admission, applied.
CASE
painless increased
following
ihe
ngo.
has
bcru
with hard, The growth c~onsiderablr
pain.
Upon
examination
rolled, hard aides of the The is well
tissuo
now,
border neck.
patient three
an
oval
and about There was
ulcer
12.-Case
2r,5
x 2 cm.
7. was
5 mm. in depth. There a generalized hyperkeratosis
had a complete and a half years
Pathozogy.-Fig. stroma. Here
Fig.
left neck dissection after the operation.
12. There are masses and there spindle cells
with
noted were
back
of
the
left
palpable lymph of the skin.
removal
of the
parotid
ear
nodes
nith
a
on both gland,
and
of carcinoma cells surrounded by a dense fibrous may be scen, but from a study of the section
Fig.
.l:i..-L':l.~~~
.
202
Blair,
Brown,
and Womack
A
B
Fig.
16--A,
Csse
Fig.
10. B, Case
16.-Case
11.
10.
FI,n.
17.-Case
Il.
Fig.
lR.-Cast
1%
IO.--Malr, fifty-fire years old, \yhite. The pxticnt noted n sm:ill papule on the two yrnrs before admission. 110 consulted n physici:in \vho gave him radium trcxtLater, a mass appeared in the neck. Examination showed an ulcer 23’2 s l$‘~ cm. in diamrter with hard, raised edges occupythe position of the vaIlate papillae and going backward for attachment to the posteriol CASE
tongue ment. ing
Fig.
EYg. formatton
Grade faucial carotid
I.
ZO.-The
is
present
section
and
pillar of the right on the right side.
shows
cell
side.
eplthelial
I?.
Proliferation
differentiation
There
19.-Case:
is
was
one
complete
large
In
a fairly
enough
lymph
node
dense fibrous group this
to
at
the
area. tumor
bifurcation
Pearl as a
of
the
A preliminary tracheotomy was done followed two weeks later hy complete excision of the tongue with an upper neck dissection on both sides. Later, a lower right neck die. section was done. Several weeks after this, a lower left neck dissection was performed. Fig. 15-8 and B, taken three years after the operation, show the neck following the block d&ec-
;1 v:lIItc!ry
of
exriaion
tlIc* m:Ixill:I,
and
:III
uf
the
gruwth
upper
right
with nrrk
rcnIov:rl
Of most
nf
the
TW ~0s 401~. time Of tlisrh:irgt*
dissection At the
right.
m:Mihlc
r\veks
later.
:~Ibl
lxtrt
r:atlium
WIS
from tlw IIqGtal, and neck. The patient died two months I:der. ‘l’hc metastntwe mnnnrg mc!tnstascs wc’rc notf4 111 spite Of thv unrecugnixed, at the time of operation. probably prcbsmt, though deetrwtion and the outcome, the prtivnt and his family w&~~~I~d the rvlivf front pain opemt iuu gave. (Fig. lti.)
:rpplird
tn
thv
wnund
P~ltkolo~~~.--Pig. but
mcvrly
arw
17. tihrous
deme
:Iround
~tlges
Tissue tiaaur. The
s&ion
stroIn:I
is
r:rdhtion.
the m:tndiblc. The c;ItIcvr rella
RIIOW n
&4~wn
them
hII* h,v:4 linixation.
IIWC
110 cvidrucv lwtnratlt of
thv
of tllv
mylohyoid
cuncrr C.\SE
Inittsd
to
ia cnusidvra airrirtoni:itOi~s
crlls I?.-
the
.\1:1Iv, hospitul,
lifL.v.sis II0 noticed
It
Whrthrr
i?c :I roujrrturr,
ns WV ymra
thwse
014,
0 smull
the
Tlw
abundant, of
or
not
r:rdi:ition
do
not
knnw
ahitc.
I.vmph to
hns tlu*
l’llrrc~ in
the
nntc
elwrk.
pictttrr cvcvks
no the
[n ghinds
in this
th:l t (*:iti89~r iufluoucrd uf IIcafor**
the thr
othrr
I IIC
wc*lerO! iv rruult
nf
:arr:Lo
nol
cua*:
cells
i\vrc aSIr
cnrcinomu.
hard
prcwmably
~liffcrc,,ltiltiol,.
rOgi0nill
is intcrcsting
lump
edgv ahowed taken frnm :I
ulrcr
US
here
nucl
degree
mods-r:de
invnsian.
muscle.
from around slmwn
roaavc~d ‘Phc
pul
show4
rl~~~tti
werr
iliffrruntint
prim:rrv
growc’th.
111~ patient
~0s
hw
:II~.
206 Examination showed on the 2.5 cm, in diameter, poorl.~ the right clavicle. A wide excision of this mass, done v;ith the actual cautcry and was performed. Following this he after the first operation. about above
FIR. 22.-There of the cells. is very little III.
shape There Grade
Fig. spuamous siderable IymDh Grade
2X-From cancer.
variation channels
is very Mltoses Abrosls
the
inner drfincd
side of the right and very hard.
cheek a granular ulcerated A few hard glands were
including removal of the full thickness several months later :I neck dissection llud :I rrpair of the cheek. IIc is now
little keratinization. There Is a marked are easily demonstrated and giant-cell nrcsent. The poor differentiation has
structure
Cell outline in the size may be seen
of
the
above
section,
It
is dif%ult
felt
tumor just
of the check, was on the right. side well, twelve years
variation in the size and formation may be seen. placed this carcinoma In
to
say
is indistinct and the nuclei are hyperchromatic. and shape of the nuclei. Mltoses are abundant. studded with the cancer cells. This tumor has
that this 1s a There IS conMany small been given a
IV.
18 and 19. This is apparently a true adenocarcinoma, papillary in one in this series arising in the buccal mucosa. Fig. 19 is a higher magnification of an area shown in Fig. 18. One sees villi containing a delicate fibrous tissue There were no demonstrable stroms and lined by well differentiated, low columnar cpithclium. metaatases to the regional lymph nodes. type,
Pathology.-Figs. and is the only
1. Cases are grouped into fairly definite anatomic sites chiefly because of their relation to treatment and prognosis, and to facilitate classification. history-taking and presentation. 2. The term “carcinoma of the jaw” is uot used because bono iu\nlvement is secondary and only incidentally influences treatment. 3. Growths u-it.h wide extension or metastases arc put in the group corresponding to the pAmar>’ growth site. Xeck tumors do occur in which no primary growth site can be determinetl, but the majority of them are mctastatic from some nnrecogni;sed ul)per respirator>* or digestive tract growlh. 4. Four arbitrary clinical stages are distinguished and are of I)rat:tical use in giving a basis for t.reatment and prognosis from calinical findings. 5. Biopsies are done in most. cases before treatment, is begun, both for (*onfirmation of diagnosis and for studying the relative degree of malignanq~ of the growth. 6. ‘In arrivin&: at a plan of treatment and prognosis, clinical and mic*roscopic findings arc considered together. So one criterion has been found to offer a basis of prognosis accurate enouph t.o prcscnt a percentage plan to tllc patient of his chances of life. 7. Growths may for a time be held in rcalativtt abeyance, but later take on much more rapid growth if not a real increase in malignancy. In this series t.here is a higher percentage of undifferentiated growths in thc~ late than in the early stages. 8. There has been observed a type of growth that in clinical aspects is cancer, but in which the microscopic picture does not show the typical drfinition of cancer. These growths may cause great destruction if not treated at least locally as cancer. 9. The degree of malignancy of metastatic gland rarcinoma followed fairly closely that of the primary growth. There may be no microscopic evidence of malignancy in the regional glands? but this dacs not. necessarily mean that. the glands are not affected. 10. Though results arc, of course, best in the ceaseswhere no carcinoma was found in the glands, there are cases in the series that show t.hat undifferentiated carcinoma even in the glands of the neck is not an absolutr4y hopcless situation. 21.5 per cent: all but. one of the 11. Thcrct is a high operative mortality, deaths occurred in advanced cases where very radical operations had been done. 12. The farther back in the mouth am1 pharynx the operation is carried, the higher the mortality. This is probably duo to increased liability to rcsp!ratory infection. 13. Rrsults of trcatnlcvlt aw tabulated.
Dr. Kobert R. that the Icork Doctor cancer of the mouth
(r;rr~cowgh, BC&WZ, Afa.~.~., said that there was no questiou in his mind Blair has been doing in tho plastic repair of wry extensivo excisions in has opened up a field of useful surgical treatment in a group of paticlnts
Hc was thorouatily in accord with that have been left very much without help iu the past. the statement that if we can only rid a man of a sloughing, offensive local lesion within the that hc dies of more rrmoto metustasis, \Yt* mouth for as much as a year’s tim?, ewn if after have accomplished a great tlral for that p:\rticulnr man’s good. These extensive oprrations ran only tn. tlonc by making use of thcx principles of plastic surgery.
As to the grading of the degree of m:~lignancy of the just what is to’be done in the individual cusc, hc had been very There ij no this principle would be more widely accepted. in a tumor case of low grade malignancy may be I)ad judgment The two following tables sho\v the results of opc~ration of the lip and cancer of thr bucral mu~sa which wcrc graded of malignancy according to the amount of differentiation of themselves. TANLE I __-_--------
-----.-.LIVING CASES Group
1
Group
II
Group Simmons
and
-----.---
Dal;lmi
-l
(Surg..
1tFSl‘LTS ,L
Ggnec.
----__
(Surp..
Cvnec.
:~ntl
ant1
;
17 11 17 11 - ----
Obst.
15:
-.-
PEK (‘KS’P .- - -.-
-
--
22.0 -.-
Obst.
.----CASES --.--.-----.----
Group I Group II Group III Group ____----- IP
- -
---
OF OPIX<.\TlOX
--------
__-__------
--
93 11
III -----_-.-.---
___.___
Simmons
tumors in thr decision as to confident that as time went on doubt that what can be dons in one of higher gradr. in a series of CRSCS of canrcr into ihree and four group? the ~11s. The tables c~xplaiu
35:
TW,
PATHOLOGIC
DEAD (‘ASES ---. ------
I”
G -.---192).
14 -.
C;KOL!PlNti - --.----.
----.---.--.--.-----~z~--~~ C(YRES
- .-.----. 377.
hl..i 70.0
.- -
12 3 1 0
PER CENT
- - -
68 21 6 0
--__--.
-
IWG).
These cases were observed at the Massachusetts General Hospital and the Collis I’. The living cases were aliro without cridence of disease Huntington Memorial Hospital. three or more years after operation. Doctor Blair had sent on to Boston a few sample slides from this series of cases that he has reported. Three different observers, Dr. Chonning C. Simmons, Dr. H. F. Hartwell, surgical pathologist at the .Massachusetts General Hospital, and the speaker had reviewed these independently. As a result of the examination of these fourteen specimens of different grades of malignancy, following the Rroders classification of four grades, in only two instances did the estimates fall more than one grade apart. In other words, they were practically all agreed upon the cases of high malignancy,, and of low malignancy; and only in the middle groups were there differences of opinion as between Grade I and Grade II, and these differences were virtually insignificant. This would seem to demonstrate that in general the method of applying this gradation principle to cancer cases was being done in a reasonably uniform manner. There will always be some differences of opinion, since the personal equation enters so largely in the eetimatc. In one respect. their principles in Boston had been a little different from those suggested originally by Doctor Droders. Ln classifying the squamous cell tumors of the skin and mouth he attempted to estimate the percentage value of differentiation in the whole tumor. Supposing there was three-quarters of the tumor that was well differentiated, and one-quarter of the mass that was less differcmtiat4, Doctor Hroders would grade the tumor at a lower degree of malignancy thau in one where those percentages were reversed. With US, we have taken the position that the most malignant bit of tumor tissue that could bc observed in the whole tumor was the one which was to be considered, so far :is th(;
prognosis was concerned, if areas were found that malignancy. Dr. squamous
and therefore, were distinctly
in a tumor of a high
which grade,
~3 generally of ~1 low nmlignanc~~ t.llc C:IW is clnssed :LW one t;t’ high
Charming C. Simmons, Boston, Jiass., remarked that it is much easier to pads If the cell carcinoma p:rthologic:~lly thau the cdcwlatous forms, wch 3s c:~nccr wctum or of the breast, althougll this has betw easier to grade squamous cell carciuoma I~:ithologic:llly than the edematous ~anccr. The clinical ;8pl~lic:rtiou of this is not yet entirely clear. It. certainly is of great ralr~e iu the prognosis of cancer of the buccal mwosa aud lip. :~nd has a distinct rebctiou to the fowl of rrcatmeut which shc~uld be employed. For esample. an extremely radical operation in this form of caucer i3 unnecessary if the tumor is of lowgrade malignancy and small, while it should be done in cwry inst:~nce if the tllmor !)rov(a~ to hc of high-grade malignanay. The term ( ccancer’f applied to all the metastasizing epithclial tumors is in some ways unfortun:ltc--carleer should bc considrwd as a regional diseasc~. There is nothing iu common bctxcc~n cancer of the skin and c:rncer of that tougur and ewris. A tumor that would bl, of low-grade malignancy in cancer of the touguc, Grncie T. is ~*ompnrabI~~ to Grade III mnligmrncy of the lip.