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Cancer of the anterior floor of the mouth
Cancer of the Anterior Floor of the Mouth Selective Choice of Treatment and Analysis of Failures
Oscar M. Gulllamondegui, MD, Houston, Texas Boyce Oliver, MD, Houston, Texas Richard Hayden, MD, Houston, Texas
Cancers of the anterior or sublingual area of the floor of the mouth are primarily treated by surgical operations or irradiation, sometimes in sequential fashion. The selection of primary treatment is critical; this decision has far-reaching consequences affecting the possible cure of the patient and his ability to perform normally in society. These tumors grow in close proximity to the anterior arch of the mandible, often invade the root of the tongue, can be seen easily by an alert examiner and frequently develop bilateral nodal metastases. Patients with cancer of the anterior floor of the mouth, particularly in the more advanced stages, present a unique challenge to the technical skills of the surgeon. Many can be cured, but a great effort must be used in preserving adequate function and normal appearance. Material
and Methods
From January 1971 through December 1975, 104 patients with squamous carcinoma of the anterior and anterolateral floor of the mouth received primary and definitive treatment at The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute. The patients had received no previous treatment for their cancers. They were followed up for 4.5 to 6.5 years, or until they died, and the records were reviewed in June 1979. The tumors were classified according to the 1978 American Joint Committee Guidelines for Clinical Staging [I] (Figure 1). Sixty-three patients had tumors in early primary stages (Ti and Ts) and 41 had tumors in late stages (Ts and Td). Thirty-six patients (35 percent) had cervical From the Department of Head and Neck Surgery, The Unlvemity of Texas system Cancer Center, M.D. Alldsmm HoSpblandTumorI~,HouSton, TSXSS.
Requests for reprints should be addressed to Oscar M. Guillamondegui. MD, M.D. Anderson Hospital and Tumcf Institute. 6723 SerWr Drive, Houston. Texas 77030. Presehd at the 26th Annual Meeting of the Society of Head and Neck Sugeons, San Francisco. California, May 14-17, 1980.
550
node metastases. More than half of the patients with advanced lesions had cervical node metastases, only one fifth of the early lesions were classified N+, and 12 patients had bilateral cervical metastases. The stage classification of the 104 patients showed a balanced distribution: stage I, 28; stage II, 23; stage III, 22; and stage IV, 31 patients. Sixty-one patients were treated only by surgical resection. Twenty-five received radiotherapy and 1 patient had only chemotherapy. Seventeen received combined therapy: 15 patients sequential surgery and irradiation and 2 simultaneous irradiation and intraarterial regional infusion of cancerocidal drugs (Figure 2). The average age in this series was 60 years. Many patients were alcoholics and heavy users of tobacco, and many had cardiorespiratory disease. Results
In patients with head and neck cancer, the appearance of cervical metastases is a catastrophic event. Sixty-eight of the 104 patients had no clinical evidence of cervical metastases on first observation; 51 of them were classified Ti and Ts. Treatment of this group of patients offered several options: (1) surgical resection of the primary lesion; (2) surgical resection of the primary tumor and elective neck dissection, most commonly supraomohyoid; (3) radiotherapy to the primary tumor, including at least the upper neck regions on both sides; or (4) combined treatment, usually surgery and postoperative irradiation. In 32 of the 68 patients, mostly those with small
lesions, the only surgical procedure performed was through intraoral resection. In these patients there were two primary site recurrences, both later controlled by additional treatment. Only five patients eventually developed cervical metastases, and in three of them a neck dissection successfully controlled the disease.
The Amwican Journal of Suquy
Cancer of Anterior Floor of Mouth
I
I
Total
68
I
I
36N+
Treatment
1 T,
1 T,
1 T,
Surgery
I28
1 18 1 8
1 T,
I Total1
1 7 1 61 1
I
104
Figure 1. Clinical staging of squamous carcinoma of the anterior floor of the mouth for the 104 patients studied
Figure 2. Treatment of the 104 patients according to T staging.
[ 11. In 19 patients with primary lesions evenly distributed in all T stages, the primary tumors were resected intraorally and supramohyoid neck dissections were electively performed, usually on both sides. None of these patients had failure exclusively in the neck, although two developed tumor recurrence in both the primary area and the neck, one of whom was saved with additional treatment. Fourteen patients, including 8 staged Tz, received radiotherapy to the primary lesions and the neck. In three patients treatment failed in the oral cavity and in three it failed in the neck, usually at the periphery of the radiation fields. Two patients were later saved by surgical resection. Three patients were successfully treated with a combination of surgery and irradiation therapy. A second major group of 36 patients had cervical metastases when first examined. Ten of them were treated with surgery alone. In seven, the tumor remained controlled above the clavicle 24 months or longer, and in three the treatment failed. However, further surgery and radiotherapy were successful in controlling the tumor in all three patients. Eleven patients received irradiation alone. In nine, the tumor persisted or recurred, in both the primary area and the neck in seven. Only one of these patients could be later saved by surgical resection. Planned sequential modalities of treatment were used in 14 patients: radiotherapy and surgery in 12, and radiotherapy and regional chemotherapy in 2. In some cases irradiation was used postoperatively, covering both the primary site and the neck. In others, modified neck dissection eradicated the residual tumor in the cervical lymph nodes after primary irradiation of the lesion of the floor of the mouth and the neck. In two instances, primary irradiation
voluma 140, october 1980
therapy was used with simultaneous regional intraarterial infusion of methotrexate or 5fluorouracil. Combined therapy was generally used in the more advanced tumors and controlled them in 9 of the 14 patients. The treatment failed in five patients, but in two of them additional surgery was successful. One patient with a tumor classified TdNsb was unsuccessfully treated with systemic chemotherapy. In the entire series of 104 patients, only 5 died from distant metastases alone, although several others developed distant metastases as well as regional recurrence. Two patients died from intercurrent disease and 10 from new primary tumors. Second primary cancers developed in 25 patients (24 percent), usually in the oral cavity and the oropharynx. The site of the second primary cancer was the oral cavity in five patients, the oropharynx in six, the hypopharynx in one, the larynx in four, the lung in two and other in seven. Four patients had third primary cancers. A review of the final outcome of the patients according to their T stage and modality of therapy shows that, for those with tumors staged Ti and Ts treated with surgery alone, the determinate survival was 89 percent; those who received radiotherapy had a determinate survival of 64 percent. In the most advanced tumors, Ts and Tq, the determinate survival was 56 percent for the patients who had surgical resection, 50 percent for those who received combined treatment and 27 percent for those treated exclusively with radiotherapy. Comments The type of treatment was not randomized. The method used was individually selected by the head
581
Gulllamondegui et al
F&we 3. Resecfiot? of tin msf#dWe In 47 patients.
and neck surgeon for each patient. Selection was based on the size, degree of infiltration and appearance of the primary tumors, the stage of the cervical metastases and many other clinical factors. The personal experience of the treating surgeon added an important but subjective component to the process of selection. Many primary tumors were resected intraorally. The defects were closed primarily or with the help of a skin graft or local flaps. For lesions adjacent to the periosteum or superficially invading the lingual aspect of the mandible, coronal resection of the bone was performed and the inner table of the mandible was removed with the tumor [2]. Of 76 patients who had surgical operations, 47 required resection of the mandible (Figure 31, and in 27 of the 47, a coronal resection was adequate to remove the primary tumor. Only five patients required resection of the anterior arch of the mandible. The patients primarily treated with irradiation received a combination of interstitial radium implants and external radiation from a cobalt source, or external therapy to the oral cavity and neck, usually in doses of 6,090 to 7,996 rads administered over 6 to 7 weeks. Analysis of the results of treatment shows that for primary lesions classified Ti and Ts, surgical resection is very effective in controlling the tumors without unacceptable loss of function or other sequellae. Very rarely, patients with T1 lesions developed cervical metastases, which were always controlled by further treatment, usually neck dissection. Surgery was always successful in controlling the primary tu-
562
mors in patients with Ts lesions. Simultaneous modified neck dissection increased the neck control rate in patients staged No. The patients who had Tg primary tumors and cervical node metastases fared well with surgical treatment of the primary tumor and in the neck. Few of these patients were treated with irradiation alone. The patients with advanced primary lesions (Ts and TJ and a clinically negative neck had effective control of the lesions after surgical resection that included neck dissection. Functional loss and difficult surgical reconstruction became a more prominent feature in treatment for more advanced primary tumors. The patients with larger primary lesions had a high incidence of cervical metastases. Irradiation therapy as the only treatment for these advanced cancers failed in a high percentage of patients, and most of the patients with recurrence could not be saved. A sequential combination of surgery and irradiation appeared to improve the control of cervical metastases in the advanced stages [3]. Summary From 1971 through 1975,104 patients with squamous carcinoma of the anterior and anterolateral floor of the mouth underwent surgery, irradiation therapy or a combination of both with the purpose of eliminating their tumors. No patient had received treatment before, and this effort was considered primary and definitive. Fifty-five patients were free of cancer at the time of this analysis, 21 had died of intercurrent disease or new primary tumors, 1 patient was alive although suffering from another primary cancer, and in 27 patients the treatment failed and they died of recurrent carcinoma of the head and neck or with distant metastases. The ultimate determinate rate of control for all stages of disease was 66 percent. A rational approach to the problem of selecting a particular form of treatment for patients with cancer of the anterior floor of the mouth in different clinical manifestations is presented. References 1. Arnerlcan Joint Committee far Cancer Staging and End Results Reporting: Manual for staging of cancer. Chicago: 1978. 2. Guillamondegui Of4 Jesse RH. Surgical treatment of advanced carcinoma of the floor of the mouth. Am J Roentgenol 1978;126:1256-9. 3. Fbtdmr GHz Textbook of radiohrapy. 2nd ed. Philadelphle: Lea 8 Febiger, 1973.
TheAmerlcsllJoumslc4surQsq
Oscar M. Gulllamondegui, MD, Houston, Texas Boyce Oliver, MD, Houston, Texas Richard Hayden, MD, Houston, Texas
Cancers of the anterior or sublingual area of the floor of the mouth are primarily treated by surgical operations or irradiation, sometimes in sequential fashion. The selection of primary treatment is critical; this decision has far-reaching consequences affecting the possible cure of the patient and his ability to perform normally in society. These tumors grow in close proximity to the anterior arch of the mandible, often invade the root of the tongue, can be seen easily by an alert examiner and frequently develop bilateral nodal metastases. Patients with cancer of the anterior floor of the mouth, particularly in the more advanced stages, present a unique challenge to the technical skills of the surgeon. Many can be cured, but a great effort must be used in preserving adequate function and normal appearance. Material
and Methods
From January 1971 through December 1975, 104 patients with squamous carcinoma of the anterior and anterolateral floor of the mouth received primary and definitive treatment at The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute. The patients had received no previous treatment for their cancers. They were followed up for 4.5 to 6.5 years, or until they died, and the records were reviewed in June 1979. The tumors were classified according to the 1978 American Joint Committee Guidelines for Clinical Staging [I] (Figure 1). Sixty-three patients had tumors in early primary stages (Ti and Ts) and 41 had tumors in late stages (Ts and Td). Thirty-six patients (35 percent) had cervical From the Department of Head and Neck Surgery, The Unlvemity of Texas system Cancer Center, M.D. Alldsmm HoSpblandTumorI~,HouSton, TSXSS.
Requests for reprints should be addressed to Oscar M. Guillamondegui. MD, M.D. Anderson Hospital and Tumcf Institute. 6723 SerWr Drive, Houston. Texas 77030. Presehd at the 26th Annual Meeting of the Society of Head and Neck Sugeons, San Francisco. California, May 14-17, 1980.
550
node metastases. More than half of the patients with advanced lesions had cervical node metastases, only one fifth of the early lesions were classified N+, and 12 patients had bilateral cervical metastases. The stage classification of the 104 patients showed a balanced distribution: stage I, 28; stage II, 23; stage III, 22; and stage IV, 31 patients. Sixty-one patients were treated only by surgical resection. Twenty-five received radiotherapy and 1 patient had only chemotherapy. Seventeen received combined therapy: 15 patients sequential surgery and irradiation and 2 simultaneous irradiation and intraarterial regional infusion of cancerocidal drugs (Figure 2). The average age in this series was 60 years. Many patients were alcoholics and heavy users of tobacco, and many had cardiorespiratory disease. Results
In patients with head and neck cancer, the appearance of cervical metastases is a catastrophic event. Sixty-eight of the 104 patients had no clinical evidence of cervical metastases on first observation; 51 of them were classified Ti and Ts. Treatment of this group of patients offered several options: (1) surgical resection of the primary lesion; (2) surgical resection of the primary tumor and elective neck dissection, most commonly supraomohyoid; (3) radiotherapy to the primary tumor, including at least the upper neck regions on both sides; or (4) combined treatment, usually surgery and postoperative irradiation. In 32 of the 68 patients, mostly those with small
lesions, the only surgical procedure performed was through intraoral resection. In these patients there were two primary site recurrences, both later controlled by additional treatment. Only five patients eventually developed cervical metastases, and in three of them a neck dissection successfully controlled the disease.
The Amwican Journal of Suquy
Cancer of Anterior Floor of Mouth
I
I
Total
68
I
I
36N+
Treatment
1 T,
1 T,
1 T,
Surgery
I28
1 18 1 8
1 T,
I Total1
1 7 1 61 1
I
104
Figure 1. Clinical staging of squamous carcinoma of the anterior floor of the mouth for the 104 patients studied
Figure 2. Treatment of the 104 patients according to T staging.
[ 11. In 19 patients with primary lesions evenly distributed in all T stages, the primary tumors were resected intraorally and supramohyoid neck dissections were electively performed, usually on both sides. None of these patients had failure exclusively in the neck, although two developed tumor recurrence in both the primary area and the neck, one of whom was saved with additional treatment. Fourteen patients, including 8 staged Tz, received radiotherapy to the primary lesions and the neck. In three patients treatment failed in the oral cavity and in three it failed in the neck, usually at the periphery of the radiation fields. Two patients were later saved by surgical resection. Three patients were successfully treated with a combination of surgery and irradiation therapy. A second major group of 36 patients had cervical metastases when first examined. Ten of them were treated with surgery alone. In seven, the tumor remained controlled above the clavicle 24 months or longer, and in three the treatment failed. However, further surgery and radiotherapy were successful in controlling the tumor in all three patients. Eleven patients received irradiation alone. In nine, the tumor persisted or recurred, in both the primary area and the neck in seven. Only one of these patients could be later saved by surgical resection. Planned sequential modalities of treatment were used in 14 patients: radiotherapy and surgery in 12, and radiotherapy and regional chemotherapy in 2. In some cases irradiation was used postoperatively, covering both the primary site and the neck. In others, modified neck dissection eradicated the residual tumor in the cervical lymph nodes after primary irradiation of the lesion of the floor of the mouth and the neck. In two instances, primary irradiation
voluma 140, october 1980
therapy was used with simultaneous regional intraarterial infusion of methotrexate or 5fluorouracil. Combined therapy was generally used in the more advanced tumors and controlled them in 9 of the 14 patients. The treatment failed in five patients, but in two of them additional surgery was successful. One patient with a tumor classified TdNsb was unsuccessfully treated with systemic chemotherapy. In the entire series of 104 patients, only 5 died from distant metastases alone, although several others developed distant metastases as well as regional recurrence. Two patients died from intercurrent disease and 10 from new primary tumors. Second primary cancers developed in 25 patients (24 percent), usually in the oral cavity and the oropharynx. The site of the second primary cancer was the oral cavity in five patients, the oropharynx in six, the hypopharynx in one, the larynx in four, the lung in two and other in seven. Four patients had third primary cancers. A review of the final outcome of the patients according to their T stage and modality of therapy shows that, for those with tumors staged Ti and Ts treated with surgery alone, the determinate survival was 89 percent; those who received radiotherapy had a determinate survival of 64 percent. In the most advanced tumors, Ts and Tq, the determinate survival was 56 percent for the patients who had surgical resection, 50 percent for those who received combined treatment and 27 percent for those treated exclusively with radiotherapy. Comments The type of treatment was not randomized. The method used was individually selected by the head
581
Gulllamondegui et al
F&we 3. Resecfiot? of tin msf#dWe In 47 patients.
and neck surgeon for each patient. Selection was based on the size, degree of infiltration and appearance of the primary tumors, the stage of the cervical metastases and many other clinical factors. The personal experience of the treating surgeon added an important but subjective component to the process of selection. Many primary tumors were resected intraorally. The defects were closed primarily or with the help of a skin graft or local flaps. For lesions adjacent to the periosteum or superficially invading the lingual aspect of the mandible, coronal resection of the bone was performed and the inner table of the mandible was removed with the tumor [2]. Of 76 patients who had surgical operations, 47 required resection of the mandible (Figure 31, and in 27 of the 47, a coronal resection was adequate to remove the primary tumor. Only five patients required resection of the anterior arch of the mandible. The patients primarily treated with irradiation received a combination of interstitial radium implants and external radiation from a cobalt source, or external therapy to the oral cavity and neck, usually in doses of 6,090 to 7,996 rads administered over 6 to 7 weeks. Analysis of the results of treatment shows that for primary lesions classified Ti and Ts, surgical resection is very effective in controlling the tumors without unacceptable loss of function or other sequellae. Very rarely, patients with T1 lesions developed cervical metastases, which were always controlled by further treatment, usually neck dissection. Surgery was always successful in controlling the primary tu-
562
mors in patients with Ts lesions. Simultaneous modified neck dissection increased the neck control rate in patients staged No. The patients who had Tg primary tumors and cervical node metastases fared well with surgical treatment of the primary tumor and in the neck. Few of these patients were treated with irradiation alone. The patients with advanced primary lesions (Ts and TJ and a clinically negative neck had effective control of the lesions after surgical resection that included neck dissection. Functional loss and difficult surgical reconstruction became a more prominent feature in treatment for more advanced primary tumors. The patients with larger primary lesions had a high incidence of cervical metastases. Irradiation therapy as the only treatment for these advanced cancers failed in a high percentage of patients, and most of the patients with recurrence could not be saved. A sequential combination of surgery and irradiation appeared to improve the control of cervical metastases in the advanced stages [3]. Summary From 1971 through 1975,104 patients with squamous carcinoma of the anterior and anterolateral floor of the mouth underwent surgery, irradiation therapy or a combination of both with the purpose of eliminating their tumors. No patient had received treatment before, and this effort was considered primary and definitive. Fifty-five patients were free of cancer at the time of this analysis, 21 had died of intercurrent disease or new primary tumors, 1 patient was alive although suffering from another primary cancer, and in 27 patients the treatment failed and they died of recurrent carcinoma of the head and neck or with distant metastases. The ultimate determinate rate of control for all stages of disease was 66 percent. A rational approach to the problem of selecting a particular form of treatment for patients with cancer of the anterior floor of the mouth in different clinical manifestations is presented. References 1. Arnerlcan Joint Committee far Cancer Staging and End Results Reporting: Manual for staging of cancer. Chicago: 1978. 2. Guillamondegui Of4 Jesse RH. Surgical treatment of advanced carcinoma of the floor of the mouth. Am J Roentgenol 1978;126:1256-9. 3. Fbtdmr GHz Textbook of radiohrapy. 2nd ed. Philadelphle: Lea 8 Febiger, 1973.
TheAmerlcsllJoumslc4surQsq