Carcinoma of the palate

Carcinoma of the Palate E. P. SHIROKOV, M.D.,Balboa From tbe

Surgical Sertice, Gorgas Hospital, Canal Zone.

of the paIate is not commonIy seen in North America and epidermoid carcinoma of the hard paIate is stated to be very rare in current textbooks [I] on cancer. In a series consisting of approximateIy five thousand cases of maIignant tumors of the oral cavity seen at the Mayo CIinic from Igo7 to x938, New and HaIIberg [5] reported that there were onIy twenty-five cases of epidermoid carcinoma of the hard paIate. Martin’s [4] figures from MemoriaI Cancer HospitaI in New York are typica of those of North American medica centers. He states that go per cent of the paIata1 cancers occurred in men, the majority of these cancers were adenocarcinomas, and the growth originated on the soft paIate in 73 per cent of the patients. It is the purpose of this paper to (I) report the strikingIy different features of this disease as seen in Panama; (2) cite the cIinica1association of chronic irritation and tobacco with epidermoid carcinoma of the paIate; and (3) make a preIiminary report on its treatment in this area since 1954. Since 1954 I have personaIIy been consuIted by fourteen patients with cancer of the paIate. OnIy one was maIe, a North American, CanaI Zone employee, whose tumor originated on the soft paIate. The remaining thirteen patients were Panamanian women, in each of whom the tumor originated primarily on the hard paIate and was an epidermoid carcinoma. AI1of these women had smoked roIIed tobacco Ieaves or smaI1 cigars with the Iit end within the mouth and against the paIate for many years. Kini and Subba Rao [3] in 1937reported this habit of “reverse smoking” with roIIed dry tobacco Ieaves in India and its association with paIata1 cancer. They found fifty-two cases of cancer of the paIate in a series of 333 ora cancers. In India the practice of “Adda Poga” or reverse smoking is induIged in by both men

C

ANCER

American Journal of Surgery, Volume

loo,

October rg6o

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Heights,Canal

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and women whiIe in Panama the habit is mostIy confined to women from the Interior. Lack of money to buy manufactured cigarettes and possibly the desire to concea1 the fact that they smoke may have been factors in the origin of this habit and its practice by the women from the Interior of Panama. To the credit of these persons, it must be admitted that smoking in this manner utiIizes more effrcientIy a11the nicotine and tars in the weed; however, a high incidence of epidermoid carcinoma deveIoping in the area of mucosa1 irritation by the Iit end of the tobacco weed is the price paid for this ef&iency. This habit becomes firmIy fixed in these persons, and in my experience even after extensive surgery and hours of expIanation, the patient wiI1cooperate only to the extent that she wiI1smoke with the Iit end against the other side of the paIate. Figure I shows the typica appearance of these tumors. StatisticaIIy significant figures on the incidence of this probIem in Panama have been impossibIe to obtain. Many of these patients never enter a hospital, and in the Interior of Panama the death certificates are often made out by the IocaI offIciaIs without the benefit of professiona medica assistance. Even the death certificates from Panama City are of littIe heIp since there is inadequate breakdown as to the specific area of origin when the cause of death is Iisted as cancer of the mouth. Figures obtained from Panama City’s Iarge Santo Tomas HospitaI are not truIy indicative of the probIem since many of these patients never go to the city, much Iess to the hospital. In addition, the practice of reverse smoking is not nearIy as common in Panama City as in the Interior. NevertheIess, the foIIowing figures were obtained. During the year 1954, 28,814 patients were admitted to Santo Tomas HospitaI. Of these, 593 had cancer. Fifty-three, or g per cent

Carcinoma

FIG. I. FIG. I. Typical

of PaIate

FIG. 2.

FIG. 3.

appearance of an epidermoid carcinoma of the hard palate.

FIG. 2. Far advanced epidermoid carcinoma of the paIate extending into the pharynx, mandibIe and invading cervical Iymph nodes (4 to 5 cm.). FIG. 3. Postoperative appearance. Patient died of a cerebrovascutar ination reveakd no evidence of residual or recurrent cancer.

of the patients with cancer, had an oraI cancer. Twenty-two, or over 40 per cent of the oraI cancers, were primariIy carcinomas of the Local

pain

exam-

charge and bIeeding from the tumor in cases in which resection was possibIe was uniformIy obtained by surgica1 resection. SurgicaI resection of these tumors is not diffIcuIt. Reflecting the cheek by cutting through the lower Iip in the midIine and extending the skin incision in a curving manner beIow the mandible and through the pIatysma ending at the mastoid process, and then freeing the mandibuIar attachments, gives exceIIent exposure. The diseased part is then on the surface. ControI of the bIood suppIy is no probIem, and if the externa1 carotid artery is Iigated prior to the intraoral work, there is Iittle bIood Ioss whiIe resecting the invoIved paIate. Since no reIaxation is necessary, anesthesia can be kept very Iight, and even the eIderIy toIerate the procedure weI1. Endotracheal anesthesia and tracheotomy at the conclusion of the resection should be routineIy empIoyed. Since the cervica1 nodes are so frequentIy invoIved, neck dissection is aIso performed when the tumor is IateraIIy pIaced or if cervica1 nodes are enIarged. Extirpation of the Iymphatics en bloc with the other IateraI neck contents from just beneath the pIatysma to the prevertebra1 fascia, from the cIavicIe upward, incIuding a portion of the mandibIe and bucca1 mucosa when necessary to get around the tumor, is performed preserving onIy the carotid artery, sympathetic chain and vagus nerve. Ligation of the externa1 carotid artery is performed to decrease the amount of intraoral bleeding at the time of surgery and decrease the chances of serious bIeeding if the tumor re-

palate. is

the most common symptom in A fou1, nauseating discharge invariably foIIowed when the mucosa1 surface was broken and infection by the intraora1 organisms occurred. CervicaI metastasis was present in the majority of patients, whiIe metastasis beIow the cIavicIes was not noted. Death is aImost invariabIy due to IocaI causes such as hemorrhage, obstruction and secondary infection, compIicated by inabiIity to swaIIow properIy, with deveIopment of inanition and puImonary probIems due to aspiration. The method of therapy in Panama City has been and is radiation. PerusaI of the records from the RadioIogicaI Institute of Panama and Santo Tomas HospitaI reveaIs not a singIe “five-year cure.” In addition, radiation did not give paIIiation and was frequentIy foIIowed by osteomyeIitis and sIough of the bony portion of the paIate. Since 1954 surgica1 extirpation has been the method of choice for patients with these paIata1 cancers at Gorgas HospitaI, CanaI Zone. AIthough our smaI1 series is statisticaIIy insignificant, the resuIts are encouraging. The inffammatory component of these tumors can be misIeading. CarefuI ora hygiene, irrigation and antibiotics for a period often markedIy decreased the size of the tumor and shouId aIways be empIoyed preoperativeIy. Relief of pain and eIimination of the disthese

accident four years later. Postmortem

patients.

531

Shirokov curs; however, it is omitted if a Iong mucosaI pedicIe ffap from the buccaI mucosa wiI1 be needed to cover the paIatine defect, or if the IateraI third of the tongue is to be used to 611 in the paIatine defect. The neck dissection, of course, precedes the intraora1 work. At times it is not feasibIe to perform the neck dissection en bloc with the paIata1 tumor. The specimens are then removed separateIy and radiation of the skip area is indicated. Figure 2 shows an advanced Iesion with additiona invoIvement of the soft palate, Iateral pharyngea1 waI1, angIe of mandibIe and cervical metastasis measuring 4 cm. in diameter. Th e postoperative appearance is shown. (Fig. 3.) The patient died of a cerebrovascuIar accident four years after surgery. Postmortem examination reveaIed no evidence of recurrent or residua1 cancer. She received great paIIiation from the surgery and probabIy wouId have been a “five-year cure” if old age and the cerebrovascuIar accident had not intervened. AIthough surgica1 excision of these tumors is reIativeIy simpIe, reconstruction of the remaining defect can be a probIem. Prostheses and obturators to pIug the paIata1 defect are poorIy toIerated by eIderIy patients and changing osseous contours due to atrophy add to the diffIcuIty. There is no one best way of cIosing the paIata1 defect. The surgeon must utiIize the tissues that are avaiIabIe and improvise. The foIIowing methods have proved to be useful in reconstructing the defect: Free skin graft: This can be employed successfuIIy only if the mucosa on the nasal side of the paIatine bone is intact. Shifting the uninvolved palatine mucosa: Just as the mucosa can be shifted to cover a congenita1 defect of the cIeft paIate, so can the mucosa be shifted to cover the defect from resection. Constructing a mucosal pedicle jlap graft from the adjacent buccal mucosa: ConsiderabIe additiona1 Iength can be obtained for this pedicle graft by fashioning it so that the free margin was the former latera aIveoIar ridge mucosa. Such a broad based pedicIe graft wiI1 reach past the midline since the cheek wiI1 naturaIIy faI1 inward on the invoIved side after resection of the paIate. Construction of a mucosal pedicle graft from 532

tbe posterior pbaryngeal wall: This is especiaIIy usefu1 for midIine Iesions and repIacing the resected portions of the soft palate. When covering the nasa1 side of the paIate, the pedicIe graft is based superiorIy. When covering the ora side, the base of the graft is pIaced inferiorly. This procedure has been used successfuIIy for many years by surgeons operating on compIicated cIeft paIates and has more recently been popuIarized by Conway [2]. Employing a denuded portion oj the intact tongue: The tongue can be mobiIized about a month Iater as a second stage procedure. Employing the lateral third of the tongue with its intact blood supply as a permanent pedicle graft: This is an exceIIent procedure for Iarge defects. The functiona resuIts of these procedures are surprisingIy good. When the tongue and IateraI bucca1 mucosa1 grafts are used to reconstruct the paIatine defect there is restriction of motion and diffIcuIty with speech and mastication initiaIIy, but with the passage of time the patient and the tissues readjust to the new aIignment very SatisfactoriIy. SUMMARY I. An unusuaIIy high incidence of epidermoid carcinoma of the paIate in Panama associated with reverse smoking (Iit end within the mouth) is noted. 2. Radiation therapy of these lesions has produced no “five-year cures” and has not given paIIiation. 3. PreIiminary resuIts of the surgica1 management of these Iesions are encouraging. 4. An outIine of the surgica1 management is presented, the onIy diflicuIt part being reconstruction of the paIatine defect. This can be accompIished by the use of an obturator, free skin graft, shifting of the uninvoIved paIatine mucosa, using the intact tongue, or fashioning the Iateral third of the tongue with its intact bIood suppIy as a pedicIe graft, and constructing mucosa1 pedicIe grafts from the bucca1 mucosa and/or the mucosa of the posterior pharyngea1 waI1.

Acknowledgment: I wish to thank Dr. Ernest0 Zubieta, Chief of the RadioIogicaI Institute, Dr. JuIio C. Wong and Mrs. PaImira Sarasqueta, Records Librarian, for making it possibIe to review the records from the RadioIogicaI

Carcinoma Institute

of Panama,

of Palate compticated cases of cleft paIate. Plastic 6 Reconstruct. Surg., 7: 214, 1951. 3. KINI, M. G. and SUBBA-RAO, K. V. Problems of cancer. India Med. Gaz., 72: 677, 1937. 4. MARTIN, H. D. Tumors of the parate. Arch. Surg., 44: 599, 1942. 5. NEW, G. B. and HALLBERG, 0. E. The end resutts of the treatment of maIignant tumors of the palate. Surg., Gynec. CPObst., 73: 520, 1941.

and Santo Tomas Hos-

pital, Panama City, Panama. REFERENCES I. ACKERMAN, L. V. and DEL REGATO, J. A. Cancer, 2nd ed. St. Louis, 1954. C. V. Mosby Co. 2. COXWAY, H. Combined use of the push back and pharyngea1 Rap procedures in the management of

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