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Epidermoid carcinoma of the mobile tongue
DECEMBER
The American
Journal
1971
of Surgery VOLUME
122
NUMBER
6
Epidermoid Carcinoma of the Mobile Tongue Treatment
by Partial Glossectomy Alone RONALD H. SPIRO, MD, New York, New York ELLIOT W. STRONG, MD, New York, New York
More than twenty years ago, surgery rather than irradiation became the preferred treatment for carcinoma of the tongue at Memorial Cancer Center, The increased salvage reported in the last study seems to reflect this change in policy [l,.Z]. Aithough surgery is thought to yield a higher “cure” rate than irradiation in patients who have advanced tongue cancer, there is disagreement about the treatment of those who have “favorable” lesions arising in the mobile tongue without clinical evidence of metastases. In many centers, irradiation is preferred, usually in conjunction with elective radical neck dissection [3-61; others advocate radical surgery [7,8]. This report will analyze the results achieved by partial glossectomy alone in patients with epidermoid carcinoma of the mobile tongue. Selection of Cases
During the years 1957 through 1963, the diagnosis of tongue cancer was recorded in 634 patients at Memorial Hospital. On review of the charts, thirty-two patients had adenocarcinoma or noninvasive epidermoid lesions, and the histologic diagnosis was not verified in four. Excluding nineteen others who received no therapy and sixteen whose records are incomplete, 563 patients were treated for invasive epidermoid carcinoma of the tongue. An extensive operation was usually performed in patients with locally advanced lesions, with or without cervical metastases, and those with tumors arising in the base of the tongue. Irradiation was the initial treatment in less than 15 per cent of the patients, whereas almost 50 per cent of the From the Head and Neck Service, Department of Surgery, Memorial Hosoital for Cancer and Allied Diseases. New York. New York. l&print requests should be addressed to Dr S-pi& Presented at the Seventeenth Annual Meeting of the Society of Head and Neck Surgeons, Vancouver. British Columbia. May 10-12, 1921.
Volume
122. December
1971
cases
previously reported from our hospital (1939 through 1953) were so treated [Z]. Whenever the lesion was confined to the mobile tongue (anterior to the circumvallate papillae) and cervical nodes were not enlarged, partial gfossectomy was the treatment of choice. Elective radical neck dissection was performed only on rare occasion when regular follow-up study was likely to be a problem because of patient unreliability or out-of-town residence. In all, 135 patients (32.9 per cent) had partial glossectomy alone as the initial, definitive treatment. Clinical Presentation
There were 112 male and 73 female patients (ratio 1.5 to 1) whose ages ranged from sixteen to ninety-three years (median sixty-three). The proportion of female patients in this selected group (40 per cent) is significantly higher than that recorded for all patients with cancer of the tongue seen during the same period (26 per cent) [ 91. Previous treatment had been given to eighteen patients, consisting of irradiation in ten instances and local excision in the others. According to the classification proposed by the American Joint Committee on Staging, ninetyfive patients had T1 lesions (2 cm or less) and seventy-seven had Tz lesions (more than 2 cm to 4 cm). Only thirteen had T, lesions (more than 4 cm). Since none had evidence of cervical node enlargement (N,) ,these three groups correspond to stages I, II, and RI, respectively. Other cancerous lesions were diagnosed in thirty-one patients (16.8 per cent), five of whom had synchronous lesions. With only three exceptions, the other tumors arose in the oral cavity (seventeen patients), laryngopharynx (seven patients), or esophagus (four patients). Eight patients were treated for multifocal tongue cancer.
707
Spiro and Strong
Results
Of 185 patients, ninety (48.7 per cent) were alive and well five years after partial glossectomy. Based on 145 determinate cases, the net “cure” rate was 62.1 per cent. This excludes thirty-nine indeterminate patients who had no evidence of recurrent or metastatic tongue cancer when they died of other causes, and one who was free of tumor when lost to follow-up study three years after surgery. Provided the primary tumor was 4 cm or less, partial glossectomy proved adequate for local control in more than 80 per cent of the determinate cases. (Table I.) Recurrence of disease in the tongue was noted in about 50 per cent of those whose lesions exceeded 4 cm. Cervical node metastases were detected after partial glossectomy in 38.4 per cent of the cases. The likelihood of such spread depended on the size of the primary lesion and varied from 29.1 per cent in patients with T1 lesions to 77 per cent in those who had Ts tumors. (Table II.) Bilateral cervical metsstases occurred in three patients, and in one patient, node involvement developed only in the opposite side of the neck. Radical neck dissection was subsequently performed in fifty-five of sixty determinate patients in whom node metastases developed. In three of these cases, the neck dissection was part of a combined operation (“commando”) for excision of a locally recurrent lesion as well. Of the five untreated patients, two had medical problems which precluded further surgery, two had unresectable disease in the neck, and one refused surgery. To determine how effectively the cervical spread was controlled, the five untreated patients were considered failures, as were eight others who died elsewhere of uncontrolled tongue cancer without specific information about the status of the neck.
TABLE I
Control of the Primary Tumor by Partial Glossectomy S’I”I”
“t#
Total
R&t
Yge
Total number of patients Determinate patients Local recurrence
95 74 6
77 61
11
3
20
0
1
0
1
“Cured” by subsequent treatment Dead of disease (no other information*) Primary control in determinate patients * Assumed
708
Incidence of Cervical Node Metastaoes after Partial Glossectomy
TABLE II
dead
5 85.1% (63/74)
with uncontrolled
4
13 10
2
77.0% (47/61)
50.0% (5/10)
disease
in primary
185 145
11 79.3% (115/145) site.
Stage I
Number of Patients
Number in Whom Metastases Developed
Per cent
28 33 10 71
29.1 42.9 77.0 38.4
95
II III Total
77 13 185
Recurrence in the dissected neck occurred in twenty-six patients. If four who died of disease without recurrent disease in the neck are added to the seventeen who remained free of tumor, it is apparent that cervical metastases, which appeared after glossectomy in sixty determinate case9, were successfully treated in only twenty-one instances (35 per cent). (Table III.) At best, exclusion of six patients whose uncontrolled neck disease may have been related to coexistent local recurrence raised the control rate to 39 per cent. Distant metastases occurred in at least nine instances, usually after treatment failure in the primary site or neck. The lung was the most common site, followed by viscera and bone. Four patients died with distant metastases but had no evidence of active local disease. Factors
Influencing
Survival
The outcome was not significantly influenced by the sex of the patient or previous treatment. As observed previously by Martin, Munster, and Sugarbaker [I], the “cure” rate appeared to be higher in younger patients. (Table IV.) Since the larger tumors were encountered with similar frequency in the younger and older patients, the difference seems to be significant. The salvage rate was most influenced by the size of the primary tumor. If it was 4 cm or less, about 66 per cent of the patients were “cured.” Only 10 per cent of those with lesions exceeding 4 cm were salvaged if partial glossectomy alone was the initial treatment. Much also depended on whether cervical metastases appeared after excision of the primary lesion in the tongue. Although this was more likely in those with larger tumors, it was entirely unpredictable in any given patient and reduced the expectation of “cure” to about 33 per cent. Comments
When a patient has an epidermoid carcinoma confined to the mobile tongue which measures 4
l’lw
Amdean
Journal
Ot Sur~rly
Epidermoid
cm or less, partial glossectomy is an effective means of controlling the local disease. Although recent reports suggest that interstitial irradiation may be equally effective for eradication of localized lesions [ IO], excision requires no specialized equipment. In experienced hands, the procedure is simple, morbidity is negligible, and the functional result is most satisfactory. For those with larger lesions (more than 4 cm), a radical operation is necessary since recurrence frequently follows local excision. Unfortunately, successful control of the primary tumor is no assurance of cure because of the strong likelihood of metastases to cervical lymph nodes. It has been shown that the “cure” rate in patients with cancer of the tongue is relatively lower than that reported for oral cancer in other sites [11]. This is probably related to the higher incidence of cervical node spread seen in those with tongue cancer. It is also possible that our policy of deferring neck dissection until metastases are palpable may have been detrimental in some instances. Almost 10 per cent of the patients never had the indicated neck dissection for one reason or another, and the disease was successfully treated in less than 40 per cent of those who had surgery. It has been suggested that cervical metastases are more readily curable if resected while still occult, that is, nonpalpable [4,7,8]. No proof of this assumption exists, but we have other data which suggest a trend towards increased survival
Carcinoma
Factors Influencing
TABLE IV
Determinate
of Mobile
Survival
Tongue
in 145
Patients Alive and W;;aFte
Factor
~__
Age 50 and under 51 through 70 71 and over Sex Male Female Previous therapy None Surgery or irradiation Size of primary lesion 2 cm or less (T,) 2 to 4 cm (T2) 4 cm (T3) Neck metastases None Appeared
later
Number of Patients
Later
Per cent
26 83 36
21 51 18
80.8 61.4 50.0
89 56
56 34
62.9 60.7
131 14
82 8
62.6
74 61 10
52 37 1
70.3 60.7 10.0
85 60
73 17
85.9 28.3
57.1
in patients with mouth cancer who have “elective” as compared to “therapeutic” neck dissection. Although operative morbidity is minimal, we have been reluctant to advise routine elective neck dissection since the nodes will prove to be negative in most instances. On the other hand, an elective operation is justified in selected patients provided that it yields the desired improvement in over-all results. Summary and Conclusion
TABLE
III
Control of Neck Metastases Partial Glossectomy Stage
I
Result Determinate
patients
S:alge
after
$;fs
Total
with 26 1
27 3
7 1
60 5
neck dissection Recurrence after radical neck dissection; primary
9
4
1
14
recurrence also Recurrence after radical neck dissection; delay
2
2
2
6
involved Dead of disease;
2
3
1
6
4
3
1
8
cervical metastases Not treated Recurrence after radical
information* Dead of disease,
no other but no 1
neck recurrence Alive and well at 5 yr Control of neck metastases * Assumed
Volume
122,
30.&
2 10 44.4%
(8/26)
(12/27)
(l/7)
disease
in neck.
dead with uncontrolled
December
1971
1 14.&
4 17 35.0% (21/60)
A series of 185 patients who had partial glossectomy for localized epidermoid carcinoma of the mobile tongue is presented. The five year “cure” rate in determinate cases was 62.1 per cent. Control of the primary tumor was achieved in at least 80 per cent of those whose lesions were 4 cm or less. Partial glossectomy was inadequate treatment when the tumor exceeded 4 cm. Spread to the cervical lymph nodes occurred after glossectomy in 29.1, 42.9, and 77.0 per cent of patients with T1, T?, and T, lesions, respectively. Radical neck dissection was reserved only for those in whom clinical evidence of metastases subsequently developed. More than 60 per cent of these patients died with uncontrolled neck disease. It seems likely that the cure rate may improve if more aggressive treatment is directed to the neck in selected patients. References 1. Martin I-fE, Munster H, Sugarbaker tongue. Arch Surg 41: BBB, 1940.
ED: Cancer
of the
709
Spiro
and
Strong
2. Frazell EL, Lucas JC: Carcinoma of the tongue: report of the management of 1,564 patients. Cancer 15: lOB5, 1962. 3. Baud J: End results of radiotherapy of cancer of the tongue. Amer J Roentgen01 63: 701, 1950. 4. Som ML: Carcinoma of the mobile portion of the tongue. Arch Otolaryng 87: 86, 1968. 5. Cade S: Treatment of cancer of the tongue. Amer J Roentgenof 63: 716, 1950. 6. Wookey H, Ash 0, Welsh K, Mustard RA: The treatment of oral cancer by a combination of radiotherapy and surgery. Ann Surg 134: 529, 1951. 7. Kremen AJ: Cancer of the tongue, a surgical technique for a primary combined en bloc resection of tongue,
710
floor of mouth and cervical lymphatics. Surgery 30: 227, 1951. 8. Ward GE, Edger-ton MT, Chambers RG, McKee DM: Cancer of the oral cavity and results of treatment by means of the composite operation. Ann Surg 150:
202, 1959. 9. Strong EW, Spiro RH: Notre experience
du cancer de la langue au Memorial H&pital. Rev Med 31: 1913, 1971. 10. Pierquin B, Chassagne D, Baillet F, Castro JR: The place of implantation in tongue and floor of mouth cancer. JAMA 215: 961, 1971. 11. Spiro RH, Frazell EL: Evaluation of radical surgical treatment of advanced cancer of the mouth. Amer J Surg
116: 571. 1968.
The
Amrrhn
Journal
of
Surgery
The American
Journal
1971
of Surgery VOLUME
122
NUMBER
6
Epidermoid Carcinoma of the Mobile Tongue Treatment
by Partial Glossectomy Alone RONALD H. SPIRO, MD, New York, New York ELLIOT W. STRONG, MD, New York, New York
More than twenty years ago, surgery rather than irradiation became the preferred treatment for carcinoma of the tongue at Memorial Cancer Center, The increased salvage reported in the last study seems to reflect this change in policy [l,.Z]. Aithough surgery is thought to yield a higher “cure” rate than irradiation in patients who have advanced tongue cancer, there is disagreement about the treatment of those who have “favorable” lesions arising in the mobile tongue without clinical evidence of metastases. In many centers, irradiation is preferred, usually in conjunction with elective radical neck dissection [3-61; others advocate radical surgery [7,8]. This report will analyze the results achieved by partial glossectomy alone in patients with epidermoid carcinoma of the mobile tongue. Selection of Cases
During the years 1957 through 1963, the diagnosis of tongue cancer was recorded in 634 patients at Memorial Hospital. On review of the charts, thirty-two patients had adenocarcinoma or noninvasive epidermoid lesions, and the histologic diagnosis was not verified in four. Excluding nineteen others who received no therapy and sixteen whose records are incomplete, 563 patients were treated for invasive epidermoid carcinoma of the tongue. An extensive operation was usually performed in patients with locally advanced lesions, with or without cervical metastases, and those with tumors arising in the base of the tongue. Irradiation was the initial treatment in less than 15 per cent of the patients, whereas almost 50 per cent of the From the Head and Neck Service, Department of Surgery, Memorial Hosoital for Cancer and Allied Diseases. New York. New York. l&print requests should be addressed to Dr S-pi& Presented at the Seventeenth Annual Meeting of the Society of Head and Neck Surgeons, Vancouver. British Columbia. May 10-12, 1921.
Volume
122. December
1971
cases
previously reported from our hospital (1939 through 1953) were so treated [Z]. Whenever the lesion was confined to the mobile tongue (anterior to the circumvallate papillae) and cervical nodes were not enlarged, partial gfossectomy was the treatment of choice. Elective radical neck dissection was performed only on rare occasion when regular follow-up study was likely to be a problem because of patient unreliability or out-of-town residence. In all, 135 patients (32.9 per cent) had partial glossectomy alone as the initial, definitive treatment. Clinical Presentation
There were 112 male and 73 female patients (ratio 1.5 to 1) whose ages ranged from sixteen to ninety-three years (median sixty-three). The proportion of female patients in this selected group (40 per cent) is significantly higher than that recorded for all patients with cancer of the tongue seen during the same period (26 per cent) [ 91. Previous treatment had been given to eighteen patients, consisting of irradiation in ten instances and local excision in the others. According to the classification proposed by the American Joint Committee on Staging, ninetyfive patients had T1 lesions (2 cm or less) and seventy-seven had Tz lesions (more than 2 cm to 4 cm). Only thirteen had T, lesions (more than 4 cm). Since none had evidence of cervical node enlargement (N,) ,these three groups correspond to stages I, II, and RI, respectively. Other cancerous lesions were diagnosed in thirty-one patients (16.8 per cent), five of whom had synchronous lesions. With only three exceptions, the other tumors arose in the oral cavity (seventeen patients), laryngopharynx (seven patients), or esophagus (four patients). Eight patients were treated for multifocal tongue cancer.
707
Spiro and Strong
Results
Of 185 patients, ninety (48.7 per cent) were alive and well five years after partial glossectomy. Based on 145 determinate cases, the net “cure” rate was 62.1 per cent. This excludes thirty-nine indeterminate patients who had no evidence of recurrent or metastatic tongue cancer when they died of other causes, and one who was free of tumor when lost to follow-up study three years after surgery. Provided the primary tumor was 4 cm or less, partial glossectomy proved adequate for local control in more than 80 per cent of the determinate cases. (Table I.) Recurrence of disease in the tongue was noted in about 50 per cent of those whose lesions exceeded 4 cm. Cervical node metastases were detected after partial glossectomy in 38.4 per cent of the cases. The likelihood of such spread depended on the size of the primary lesion and varied from 29.1 per cent in patients with T1 lesions to 77 per cent in those who had Ts tumors. (Table II.) Bilateral cervical metsstases occurred in three patients, and in one patient, node involvement developed only in the opposite side of the neck. Radical neck dissection was subsequently performed in fifty-five of sixty determinate patients in whom node metastases developed. In three of these cases, the neck dissection was part of a combined operation (“commando”) for excision of a locally recurrent lesion as well. Of the five untreated patients, two had medical problems which precluded further surgery, two had unresectable disease in the neck, and one refused surgery. To determine how effectively the cervical spread was controlled, the five untreated patients were considered failures, as were eight others who died elsewhere of uncontrolled tongue cancer without specific information about the status of the neck.
TABLE I
Control of the Primary Tumor by Partial Glossectomy S’I”I”
“t#
Total
R&t
Yge
Total number of patients Determinate patients Local recurrence
95 74 6
77 61
11
3
20
0
1
0
1
“Cured” by subsequent treatment Dead of disease (no other information*) Primary control in determinate patients * Assumed
708
Incidence of Cervical Node Metastaoes after Partial Glossectomy
TABLE II
dead
5 85.1% (63/74)
with uncontrolled
4
13 10
2
77.0% (47/61)
50.0% (5/10)
disease
in primary
185 145
11 79.3% (115/145) site.
Stage I
Number of Patients
Number in Whom Metastases Developed
Per cent
28 33 10 71
29.1 42.9 77.0 38.4
95
II III Total
77 13 185
Recurrence in the dissected neck occurred in twenty-six patients. If four who died of disease without recurrent disease in the neck are added to the seventeen who remained free of tumor, it is apparent that cervical metastases, which appeared after glossectomy in sixty determinate case9, were successfully treated in only twenty-one instances (35 per cent). (Table III.) At best, exclusion of six patients whose uncontrolled neck disease may have been related to coexistent local recurrence raised the control rate to 39 per cent. Distant metastases occurred in at least nine instances, usually after treatment failure in the primary site or neck. The lung was the most common site, followed by viscera and bone. Four patients died with distant metastases but had no evidence of active local disease. Factors
Influencing
Survival
The outcome was not significantly influenced by the sex of the patient or previous treatment. As observed previously by Martin, Munster, and Sugarbaker [I], the “cure” rate appeared to be higher in younger patients. (Table IV.) Since the larger tumors were encountered with similar frequency in the younger and older patients, the difference seems to be significant. The salvage rate was most influenced by the size of the primary tumor. If it was 4 cm or less, about 66 per cent of the patients were “cured.” Only 10 per cent of those with lesions exceeding 4 cm were salvaged if partial glossectomy alone was the initial treatment. Much also depended on whether cervical metastases appeared after excision of the primary lesion in the tongue. Although this was more likely in those with larger tumors, it was entirely unpredictable in any given patient and reduced the expectation of “cure” to about 33 per cent. Comments
When a patient has an epidermoid carcinoma confined to the mobile tongue which measures 4
l’lw
Amdean
Journal
Ot Sur~rly
Epidermoid
cm or less, partial glossectomy is an effective means of controlling the local disease. Although recent reports suggest that interstitial irradiation may be equally effective for eradication of localized lesions [ IO], excision requires no specialized equipment. In experienced hands, the procedure is simple, morbidity is negligible, and the functional result is most satisfactory. For those with larger lesions (more than 4 cm), a radical operation is necessary since recurrence frequently follows local excision. Unfortunately, successful control of the primary tumor is no assurance of cure because of the strong likelihood of metastases to cervical lymph nodes. It has been shown that the “cure” rate in patients with cancer of the tongue is relatively lower than that reported for oral cancer in other sites [11]. This is probably related to the higher incidence of cervical node spread seen in those with tongue cancer. It is also possible that our policy of deferring neck dissection until metastases are palpable may have been detrimental in some instances. Almost 10 per cent of the patients never had the indicated neck dissection for one reason or another, and the disease was successfully treated in less than 40 per cent of those who had surgery. It has been suggested that cervical metastases are more readily curable if resected while still occult, that is, nonpalpable [4,7,8]. No proof of this assumption exists, but we have other data which suggest a trend towards increased survival
Carcinoma
Factors Influencing
TABLE IV
Determinate
of Mobile
Survival
Tongue
in 145
Patients Alive and W;;aFte
Factor
~__
Age 50 and under 51 through 70 71 and over Sex Male Female Previous therapy None Surgery or irradiation Size of primary lesion 2 cm or less (T,) 2 to 4 cm (T2) 4 cm (T3) Neck metastases None Appeared
later
Number of Patients
Later
Per cent
26 83 36
21 51 18
80.8 61.4 50.0
89 56
56 34
62.9 60.7
131 14
82 8
62.6
74 61 10
52 37 1
70.3 60.7 10.0
85 60
73 17
85.9 28.3
57.1
in patients with mouth cancer who have “elective” as compared to “therapeutic” neck dissection. Although operative morbidity is minimal, we have been reluctant to advise routine elective neck dissection since the nodes will prove to be negative in most instances. On the other hand, an elective operation is justified in selected patients provided that it yields the desired improvement in over-all results. Summary and Conclusion
TABLE
III
Control of Neck Metastases Partial Glossectomy Stage
I
Result Determinate
patients
S:alge
after
$;fs
Total
with 26 1
27 3
7 1
60 5
neck dissection Recurrence after radical neck dissection; primary
9
4
1
14
recurrence also Recurrence after radical neck dissection; delay
2
2
2
6
involved Dead of disease;
2
3
1
6
4
3
1
8
cervical metastases Not treated Recurrence after radical
information* Dead of disease,
no other but no 1
neck recurrence Alive and well at 5 yr Control of neck metastases * Assumed
Volume
122,
30.&
2 10 44.4%
(8/26)
(12/27)
(l/7)
disease
in neck.
dead with uncontrolled
December
1971
1 14.&
4 17 35.0% (21/60)
A series of 185 patients who had partial glossectomy for localized epidermoid carcinoma of the mobile tongue is presented. The five year “cure” rate in determinate cases was 62.1 per cent. Control of the primary tumor was achieved in at least 80 per cent of those whose lesions were 4 cm or less. Partial glossectomy was inadequate treatment when the tumor exceeded 4 cm. Spread to the cervical lymph nodes occurred after glossectomy in 29.1, 42.9, and 77.0 per cent of patients with T1, T?, and T, lesions, respectively. Radical neck dissection was reserved only for those in whom clinical evidence of metastases subsequently developed. More than 60 per cent of these patients died with uncontrolled neck disease. It seems likely that the cure rate may improve if more aggressive treatment is directed to the neck in selected patients. References 1. Martin I-fE, Munster H, Sugarbaker tongue. Arch Surg 41: BBB, 1940.
ED: Cancer
of the
709
Spiro
and
Strong
2. Frazell EL, Lucas JC: Carcinoma of the tongue: report of the management of 1,564 patients. Cancer 15: lOB5, 1962. 3. Baud J: End results of radiotherapy of cancer of the tongue. Amer J Roentgen01 63: 701, 1950. 4. Som ML: Carcinoma of the mobile portion of the tongue. Arch Otolaryng 87: 86, 1968. 5. Cade S: Treatment of cancer of the tongue. Amer J Roentgenof 63: 716, 1950. 6. Wookey H, Ash 0, Welsh K, Mustard RA: The treatment of oral cancer by a combination of radiotherapy and surgery. Ann Surg 134: 529, 1951. 7. Kremen AJ: Cancer of the tongue, a surgical technique for a primary combined en bloc resection of tongue,
710
floor of mouth and cervical lymphatics. Surgery 30: 227, 1951. 8. Ward GE, Edger-ton MT, Chambers RG, McKee DM: Cancer of the oral cavity and results of treatment by means of the composite operation. Ann Surg 150:
202, 1959. 9. Strong EW, Spiro RH: Notre experience
du cancer de la langue au Memorial H&pital. Rev Med 31: 1913, 1971. 10. Pierquin B, Chassagne D, Baillet F, Castro JR: The place of implantation in tongue and floor of mouth cancer. JAMA 215: 961, 1971. 11. Spiro RH, Frazell EL: Evaluation of radical surgical treatment of advanced cancer of the mouth. Amer J Surg
116: 571. 1968.
The
Amrrhn
Journal
of
Surgery