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Epidermoid carcinoma of the palate
Epidermoid Carcinoma of the Palate ERICK R RATZER, MD, Denver, Colorado ROBERT J SCHWEITZER, MD, Oakland,
California
EDGAR L FRAZELL, MD, New York, New York
Experience in the management of tumors of the palate at Memorial Hospital was last reported in 1942 [I]. In that paper Martin included information obtained from 103 patients with benign and malignant tumors of the palate observed on the Head and Neck Service from 1929 through 1936. A detailed study of the possible etiologic factors, incidence of benign and malignant tumors, and the anatomy of the structures involved was made and much of this information needs no repetition. On the other hand, a much larger body of material has now been accumulated concerning the clinical course and response to current treatment methods of malignant tumors at this site. The object of this paper is to present only the experience with epidermoid carcinoma of the palate. The nonepidermoid tumors will be the subject of a second report. Anatomy
of the Palate
The palate forms the roof of the mouth. Anatomically and functionally the palate consists of two distinct structures which are continuous with each other and are so described in standard textbooks [l-3]. The hard palate, which forms a partition between the oral and nasal cavities, is formed by the palatine processes of the maxilla and the horizontal plate of the palatine bone. It has stratified squamous type of epithelium covering its oral surface. It is bounded by the alveolar arches and gums in front and at the sides; behind, it is continuous with the soft palate. The fixed nature of the structure possibly accounts for the sometimes sluggish nature of epidermoid carcinoma arising at this site. The soft palate, on the other hand, is a flexible structure consisting of a fold of mucous membrane enclosing muscular fibers and aponeuroses, vessels, nerves, lymphoid tissue, and mucous glands. It is attached anteriorly to the hard palate and is continuous laterally with the supratonisllar fossae and tonsillar pillars. The latter structures curve upwards and backwards to form the posterior free edge of the soft palate, From the Head and Neck Service, Department of Surgery, Memorial-Sloan Kettering Cancer Center, New York, New York. This work was supported in part by the USPHS Traineeship Grant Number CST-358-666 from the Cancer Control Program. This paper was read before the James Ewing Society, April 15. 1967. Reprint requests should be addressed to Dr Ratzer, Univerity of Colorado Medical Center, 4200 E 9th Avenue, Denver, Colorado 80220.
294
in the center of which is the uvula. The soft palate comprises the central portion of the so-called faucial arch and has as its function a sphincter-like action which prevents regurgitation into the nasal cavity during the act of deglutition. Clinical
Material
During the twenty-two year period from 1939 to 1960 inclusive, 422 patients with epidermoid carcinoma of the palate were observed at this hospital. One hundred twenty-three originated on the hard palate and 299 on the soft palate. This represents the total experience and includes all cases, early, late, treated and not treated, in whom the diagnosis was histologically confirmed. All of the tumors arose from the palate; those arising from adjacent structures with secondary invasion of the palate were excluded. Ninetysix per cent of the patients were managed on the Head and Neck Service and this resulted in considerable uniformity of treatment methods. The remainder of the patients were cared for by other physicians on the hospital staff. As would be expected in a cancer institute, a sizable proportion of the material represents prior treatment failures. The distribution of cases (Table I) shows that 27 per cent of the patients with hard palate tumors and 18 per cent of those with soft palate lesions had their initial treatment elsewhere. Prior treatment included surgery, radiation, or a combination of these two methods. In some patients prior treatment had little influence on the ultimate result achieved, but in others it ruled out the possibility of cure. Also, in some it undoubtedly influenced the decision concerning treatment methods to be used, and in others it may have been the deciding factor of whether or not to treat the disease. Findings
on Admission
Epidermoid carcinoma of the palate is predominately a disease of the elderly. The most common decade of occurrence in this series was the seventh (sixty to sixty-nine years). The youngest patient was a twenty-three year old man and the oldest was an eighty-nine year old woman, both of whom had cancer of the hard palate. Sex Distribution. As is the case in almost all other Age.
The
American
Journal
of Surgery
Epidermoid
varieties of epidermoid carcinoma of the head and neck, epidermoid cancer of the palate occurs predominately in men. There were 347 men (82 per cent) and seventy-five women (18 per cent) in this series. Durdion of Symptoms. The median duration of symptoms before seeking medical advice was four and a half months. The range was from a few days to more than ten years. Tumor Size. Seventy-nine per cent of the patients had the size or status of the primary tumor recorded on admission. About half were 2.9 cm or less in diameter, whereas the rest ranged from 3.0 cm to more than 10.0 cm. No residual tumor could be felt at the primary site in twenty-five patients (6 per cent of the entire series), implying control here by prior therapy. Only eight of these patients were entirely free of cancer, however, for the remainder presented with cervical metastases. Stage of Disease on Admission. Table II lists the stage of disease that was recorded on admission for all of the patients. Distant metastases were rarely found on admission, or for that matter, at any time in the clinical course of these patients. About one third of the patients had the cancer confined to the site of origin without invasion of adjacent structures. If the hard palate is considered separately, almost half (sixty) of the patients presented this way. Cervical metastases were found on admission in 126 patients, and 87 per cent of these (110) had epidermoid carcinoma of the soft palate. This represented 37 per cent of all cases of soft palate tumors, compared to only 13 per cent of cases of hard palate tumors. Treatment
Epidermoid cancer of the palate may be successfully treated by either radiation therapy or surgery. Most observers favor surgery over irradiation for the hard palate lesions. Tumors of the soft palate, on the other hand, are highly sensitive to irradiation and comparable cure rates are achieved by either radiation therapy or surgery. In this series, for the soft palate cancer the two treatment modalities were employed in approximately equal numbers. For both hard and soft palate tumors, the choice of one treatment method over the other was based on the following factors: (1) site of origin; (2) tumor size; (3) stage of disease; (4) history of previous treatment. It should also be noted that in keeping with service policies there has been a tendency in recent years to emphasize surgical procedures in the management of cancer of the head and neck. This in part has been due to the generally advanced nature of the disease in the patients we see and the high incidence of “secondary” cases. Three hundred eighty-one (90 per cent) of the 422 patients Vol.
119, March
1970
TABLE
I
Carcinoma
of Palate
Incidence of Previous Treatment in Patients with Epidermoid Carcinoma of the Palate
Site
Total
Hard palate Soft palate Total
123 299 422
._
Previous Treatment
Per cent
33 55 88
27 18 21
received treatment for cure at Memorial Hospital, and surgery was used alone or in combination in 50 per cent of these patients. However, if the first eleven years of the period are compared to the last eleven years, the percentage of patients treated surgically increased from 30 per cent to 74 per cent. This reflects mainly a change in policy in the management of cancer of the soft palate. It is not the purpose of this report to outline specific recommendations and offer detailed descriptions of various treatment methods for epidermoid carcinoma of the palate. There are too many different clinical situations possible in this disease, each one requiring a somewhat different approach, to make this practical. However, a few generalizations concerning the current management policies at Memorial Hospital may be helpful. 1. Surgery is preferred for almost all hard palate epidermoid carcinomas because the underlying bone limits the amount of irradiation that can be safely given. 2. Some early well localized soft palate lesions are amenable to surgical excision without causing significant functional disability. Those of a diffuse nature are best treated by radiation therapy. Advanced lesions exhibiting extensive local involvement plus regional lymph node metastases are probably best managed by a combination of surgery and radiation therapy. 3. Cervical lymph node metastases are treated by surgery (radical neck dissection). Table III lists the treatment methods for the entire series according to the anatomic site of origin.
TABLE
II
Stage
Stage
__
In situ Localized Invasion of adjacent structures Cervical metastases Distant metastases No tumor present
of Disease
on Admission
Hard Palate
Soft Palate
Total
Per cent
0 60
14 85
14 145
3 34
40 16 1 6 123
85 110 3 2 299
125 126* 4 8 422
30 30 1 2 100
* Seventeen patients had the previous treatment elsewhere.
primary
tumor
controlled
by
295
Ratzer.
Schweitzer,
TABLE _._~~_
III
~---
Therapy
~~ Surgery Radiation
and Frazell
______~. Hard Palate
._~~__~.
therapy
__
Clinical
Soft Palate
Total
Per cent
112 139
180 166
43 39
22 26 299 _____
35 41 422
8 100 100
68 27
Surgery-Radiation therapy None __--
years after treatment; all of the remaining alive at five years had no evidence of tumor.
Methods of Treatment
13 15 123
..-
Course
after
Treatment
The predominate cause of failure to cure patients with epidermoid carcinoma of the palate was recurrence at the primary site, this being true for both the hard and soft palate. Local recurrence was present in 68 per cent of the failures in this series. In many of these patients there was also additional spread of the cancer. In twenty seven patients distant metastases developed after treatment, but in only eight was this the solitary manifestation of failure. Cervical metastases developed, after initial therapy had controlled the primary tumor, with some frequency only in epidermoid carcinoma of the soft palate. Even so, this situation was not seen often enough to warrant investigation of the value of “prophylactic” radical neck dissection. Additional treatment was successful in salvaging some of the patients in whom treatment for either local recurrences only or cervical metastases only had failed. No patient in whom cervical metastases developed simultaneously with local recurrence was saved regardless of the type of secondary treatment employed. End
Results
For epidermoid carcinoma of the palate the absolute five year cure rate was 22 per cent (ninety-one of 422), whereas for determinate cases it was 30 per cent (ninety-one of 304). Table IV illustrates that survival rates were essentially the same regardless of whether the site of origin was the hard or soft palate. When treatment fails to cure a patient with epidermoid cancer of the head and neck area, this failure is almost always apparent within two years. Accordingly, any patient free of cancer at five years can for all practical purposes be considered cured. In this series, only three patients were living with cancer present five
TABLE
End Results of Treatment
IV
Five Year Cures Site Hard palate Soft palate Total ~~_____~_ 296
Absolute 24% (29/123) 21% (62/290) 22% (91/422)
Determinate 31% (29/94) 30% (62/210) 30% (91/304)
Factors
Influencing
patients
Prognosis
In the final analysis it is the survival rate of all the patients that is the most important statistic in determining the effect of treatment on this disease, but this alone rarely offers help in evaluating the prognosis of the individual patient. It is apparent that numerous conditions influence the possibility of cure and several have been examined for the patients in this series. The information has been obtained from patients for whom the results of treatment are known, that is, determinate end results, and therefore the final table (Table V) contains only 304 patients, rather than 422. The factors evaluated were age, sex, previous treatment, size of the primary tumor, anatomic site of origin, stage of disease on admission, and treatment received at Memorial Hospital. Age. It does not appear that age alone has any prognostic significance in epidermoid carcinoma of the palate. Treatment decisions were not influenced by age except in a few instances of associated medical diseases which, as would be expected, were more frequently seen in the elderly. SGC. As is the case with other forms of cancer of the mouth, male patients with cancer of the palate fared less well than did female patients. No satisfactory cause for this has been observed. Size of the Primary Tumor. The size of the primary tumor has definite prognostic significance. The information relates only to those tumors less than 3.0 cm in diameter compared to those greater than this size, The smaller size lesions have the better cure rate, that is, 54 per cent versus 16 per cent. Larger tumors have a higher local recurrence rate which probably is a reflection of the inherent difficulty of excising them with adequate margins. Larger lesions also have a higher incidence of cervical lymph node metastases when first examined and this is also associated with decreased survival.
Anatomic
Site of Origin of the Primary
Tumor.
Whether the tumor originates on the hard or the soft palate does not of itself seem to have prognostic significance. The cure rate was slightly better, but not significantly so, in patients with tumors of the hard palate. The almost similar cure rates for both tumors of the hard and of the soft palate require some scrutiny, however, since a larger percentage of those with cancer of the soft palate had more advanced disease on admission. The difference was compensated for by the low cure rate ( 18 per cent) of those with hard palate tumors in which the primary tumor had enlarged to the extent of invading adjacent structures. Direct extension of soft palate primary tumors had a 31 per cent cure rate. End results were similar in patients with The American
Journal
of Surgery
Epidermoid TABLE
Factors
V
Influencing
Prognosis
in Determinate
Cases CURES Factor
Age (YO 20-29 30-39 40-49 50-59 6&69 70-79 80-89 Sex Female Male Previous treatment Primary cases Secondary cases Size of primary tumor Less than 3.0 cm Over 3.0 cm None palpable Not recorded Primary site Hard palate Soft palate Stage of Disease on Admission Localized Invasion of adjacent structures Cervical metastases Other Treatment at Memorial Hospital None Surgery Radiation therapy Surgery-radiation therapy
Total Number
Number
2 4 45 86 113 46 8
1 1 10 32 35 10 2
50 25 22 37 31 22 25
64 240
25 66
39 27
251 53
81 10
32 19
107 116 17 64
58 19 3 11
54 16 18 17
94 210
29 62
31 30
106
57
54
91 102 5
25 8 1
27 8 20
2 144 128 30
0 54 36 1
0 38 28 3
Per cent --_-~
potentially curable lesions of the two other stage classifications. Stage of Disease on Admission. The most striking observation was the serious decline in survival for patients who presented with cervical lymph node metastases compared to those in whom cancer was confined to the oral cavity. Cure rate was only 8 per cent when nodes were present on admission. When cervical metastases developed subsequent to control of the primary tumor, the five -year cure rate was 15 per cent. When cancer was confined to the primary site of origin, the cure rate was twice that of tumors that had invaded adjacent structures such as gingiva, tongue, and buccal mucosa. As previously stated, results were
Vol.
119, March
1970
Carcinoma
of Palate
much worse with hard palate tumors with local extension than with those of the soft palate. No obvious reason was found for this difference. Previous Treatment. Patients who had initial treatment at Memorial Hospital (primary cases) had a better five year cure rate than those who were seen after having had their initial treatment elsewhere (secondary cases). Many of the patients in the secondary group had advanced incurable disease when first seen and some of them could not be treated. The secondary cases treated at Memorial Hospital had a higher percentage of advanced disease when compared to the primary group. Survival rates were the same for both primary and secondary cases at the same stage of disease regardless of the type of previous treatment. Treatment at Memorial Hospital. In this series, for reasons previously stated, surgery is the favored treatment method for epidermoid carcinoma of the palate. Surgery is the treatment of choice for cervical lymph node metastases (radical neck dissection), but currently preoperative irradiation is extensively employed. In the early portion of the period under review, radiation therapy was the treatment selected in more than half of the patients with epidermoid carcinoma of the soft palate. A more recent trend to surgery has not demonstrated a substantial improvement in end results. Summary
From 1939 through 1960, 422 patients with epidermoid carcinoma of the palate were observed at Memorial Hospital. One hundred twenty-three lesions originated on the hard palate and 299 on the soft palate. Ninety per cent of these patients (381) were treated for cure. Surgery was preferred for the primary tumor and cervical metastases if present. The absolute five year cure rate was 22 per cent, whereas the determinate cure rate was 30 per cent. The main cause of treatment failure was recurrence at the primary site. Small tumors confined to their primary site of origin had the best prognosis. References 1. Martin H: Tumors of the palate (benign and malignant). Arch Surg 44: 599, 1942. 2. Gray H: Anatomy of the Human Body, 28th ed. (Goss CM, ed). Philadelphia, Lea & Febiger, 1966. 3. Thorek P: Anatomy in Surgery. p 155, Philadelphia, JB Lippincott, 1951.
297
California
EDGAR L FRAZELL, MD, New York, New York
Experience in the management of tumors of the palate at Memorial Hospital was last reported in 1942 [I]. In that paper Martin included information obtained from 103 patients with benign and malignant tumors of the palate observed on the Head and Neck Service from 1929 through 1936. A detailed study of the possible etiologic factors, incidence of benign and malignant tumors, and the anatomy of the structures involved was made and much of this information needs no repetition. On the other hand, a much larger body of material has now been accumulated concerning the clinical course and response to current treatment methods of malignant tumors at this site. The object of this paper is to present only the experience with epidermoid carcinoma of the palate. The nonepidermoid tumors will be the subject of a second report. Anatomy
of the Palate
The palate forms the roof of the mouth. Anatomically and functionally the palate consists of two distinct structures which are continuous with each other and are so described in standard textbooks [l-3]. The hard palate, which forms a partition between the oral and nasal cavities, is formed by the palatine processes of the maxilla and the horizontal plate of the palatine bone. It has stratified squamous type of epithelium covering its oral surface. It is bounded by the alveolar arches and gums in front and at the sides; behind, it is continuous with the soft palate. The fixed nature of the structure possibly accounts for the sometimes sluggish nature of epidermoid carcinoma arising at this site. The soft palate, on the other hand, is a flexible structure consisting of a fold of mucous membrane enclosing muscular fibers and aponeuroses, vessels, nerves, lymphoid tissue, and mucous glands. It is attached anteriorly to the hard palate and is continuous laterally with the supratonisllar fossae and tonsillar pillars. The latter structures curve upwards and backwards to form the posterior free edge of the soft palate, From the Head and Neck Service, Department of Surgery, Memorial-Sloan Kettering Cancer Center, New York, New York. This work was supported in part by the USPHS Traineeship Grant Number CST-358-666 from the Cancer Control Program. This paper was read before the James Ewing Society, April 15. 1967. Reprint requests should be addressed to Dr Ratzer, Univerity of Colorado Medical Center, 4200 E 9th Avenue, Denver, Colorado 80220.
294
in the center of which is the uvula. The soft palate comprises the central portion of the so-called faucial arch and has as its function a sphincter-like action which prevents regurgitation into the nasal cavity during the act of deglutition. Clinical
Material
During the twenty-two year period from 1939 to 1960 inclusive, 422 patients with epidermoid carcinoma of the palate were observed at this hospital. One hundred twenty-three originated on the hard palate and 299 on the soft palate. This represents the total experience and includes all cases, early, late, treated and not treated, in whom the diagnosis was histologically confirmed. All of the tumors arose from the palate; those arising from adjacent structures with secondary invasion of the palate were excluded. Ninetysix per cent of the patients were managed on the Head and Neck Service and this resulted in considerable uniformity of treatment methods. The remainder of the patients were cared for by other physicians on the hospital staff. As would be expected in a cancer institute, a sizable proportion of the material represents prior treatment failures. The distribution of cases (Table I) shows that 27 per cent of the patients with hard palate tumors and 18 per cent of those with soft palate lesions had their initial treatment elsewhere. Prior treatment included surgery, radiation, or a combination of these two methods. In some patients prior treatment had little influence on the ultimate result achieved, but in others it ruled out the possibility of cure. Also, in some it undoubtedly influenced the decision concerning treatment methods to be used, and in others it may have been the deciding factor of whether or not to treat the disease. Findings
on Admission
Epidermoid carcinoma of the palate is predominately a disease of the elderly. The most common decade of occurrence in this series was the seventh (sixty to sixty-nine years). The youngest patient was a twenty-three year old man and the oldest was an eighty-nine year old woman, both of whom had cancer of the hard palate. Sex Distribution. As is the case in almost all other Age.
The
American
Journal
of Surgery
Epidermoid
varieties of epidermoid carcinoma of the head and neck, epidermoid cancer of the palate occurs predominately in men. There were 347 men (82 per cent) and seventy-five women (18 per cent) in this series. Durdion of Symptoms. The median duration of symptoms before seeking medical advice was four and a half months. The range was from a few days to more than ten years. Tumor Size. Seventy-nine per cent of the patients had the size or status of the primary tumor recorded on admission. About half were 2.9 cm or less in diameter, whereas the rest ranged from 3.0 cm to more than 10.0 cm. No residual tumor could be felt at the primary site in twenty-five patients (6 per cent of the entire series), implying control here by prior therapy. Only eight of these patients were entirely free of cancer, however, for the remainder presented with cervical metastases. Stage of Disease on Admission. Table II lists the stage of disease that was recorded on admission for all of the patients. Distant metastases were rarely found on admission, or for that matter, at any time in the clinical course of these patients. About one third of the patients had the cancer confined to the site of origin without invasion of adjacent structures. If the hard palate is considered separately, almost half (sixty) of the patients presented this way. Cervical metastases were found on admission in 126 patients, and 87 per cent of these (110) had epidermoid carcinoma of the soft palate. This represented 37 per cent of all cases of soft palate tumors, compared to only 13 per cent of cases of hard palate tumors. Treatment
Epidermoid cancer of the palate may be successfully treated by either radiation therapy or surgery. Most observers favor surgery over irradiation for the hard palate lesions. Tumors of the soft palate, on the other hand, are highly sensitive to irradiation and comparable cure rates are achieved by either radiation therapy or surgery. In this series, for the soft palate cancer the two treatment modalities were employed in approximately equal numbers. For both hard and soft palate tumors, the choice of one treatment method over the other was based on the following factors: (1) site of origin; (2) tumor size; (3) stage of disease; (4) history of previous treatment. It should also be noted that in keeping with service policies there has been a tendency in recent years to emphasize surgical procedures in the management of cancer of the head and neck. This in part has been due to the generally advanced nature of the disease in the patients we see and the high incidence of “secondary” cases. Three hundred eighty-one (90 per cent) of the 422 patients Vol.
119, March
1970
TABLE
I
Carcinoma
of Palate
Incidence of Previous Treatment in Patients with Epidermoid Carcinoma of the Palate
Site
Total
Hard palate Soft palate Total
123 299 422
._
Previous Treatment
Per cent
33 55 88
27 18 21
received treatment for cure at Memorial Hospital, and surgery was used alone or in combination in 50 per cent of these patients. However, if the first eleven years of the period are compared to the last eleven years, the percentage of patients treated surgically increased from 30 per cent to 74 per cent. This reflects mainly a change in policy in the management of cancer of the soft palate. It is not the purpose of this report to outline specific recommendations and offer detailed descriptions of various treatment methods for epidermoid carcinoma of the palate. There are too many different clinical situations possible in this disease, each one requiring a somewhat different approach, to make this practical. However, a few generalizations concerning the current management policies at Memorial Hospital may be helpful. 1. Surgery is preferred for almost all hard palate epidermoid carcinomas because the underlying bone limits the amount of irradiation that can be safely given. 2. Some early well localized soft palate lesions are amenable to surgical excision without causing significant functional disability. Those of a diffuse nature are best treated by radiation therapy. Advanced lesions exhibiting extensive local involvement plus regional lymph node metastases are probably best managed by a combination of surgery and radiation therapy. 3. Cervical lymph node metastases are treated by surgery (radical neck dissection). Table III lists the treatment methods for the entire series according to the anatomic site of origin.
TABLE
II
Stage
Stage
__
In situ Localized Invasion of adjacent structures Cervical metastases Distant metastases No tumor present
of Disease
on Admission
Hard Palate
Soft Palate
Total
Per cent
0 60
14 85
14 145
3 34
40 16 1 6 123
85 110 3 2 299
125 126* 4 8 422
30 30 1 2 100
* Seventeen patients had the previous treatment elsewhere.
primary
tumor
controlled
by
295
Ratzer.
Schweitzer,
TABLE _._~~_
III
~---
Therapy
~~ Surgery Radiation
and Frazell
______~. Hard Palate
._~~__~.
therapy
__
Clinical
Soft Palate
Total
Per cent
112 139
180 166
43 39
22 26 299 _____
35 41 422
8 100 100
68 27
Surgery-Radiation therapy None __--
years after treatment; all of the remaining alive at five years had no evidence of tumor.
Methods of Treatment
13 15 123
..-
Course
after
Treatment
The predominate cause of failure to cure patients with epidermoid carcinoma of the palate was recurrence at the primary site, this being true for both the hard and soft palate. Local recurrence was present in 68 per cent of the failures in this series. In many of these patients there was also additional spread of the cancer. In twenty seven patients distant metastases developed after treatment, but in only eight was this the solitary manifestation of failure. Cervical metastases developed, after initial therapy had controlled the primary tumor, with some frequency only in epidermoid carcinoma of the soft palate. Even so, this situation was not seen often enough to warrant investigation of the value of “prophylactic” radical neck dissection. Additional treatment was successful in salvaging some of the patients in whom treatment for either local recurrences only or cervical metastases only had failed. No patient in whom cervical metastases developed simultaneously with local recurrence was saved regardless of the type of secondary treatment employed. End
Results
For epidermoid carcinoma of the palate the absolute five year cure rate was 22 per cent (ninety-one of 422), whereas for determinate cases it was 30 per cent (ninety-one of 304). Table IV illustrates that survival rates were essentially the same regardless of whether the site of origin was the hard or soft palate. When treatment fails to cure a patient with epidermoid cancer of the head and neck area, this failure is almost always apparent within two years. Accordingly, any patient free of cancer at five years can for all practical purposes be considered cured. In this series, only three patients were living with cancer present five
TABLE
End Results of Treatment
IV
Five Year Cures Site Hard palate Soft palate Total ~~_____~_ 296
Absolute 24% (29/123) 21% (62/290) 22% (91/422)
Determinate 31% (29/94) 30% (62/210) 30% (91/304)
Factors
Influencing
patients
Prognosis
In the final analysis it is the survival rate of all the patients that is the most important statistic in determining the effect of treatment on this disease, but this alone rarely offers help in evaluating the prognosis of the individual patient. It is apparent that numerous conditions influence the possibility of cure and several have been examined for the patients in this series. The information has been obtained from patients for whom the results of treatment are known, that is, determinate end results, and therefore the final table (Table V) contains only 304 patients, rather than 422. The factors evaluated were age, sex, previous treatment, size of the primary tumor, anatomic site of origin, stage of disease on admission, and treatment received at Memorial Hospital. Age. It does not appear that age alone has any prognostic significance in epidermoid carcinoma of the palate. Treatment decisions were not influenced by age except in a few instances of associated medical diseases which, as would be expected, were more frequently seen in the elderly. SGC. As is the case with other forms of cancer of the mouth, male patients with cancer of the palate fared less well than did female patients. No satisfactory cause for this has been observed. Size of the Primary Tumor. The size of the primary tumor has definite prognostic significance. The information relates only to those tumors less than 3.0 cm in diameter compared to those greater than this size, The smaller size lesions have the better cure rate, that is, 54 per cent versus 16 per cent. Larger tumors have a higher local recurrence rate which probably is a reflection of the inherent difficulty of excising them with adequate margins. Larger lesions also have a higher incidence of cervical lymph node metastases when first examined and this is also associated with decreased survival.
Anatomic
Site of Origin of the Primary
Tumor.
Whether the tumor originates on the hard or the soft palate does not of itself seem to have prognostic significance. The cure rate was slightly better, but not significantly so, in patients with tumors of the hard palate. The almost similar cure rates for both tumors of the hard and of the soft palate require some scrutiny, however, since a larger percentage of those with cancer of the soft palate had more advanced disease on admission. The difference was compensated for by the low cure rate ( 18 per cent) of those with hard palate tumors in which the primary tumor had enlarged to the extent of invading adjacent structures. Direct extension of soft palate primary tumors had a 31 per cent cure rate. End results were similar in patients with The American
Journal
of Surgery
Epidermoid TABLE
Factors
V
Influencing
Prognosis
in Determinate
Cases CURES Factor
Age (YO 20-29 30-39 40-49 50-59 6&69 70-79 80-89 Sex Female Male Previous treatment Primary cases Secondary cases Size of primary tumor Less than 3.0 cm Over 3.0 cm None palpable Not recorded Primary site Hard palate Soft palate Stage of Disease on Admission Localized Invasion of adjacent structures Cervical metastases Other Treatment at Memorial Hospital None Surgery Radiation therapy Surgery-radiation therapy
Total Number
Number
2 4 45 86 113 46 8
1 1 10 32 35 10 2
50 25 22 37 31 22 25
64 240
25 66
39 27
251 53
81 10
32 19
107 116 17 64
58 19 3 11
54 16 18 17
94 210
29 62
31 30
106
57
54
91 102 5
25 8 1
27 8 20
2 144 128 30
0 54 36 1
0 38 28 3
Per cent --_-~
potentially curable lesions of the two other stage classifications. Stage of Disease on Admission. The most striking observation was the serious decline in survival for patients who presented with cervical lymph node metastases compared to those in whom cancer was confined to the oral cavity. Cure rate was only 8 per cent when nodes were present on admission. When cervical metastases developed subsequent to control of the primary tumor, the five -year cure rate was 15 per cent. When cancer was confined to the primary site of origin, the cure rate was twice that of tumors that had invaded adjacent structures such as gingiva, tongue, and buccal mucosa. As previously stated, results were
Vol.
119, March
1970
Carcinoma
of Palate
much worse with hard palate tumors with local extension than with those of the soft palate. No obvious reason was found for this difference. Previous Treatment. Patients who had initial treatment at Memorial Hospital (primary cases) had a better five year cure rate than those who were seen after having had their initial treatment elsewhere (secondary cases). Many of the patients in the secondary group had advanced incurable disease when first seen and some of them could not be treated. The secondary cases treated at Memorial Hospital had a higher percentage of advanced disease when compared to the primary group. Survival rates were the same for both primary and secondary cases at the same stage of disease regardless of the type of previous treatment. Treatment at Memorial Hospital. In this series, for reasons previously stated, surgery is the favored treatment method for epidermoid carcinoma of the palate. Surgery is the treatment of choice for cervical lymph node metastases (radical neck dissection), but currently preoperative irradiation is extensively employed. In the early portion of the period under review, radiation therapy was the treatment selected in more than half of the patients with epidermoid carcinoma of the soft palate. A more recent trend to surgery has not demonstrated a substantial improvement in end results. Summary
From 1939 through 1960, 422 patients with epidermoid carcinoma of the palate were observed at Memorial Hospital. One hundred twenty-three lesions originated on the hard palate and 299 on the soft palate. Ninety per cent of these patients (381) were treated for cure. Surgery was preferred for the primary tumor and cervical metastases if present. The absolute five year cure rate was 22 per cent, whereas the determinate cure rate was 30 per cent. The main cause of treatment failure was recurrence at the primary site. Small tumors confined to their primary site of origin had the best prognosis. References 1. Martin H: Tumors of the palate (benign and malignant). Arch Surg 44: 599, 1942. 2. Gray H: Anatomy of the Human Body, 28th ed. (Goss CM, ed). Philadelphia, Lea & Febiger, 1966. 3. Thorek P: Anatomy in Surgery. p 155, Philadelphia, JB Lippincott, 1951.
297