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Radical Surgical Treatment of Intraoral Carcinoma
Radical Surgical Treatment of Intraoral Carcinoma
JAMES K. MASSON, M.D.
IN
THE LIGHT of our present knowledge, radical surgical treatment for malignant lesions of the oral cavity usually means resection of the primary lesion and the regional lymphatic channels by an en bloc procedure. This frequently involves removal of part or all of the mandible, depending on the nature and location of the intraoral primary lesion, and radical dissection of the cervical lymphatics. The surgical technique evolved about the time of World War II and was referred to by some as the "commando" operation. This term is gradually being replaced by more definitive terminology, such as "hemimandibulectomy and neck dissection" or "the combined operation," indicating the treatment of both primary and secondary lesions as a combined procedure. Actually, many technical procedures were conceived and carried out more than 60 years ago by Butlin, Kocher, Crile, and others; but it was only with the advent of antibiotics, the advancement of anesthesiology, the availability of unlimited supplies of whole blood and parenteral fluids, and other such modern developments that extensive surgical resections for intra-oral cancer became really feasible. Prior to World War II, the operative mortality and morbidity for such a procedure was too great. Now it is considered the treatment of choice not only for complicated advanced lesions but also for many earlier uncomplicated primary malignant neoplasms.
TYPES OF LESIONS
Diseases of the oral cavity are numerous and extremely varied. Many are pathologic entities involving the mouth primarily, while others are manifestations of some underlying systemic disorder. Both benign and malignant tumors are encountered in this region, but discussion of the radical surgical treatment for intraoral lesions is limited almost completely to the treatment for malignant tumors-most specifically, for squamous cell carcinoma. Other malignant tumors that may arise in the oral cavity include adenocarcinoma, melanoepithelioma, hemangio-
1013
l 1014
JAMES
K.
MASSON
endothelioma, plasmacytoma, rhabdomyoma, and various sarcomas such as small round cell sarcoma, fibrosarcoma, myxosarcoma, lymphosarcoma, chondrosarcoma, and osteogenic sarcoma. However, this group of tumors comprises only about 10 per cent of the malignant tumors encountered in the oral cavity. The vast majority (about 90 per cent) are squamous cell epitheliomas. All these lesions vary greatly in their clinical appearance and in their cellular activity and rate of growth. Grading by Broders' method is very helpful in prognosis. From a recent review of results of our combined operations for cancer of the mouth, it appears that patients with lesions of grade 1 and 2 have a five-year survival rate of about 50 per cent and those with grade 3 lesions have a rate of about 25 per cent; but none of those with grade 4 lesions lived as long as three years. Of the squamous cell epitheliomas in the mouth-but excluding those of the upper jaw and antrum-about 5 per cent were grade 1, 60 per cent grade 2,30 per cent grade 3, and 5 per cent grade 4. Thus about two-thirds of the squamous cell epitheliomas are of low grade. These often are rather inactive lesions that may have a papillary or granular ulcerated appearance. The other third are high-grade epitheliomas and tend to be much more vascular, bulky, and friable. ETIOLOGY AND DIAGNOSIS
Cancer of the mouth may occur at any age and in both sexes, but it is most common between 50 and 60 years and about nine times more frequent in men than in women. It is most often located on the lower alveolus, in the floor of the mouth, and on the tongue. The primary cause of cancer in any part of the body is unknown, of course; but in the mouth certain local factors seem to playa positive role in the formation of premalignant and malignant lesions. Several forms of chronic irritation are known to be important contributing factors. Dental sepsis, ill-fitting dentures, excessive use of tobacco and alcohol, and syphilitic glossitis are forms of chronic irritation which may lead to the development of leukoplakia of the oral mucous membranes. This condition frequently precedes cancer and undergoes malignant change if it is allowed to persist long enough. The symptoms most frequently complained of are a lump, an open sore, or simply a sore throat. Cancer of the tongue most commonly is situated on the lateral borders of the middle third of the tongue; the next ')lost likely site is the posterior third or base of the tongue. Often lesions in the base of the tongue and the tonsillar region produce few symptoms until they are far advanced. Usually at this stage ulceration and infection have occurred, and the first symptom may be pain on swallowing or on talking that typically extends up into the ear. Not infrequently the first evidence of disease may be)he appearance of a painless lump in the neck
Radical Surgical Treatment of Intraoral Carcinoma
1015
due to metastatic involvement of a cervical lymph node by a highly malignant cancer in the posterior part of the oral cavity. The clinical appearance of oral cancers varies, depending upon the cell type and stage of development. Usually a large, bulky, vascular, friable tumor is sarcoma or high-grade squamous cell epithelioma, and usually it develops over a short period. Squamous cell epithelioma may appear as an indurated plaque or a superficial ulcer. It may be papillary, smooth, or nodular, or may appear as a fissured patch of leukoplakia or as a deep, necrotic ulcer covered with slough. As the disease progresses, the ulceration with deep infiltration and secondary infection becomes more pronounced. In the late stages there is increasing infiltration of the tissues and, depending upon the location, involvement of the underlying bone. Involvement of muscles of the tongue and floor of the mouth and jaws produces limitation of movement, causing difficulty in speaking and swallowing and eventually, with edema and tumor in the pharynx, difficulty in breathing. With the deepening ulceration, hemorrhages occur as larger vessels are eroded by the cancer. Death eventually occurs as a result of respiratory obstruction, hemorrhage, malnutrition, and metastasis. Diagnosis of cancer of the mouth is not difficult. The earlier the diagnosis is made and the sooner treatment is given, the better will be the patient's chance for survival. Almost any prior treatment that has been ineffective obscures the clinical situation, and some measures even interfere with the microscopic identification of the tumor. Biopsy must be performed routinely and preparation should be made to proceed immediately with whatever therapy the surgeon thinks is indicated. TREATMENT
General Considerations
In the treatment and management of malignant lesions of the oral cavity, it is essential to have a thorough knowledge of general and plastic surgery and an understanding of the practical uses and limitations of the various forms of radiotherapy. The best treatment of intraoral cancer is performed by a team. Surgeon, radiologist, pathologist, and prosthodontist all must work in close harmony to obtain the maximal benefits for the patient. The exact form of treatment varies with the individual case, but basically it is either operation or radiotherapy or a combination of both. In some cases-usually those in which additional surgical treatment or irradiation cannot be given for recurrent or advanced cancer-the newer chemical agents may be tried systemically or locally. With respect to squamous cell carcinoma of the mouth, at least,
1016
JAMES
K.
MASSON
the results of chemotherapy to date have been discouraging. Possibly in the future some more satisfactory agent will be forthcoming. At this time, surgical treatment offers the best long-term results in the treatment of malignant neoplasms of the head and neck. For lesions in the nasopharynx, tonsil, soft palate, and base of tongue, radiation alone or in combination with operation may be considered initially. Many of these lesions are high-grade squamous cell epitheliomas, sarcomas, lymphomas, and undifferentiated neoplasms. The more common welldifferentiated epidermoid lesions, which are only moderately radiosensitive in their primary foci, may become very radioresistant when they invade bone and metastasize to the regional nodes. This holds true for adenocarcinoma too. Although any cancer can be destroyed with the newer supervoltage irradiation available today, there are definite limits within which this therapy must be confined. If irradiation goes beyond these limits of tolerance, severe radionecrosis and damage to other tissues may worsen rather than improve the patient's condition. Occasions for Simple Operations
Many cancers of the mouth are small and can be removed completely by generous local excision. After they have become infiltrative and attained a diameter of 2 em., however, it may be difficult to excise widely enough by local techniques. Cancer often arises in areas of thickened leukoplakia on the midbuccal surface at the level of the occlusal plane of the teeth and on the alveolar ridge beneath dentures. Sometimes cautery suffices, but for most such lesions excision is preferable. Local excision may be adequate for even a fairly large epithelioma involving the buccal surface of the cheek. (Lesions involving the full thickness of the cheek often involve the periosteum of the mandible also, necessitating hemimandibulectomy and neck dissection.) Primary lesions near the molar region and the commissure of the jaws carry a poorer prognosis than those situated more anteriorly. For a lesion on the anterior third of the tongue, hemiglossectomy may be adequate (though clinical evidence that a cervical node is enlarged calls for neck dissection as a separate secondary procedure). Occ~.sions
for Radical Operations
. InmOst other situations in the mouth, an infiltrating cancer 2 cm. or iarger'in diaineter will be in close proximity to the mandible or it will be in the base of the tongue or in the tonsillar fossa. In all such cases, radical measures are needed for acceptable prognosis. The combined or commando !operation meets the requirements. It includes the excision of the primary lesion and the lymphatic node-bearing area in one en bloc resee'tlon and rehabilitates the patient both cosmetically and functionally. 'I;: Cancer of the floor of the mouth behaves like Cancer of the tongue
Radical Surgical Treatment of Intraoral Carcinoma
1017
Fig. 1. a and b, Appearance 3 years after removal of grade 3 osteoblastic osteogenic sarcoma which was bulging into mouth and expanding mandible, had perforated cheek near mandibular angle, and had produced pathologic fracture of mandible. Treatment required total resection of right mandible and resection of left mandible to region of mental foramen. Large perforation of cheek was closed eventually by large acromial-pectoral flap.
except that with cancer of the floor of the mouth metastasis is earlier and involvement of the periosteum of the mandible is more likely. Whenever the cancer is attached to the periosteum of the mandible or is thought to infiltrate the cheek, alveolus, or floor of the mouth close to the bone, the bone should be removed by segmental resection, usually extending from just above the angle of the mandible to the bicuspid region, or even to the midline, depending upon the location of the infiltrating primary lesion (Fig. 1). The reason for removal of the mandible in the adequate surgical treatment of cancer in this region is that the lymphatic channels run through or close to the periosteum of the mandible en route to the submandibular nodes. An adequate procedure, then, removes the primary lesion, a wide edge of surrounding soft tissue, the attached or closely adjacent mandible, and the entire regional lymphatic system (Fig. 2). If the cancer appears roentgenographically to involve the bone, or is . thought to do so at the time of operation, then a complete hemimandibulectomy from the midline to the joint (with disarticulation) is accomplished, rather than a segmental resection which would leave behind cancellous bone and periosteum in which there well might be residual tumor.
1
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JAMES
K.
MASSON
Fig. 2. Defect after hemiglossectomy, hemimandibulectomy, and radical neck dissection. Cheek and lip flap are elevated and skin flaps on neck are reflected medially and laterally.
Occasions for Neck Dissection
As a general rule for all of these cases, whenever it is necessary to enter the neck in order to remove the primary lesion-as is necessary when the mandible is removed because of a malignant growth in the tongue, floor of the mouth, cheek, or gingiva-then radical neck dissection should be combined with the en bloc excision. This rule applies whether or not any enlarged lymph nodes can be discovered clinically, for investigation of intraoral carcinoma has shown that operation reveals metastatic involvement of cervical nodes in 15 per cent of cases in which they were negative clinically and proves absence of involvement in 15 per cent of cases in which they were positive clinically.4 Further, ipsilateral radical neck dissection is indicated, whether nodes can be felt or not, whenever the primary lesion is in the tongue, tonsil, floor of the mouth, or hypopharynx-even if the mandible is preserved. Bilateral radical neck dissection, either simultaneous or two-stage, is
r
Radical Surgical Treatment of Intraoral Carcinoma
1019
r' Fig. 3. Appearance 9 years after combined operation and staged bilateral radical neck dissection, with iliac bone graft to replace sacrificed right mandible. Lesion was grade 2 squamous cell epithelioma of right side of floor of mouth.
indicated when there is clinical evidence of metastatic disease on both sides of the neck and the primary and secondary tumors alike are resectable (Fig. 3). Suprahyoid neck dissection is not a complete cancer operation and is used only in selected cases when more extensive surgical procedures are not advisable. Management of Surgical Defects
If the primary lesion is situated anteriorly in the floor of the mouth, it is necessary to sacrifice the anterior portion of both sides of the mandible, thus leaving a severe deformity. Tumors in this location, however, are particularly treacherous and conservative treatment leads only to more serious recurrent lesions. Occasionally with deeply infiltrating lesions involving the bone and floor of the mouth on both sides, resection of the mandible must be total, with disarticulation from both joints. Usually reconstruction of the floor of the mouth with local tissue is possible. Sometimes reconstruction with distant tube flaps migrated to the region is the only alternative (Fig. 4). For cancer of the tongue, removal by partial glossectomy or hemiglossectomy, with neck dissection, is the treatment of choice; and usually segmental resection of the mandible is necessary to facilitate closure, even if the tumor does not actually encroach upon the jaw. With resection posteriorly, it would not be possible to approximate the tissues unless bone were removed. The mandible ordinarily can be divided above the angle and in the region of the mental foramen. If there is enough substance to obtain a good two-layer closure on the inside, in selected cases
1020
JAMES
K.
MASSON
Fig. 4. a and b, Preoperative views showing fungating "through-and-through" grade 3 squamous cell lesion of floor of mouth and mandible with pathologic fracture. c and d, Appearance after total mandibulectomy from joint to joint and total removal of floor of mouth and chin with bilateral suprahyoid neck dissection. Rljconstruction was accomplished with acromial·pectoral tube flaps. When last heard from more than 5 years after operation, patient had had no recurrence.
the use of a Kirschner wire prosthesis is quite advantageous in helping to keep the remaining mandible in near-normal position (Fig. 5). More frequently, no replacement of the resected bone is necessary and the deformity often is minimal (Fig. 6). After excision of cancer in leukoplakia of the buccal mucosa and lower gingiva, any resultant defect too large for primary closure must be grafted; and as a rule, intraoral grafts of free skin do very well if properly applied and supported with a firm stent type of dressing. Usually they are immobilized by sutures placed through the cheek and tied over a stent on the outside of the cheek as well. Some lesions may involve the full thickness of the cheek and reconstruction by tubepedicle flaps to supply lining as well as cutaneous coverage will be necessary. Palliation and Preoperative Irradiation
The combined operation is advised occasionally as a palliative pro-
Radical Surgical Treatment of Intraoral Carcinoma
1021
Fig. 5. Appearance after hemimandibulectomy and radical neck dissection for grade 3 squamous cell epithelioma in region of left lower alveolus with immediate insertion of Kirschner wire prosthesis. Note almost normal facial symmetry.
Fig. 6. Appearance after hemimandibulectomy and radical neck dissection for grade 3 squamous cell epithelioma of right lateral region of tongue, right tonsillar fossa, and right side of soft palate. No prosthesis was used because adequate cover was not available. Note minimal deformity which often can be obtained if about 2 cm. of bone at symphysis can be preserved. Involved cheek is flattened and chin deviates slightly toward operated side.
1022
JAMES
K.
MASSON
cedure when there is no hope of removing all the diseased tissue. In this situation the operation usually is done to remove a large, necrotic, foulsmelling, and sometimes painful mass. If the patient can be made more comfortable and if his general outlook is improved, even for a rather short time, sometimes it is well worth the effort. When a tumor is encountered that is too large to be excised safely or when there is no reasonable hope of removing it all, often it can be treated by external irradiation. Sometimes this therapy reduces the size of inoperable lesions so much that they come within operable limits and can be excised, usually six to eight weeks after the irradiation treatments are concluded. In the surgical specimens some residual active tumor may be discernible microscopically, indicating the wisdom of using all means available to control the disease. After recently reviewing the morbidity and mortality of clinic patients who underwent radical operations for intraoral cancer, I think such treatment should be recommended as a procedure of choice in the earlier stages of the disease as well as in the advanced. Our patients had an average hospital stay of 17 days. Two-thirds had no complications and one-third had minor complications such as temporary oral cutaneous fistulas or wound infection. Hospital mortality for the group was 3.3 per cent. REFERENCES 1. Butlin, H. T.: On the Operative Surgery of Malignant Disease. London, J. & A.
Churchill, Ltd., 1887, 408 pp. 2. Crile, G.: Excision of cancer of head and neck: With special reference to plan of dissection based on one hundred and thirty-two operations. J.A.M.A. 47: 1780-1785 (Dec. 1) 1906. 3. Kocher, T.: Operative Surgery. New York, William Wood & Company, 1894, 279 pp. 4. Simons, J. N., Masson, J. K. and Beahrs, O. H.: Results of radical treatment for intraoral cancer. (Unpublished data.)
JAMES K. MASSON, M.D.
IN
THE LIGHT of our present knowledge, radical surgical treatment for malignant lesions of the oral cavity usually means resection of the primary lesion and the regional lymphatic channels by an en bloc procedure. This frequently involves removal of part or all of the mandible, depending on the nature and location of the intraoral primary lesion, and radical dissection of the cervical lymphatics. The surgical technique evolved about the time of World War II and was referred to by some as the "commando" operation. This term is gradually being replaced by more definitive terminology, such as "hemimandibulectomy and neck dissection" or "the combined operation," indicating the treatment of both primary and secondary lesions as a combined procedure. Actually, many technical procedures were conceived and carried out more than 60 years ago by Butlin, Kocher, Crile, and others; but it was only with the advent of antibiotics, the advancement of anesthesiology, the availability of unlimited supplies of whole blood and parenteral fluids, and other such modern developments that extensive surgical resections for intra-oral cancer became really feasible. Prior to World War II, the operative mortality and morbidity for such a procedure was too great. Now it is considered the treatment of choice not only for complicated advanced lesions but also for many earlier uncomplicated primary malignant neoplasms.
TYPES OF LESIONS
Diseases of the oral cavity are numerous and extremely varied. Many are pathologic entities involving the mouth primarily, while others are manifestations of some underlying systemic disorder. Both benign and malignant tumors are encountered in this region, but discussion of the radical surgical treatment for intraoral lesions is limited almost completely to the treatment for malignant tumors-most specifically, for squamous cell carcinoma. Other malignant tumors that may arise in the oral cavity include adenocarcinoma, melanoepithelioma, hemangio-
1013
l 1014
JAMES
K.
MASSON
endothelioma, plasmacytoma, rhabdomyoma, and various sarcomas such as small round cell sarcoma, fibrosarcoma, myxosarcoma, lymphosarcoma, chondrosarcoma, and osteogenic sarcoma. However, this group of tumors comprises only about 10 per cent of the malignant tumors encountered in the oral cavity. The vast majority (about 90 per cent) are squamous cell epitheliomas. All these lesions vary greatly in their clinical appearance and in their cellular activity and rate of growth. Grading by Broders' method is very helpful in prognosis. From a recent review of results of our combined operations for cancer of the mouth, it appears that patients with lesions of grade 1 and 2 have a five-year survival rate of about 50 per cent and those with grade 3 lesions have a rate of about 25 per cent; but none of those with grade 4 lesions lived as long as three years. Of the squamous cell epitheliomas in the mouth-but excluding those of the upper jaw and antrum-about 5 per cent were grade 1, 60 per cent grade 2,30 per cent grade 3, and 5 per cent grade 4. Thus about two-thirds of the squamous cell epitheliomas are of low grade. These often are rather inactive lesions that may have a papillary or granular ulcerated appearance. The other third are high-grade epitheliomas and tend to be much more vascular, bulky, and friable. ETIOLOGY AND DIAGNOSIS
Cancer of the mouth may occur at any age and in both sexes, but it is most common between 50 and 60 years and about nine times more frequent in men than in women. It is most often located on the lower alveolus, in the floor of the mouth, and on the tongue. The primary cause of cancer in any part of the body is unknown, of course; but in the mouth certain local factors seem to playa positive role in the formation of premalignant and malignant lesions. Several forms of chronic irritation are known to be important contributing factors. Dental sepsis, ill-fitting dentures, excessive use of tobacco and alcohol, and syphilitic glossitis are forms of chronic irritation which may lead to the development of leukoplakia of the oral mucous membranes. This condition frequently precedes cancer and undergoes malignant change if it is allowed to persist long enough. The symptoms most frequently complained of are a lump, an open sore, or simply a sore throat. Cancer of the tongue most commonly is situated on the lateral borders of the middle third of the tongue; the next ')lost likely site is the posterior third or base of the tongue. Often lesions in the base of the tongue and the tonsillar region produce few symptoms until they are far advanced. Usually at this stage ulceration and infection have occurred, and the first symptom may be pain on swallowing or on talking that typically extends up into the ear. Not infrequently the first evidence of disease may be)he appearance of a painless lump in the neck
Radical Surgical Treatment of Intraoral Carcinoma
1015
due to metastatic involvement of a cervical lymph node by a highly malignant cancer in the posterior part of the oral cavity. The clinical appearance of oral cancers varies, depending upon the cell type and stage of development. Usually a large, bulky, vascular, friable tumor is sarcoma or high-grade squamous cell epithelioma, and usually it develops over a short period. Squamous cell epithelioma may appear as an indurated plaque or a superficial ulcer. It may be papillary, smooth, or nodular, or may appear as a fissured patch of leukoplakia or as a deep, necrotic ulcer covered with slough. As the disease progresses, the ulceration with deep infiltration and secondary infection becomes more pronounced. In the late stages there is increasing infiltration of the tissues and, depending upon the location, involvement of the underlying bone. Involvement of muscles of the tongue and floor of the mouth and jaws produces limitation of movement, causing difficulty in speaking and swallowing and eventually, with edema and tumor in the pharynx, difficulty in breathing. With the deepening ulceration, hemorrhages occur as larger vessels are eroded by the cancer. Death eventually occurs as a result of respiratory obstruction, hemorrhage, malnutrition, and metastasis. Diagnosis of cancer of the mouth is not difficult. The earlier the diagnosis is made and the sooner treatment is given, the better will be the patient's chance for survival. Almost any prior treatment that has been ineffective obscures the clinical situation, and some measures even interfere with the microscopic identification of the tumor. Biopsy must be performed routinely and preparation should be made to proceed immediately with whatever therapy the surgeon thinks is indicated. TREATMENT
General Considerations
In the treatment and management of malignant lesions of the oral cavity, it is essential to have a thorough knowledge of general and plastic surgery and an understanding of the practical uses and limitations of the various forms of radiotherapy. The best treatment of intraoral cancer is performed by a team. Surgeon, radiologist, pathologist, and prosthodontist all must work in close harmony to obtain the maximal benefits for the patient. The exact form of treatment varies with the individual case, but basically it is either operation or radiotherapy or a combination of both. In some cases-usually those in which additional surgical treatment or irradiation cannot be given for recurrent or advanced cancer-the newer chemical agents may be tried systemically or locally. With respect to squamous cell carcinoma of the mouth, at least,
1016
JAMES
K.
MASSON
the results of chemotherapy to date have been discouraging. Possibly in the future some more satisfactory agent will be forthcoming. At this time, surgical treatment offers the best long-term results in the treatment of malignant neoplasms of the head and neck. For lesions in the nasopharynx, tonsil, soft palate, and base of tongue, radiation alone or in combination with operation may be considered initially. Many of these lesions are high-grade squamous cell epitheliomas, sarcomas, lymphomas, and undifferentiated neoplasms. The more common welldifferentiated epidermoid lesions, which are only moderately radiosensitive in their primary foci, may become very radioresistant when they invade bone and metastasize to the regional nodes. This holds true for adenocarcinoma too. Although any cancer can be destroyed with the newer supervoltage irradiation available today, there are definite limits within which this therapy must be confined. If irradiation goes beyond these limits of tolerance, severe radionecrosis and damage to other tissues may worsen rather than improve the patient's condition. Occasions for Simple Operations
Many cancers of the mouth are small and can be removed completely by generous local excision. After they have become infiltrative and attained a diameter of 2 em., however, it may be difficult to excise widely enough by local techniques. Cancer often arises in areas of thickened leukoplakia on the midbuccal surface at the level of the occlusal plane of the teeth and on the alveolar ridge beneath dentures. Sometimes cautery suffices, but for most such lesions excision is preferable. Local excision may be adequate for even a fairly large epithelioma involving the buccal surface of the cheek. (Lesions involving the full thickness of the cheek often involve the periosteum of the mandible also, necessitating hemimandibulectomy and neck dissection.) Primary lesions near the molar region and the commissure of the jaws carry a poorer prognosis than those situated more anteriorly. For a lesion on the anterior third of the tongue, hemiglossectomy may be adequate (though clinical evidence that a cervical node is enlarged calls for neck dissection as a separate secondary procedure). Occ~.sions
for Radical Operations
. InmOst other situations in the mouth, an infiltrating cancer 2 cm. or iarger'in diaineter will be in close proximity to the mandible or it will be in the base of the tongue or in the tonsillar fossa. In all such cases, radical measures are needed for acceptable prognosis. The combined or commando !operation meets the requirements. It includes the excision of the primary lesion and the lymphatic node-bearing area in one en bloc resee'tlon and rehabilitates the patient both cosmetically and functionally. 'I;: Cancer of the floor of the mouth behaves like Cancer of the tongue
Radical Surgical Treatment of Intraoral Carcinoma
1017
Fig. 1. a and b, Appearance 3 years after removal of grade 3 osteoblastic osteogenic sarcoma which was bulging into mouth and expanding mandible, had perforated cheek near mandibular angle, and had produced pathologic fracture of mandible. Treatment required total resection of right mandible and resection of left mandible to region of mental foramen. Large perforation of cheek was closed eventually by large acromial-pectoral flap.
except that with cancer of the floor of the mouth metastasis is earlier and involvement of the periosteum of the mandible is more likely. Whenever the cancer is attached to the periosteum of the mandible or is thought to infiltrate the cheek, alveolus, or floor of the mouth close to the bone, the bone should be removed by segmental resection, usually extending from just above the angle of the mandible to the bicuspid region, or even to the midline, depending upon the location of the infiltrating primary lesion (Fig. 1). The reason for removal of the mandible in the adequate surgical treatment of cancer in this region is that the lymphatic channels run through or close to the periosteum of the mandible en route to the submandibular nodes. An adequate procedure, then, removes the primary lesion, a wide edge of surrounding soft tissue, the attached or closely adjacent mandible, and the entire regional lymphatic system (Fig. 2). If the cancer appears roentgenographically to involve the bone, or is . thought to do so at the time of operation, then a complete hemimandibulectomy from the midline to the joint (with disarticulation) is accomplished, rather than a segmental resection which would leave behind cancellous bone and periosteum in which there well might be residual tumor.
1
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JAMES
K.
MASSON
Fig. 2. Defect after hemiglossectomy, hemimandibulectomy, and radical neck dissection. Cheek and lip flap are elevated and skin flaps on neck are reflected medially and laterally.
Occasions for Neck Dissection
As a general rule for all of these cases, whenever it is necessary to enter the neck in order to remove the primary lesion-as is necessary when the mandible is removed because of a malignant growth in the tongue, floor of the mouth, cheek, or gingiva-then radical neck dissection should be combined with the en bloc excision. This rule applies whether or not any enlarged lymph nodes can be discovered clinically, for investigation of intraoral carcinoma has shown that operation reveals metastatic involvement of cervical nodes in 15 per cent of cases in which they were negative clinically and proves absence of involvement in 15 per cent of cases in which they were positive clinically.4 Further, ipsilateral radical neck dissection is indicated, whether nodes can be felt or not, whenever the primary lesion is in the tongue, tonsil, floor of the mouth, or hypopharynx-even if the mandible is preserved. Bilateral radical neck dissection, either simultaneous or two-stage, is
r
Radical Surgical Treatment of Intraoral Carcinoma
1019
r' Fig. 3. Appearance 9 years after combined operation and staged bilateral radical neck dissection, with iliac bone graft to replace sacrificed right mandible. Lesion was grade 2 squamous cell epithelioma of right side of floor of mouth.
indicated when there is clinical evidence of metastatic disease on both sides of the neck and the primary and secondary tumors alike are resectable (Fig. 3). Suprahyoid neck dissection is not a complete cancer operation and is used only in selected cases when more extensive surgical procedures are not advisable. Management of Surgical Defects
If the primary lesion is situated anteriorly in the floor of the mouth, it is necessary to sacrifice the anterior portion of both sides of the mandible, thus leaving a severe deformity. Tumors in this location, however, are particularly treacherous and conservative treatment leads only to more serious recurrent lesions. Occasionally with deeply infiltrating lesions involving the bone and floor of the mouth on both sides, resection of the mandible must be total, with disarticulation from both joints. Usually reconstruction of the floor of the mouth with local tissue is possible. Sometimes reconstruction with distant tube flaps migrated to the region is the only alternative (Fig. 4). For cancer of the tongue, removal by partial glossectomy or hemiglossectomy, with neck dissection, is the treatment of choice; and usually segmental resection of the mandible is necessary to facilitate closure, even if the tumor does not actually encroach upon the jaw. With resection posteriorly, it would not be possible to approximate the tissues unless bone were removed. The mandible ordinarily can be divided above the angle and in the region of the mental foramen. If there is enough substance to obtain a good two-layer closure on the inside, in selected cases
1020
JAMES
K.
MASSON
Fig. 4. a and b, Preoperative views showing fungating "through-and-through" grade 3 squamous cell lesion of floor of mouth and mandible with pathologic fracture. c and d, Appearance after total mandibulectomy from joint to joint and total removal of floor of mouth and chin with bilateral suprahyoid neck dissection. Rljconstruction was accomplished with acromial·pectoral tube flaps. When last heard from more than 5 years after operation, patient had had no recurrence.
the use of a Kirschner wire prosthesis is quite advantageous in helping to keep the remaining mandible in near-normal position (Fig. 5). More frequently, no replacement of the resected bone is necessary and the deformity often is minimal (Fig. 6). After excision of cancer in leukoplakia of the buccal mucosa and lower gingiva, any resultant defect too large for primary closure must be grafted; and as a rule, intraoral grafts of free skin do very well if properly applied and supported with a firm stent type of dressing. Usually they are immobilized by sutures placed through the cheek and tied over a stent on the outside of the cheek as well. Some lesions may involve the full thickness of the cheek and reconstruction by tubepedicle flaps to supply lining as well as cutaneous coverage will be necessary. Palliation and Preoperative Irradiation
The combined operation is advised occasionally as a palliative pro-
Radical Surgical Treatment of Intraoral Carcinoma
1021
Fig. 5. Appearance after hemimandibulectomy and radical neck dissection for grade 3 squamous cell epithelioma in region of left lower alveolus with immediate insertion of Kirschner wire prosthesis. Note almost normal facial symmetry.
Fig. 6. Appearance after hemimandibulectomy and radical neck dissection for grade 3 squamous cell epithelioma of right lateral region of tongue, right tonsillar fossa, and right side of soft palate. No prosthesis was used because adequate cover was not available. Note minimal deformity which often can be obtained if about 2 cm. of bone at symphysis can be preserved. Involved cheek is flattened and chin deviates slightly toward operated side.
1022
JAMES
K.
MASSON
cedure when there is no hope of removing all the diseased tissue. In this situation the operation usually is done to remove a large, necrotic, foulsmelling, and sometimes painful mass. If the patient can be made more comfortable and if his general outlook is improved, even for a rather short time, sometimes it is well worth the effort. When a tumor is encountered that is too large to be excised safely or when there is no reasonable hope of removing it all, often it can be treated by external irradiation. Sometimes this therapy reduces the size of inoperable lesions so much that they come within operable limits and can be excised, usually six to eight weeks after the irradiation treatments are concluded. In the surgical specimens some residual active tumor may be discernible microscopically, indicating the wisdom of using all means available to control the disease. After recently reviewing the morbidity and mortality of clinic patients who underwent radical operations for intraoral cancer, I think such treatment should be recommended as a procedure of choice in the earlier stages of the disease as well as in the advanced. Our patients had an average hospital stay of 17 days. Two-thirds had no complications and one-third had minor complications such as temporary oral cutaneous fistulas or wound infection. Hospital mortality for the group was 3.3 per cent. REFERENCES 1. Butlin, H. T.: On the Operative Surgery of Malignant Disease. London, J. & A.
Churchill, Ltd., 1887, 408 pp. 2. Crile, G.: Excision of cancer of head and neck: With special reference to plan of dissection based on one hundred and thirty-two operations. J.A.M.A. 47: 1780-1785 (Dec. 1) 1906. 3. Kocher, T.: Operative Surgery. New York, William Wood & Company, 1894, 279 pp. 4. Simons, J. N., Masson, J. K. and Beahrs, O. H.: Results of radical treatment for intraoral cancer. (Unpublished data.)