Squamous-cell carcinoma of the floor of the mouth with extensive mandibular involvement

Squamous-cell carcinoma of the floor of the mouth with extensive mandibular involvement

The case of a patient with an cstensiw squamous-cell carcinoma of the floor of thv mouth with erosion of the m:~ndilmlar l~onc iy prewntrd. The history and initial clinical picture were consistcwt with c~ithor varvinoma with sup~~rimpos~~l infwtion or chronic osteomyelitis with an :Lcwtcl wawrb:~tion. A (liscussion of tliagnosis and treatment of carcinoma of the floor of tlrc mouth follo\vs this wsc wport.

M

asillary a.ntl mandibular tumors have often been misdiagnosed because of coexisting pain and swelling of apparently odontogenic origin. Case reports as far back as 1879 show acute tlental symptoms arising in a.reas Iatcr to be diagnosed as tumor. Freyer reports a cast of “myeloid tumor” was first noticed in a patient who had swollen gingira associated with tooth pain. The following c+ascis being prcsentect not only t,o show the unusual course and extensiveness of the lesion, but also to cmphasizc the importance of establishing a proper differential diagnosis. that

CASE

REPORT

h 33.year-old man was seen in the Oral Surgery Department of the Boston City Hospital for evaluation of a swelling of the left side of the fact. The patient complained of pain and swelling of 2 weeks’ duration, subsequent to the self-extrwtion of three left mandibular teeth with a rusty pair of pliers. He admitted that the left, mandibular swelling had existed intrrmittently for almost 4 years, dating back to a fracture of the left mandiNe (Fig. 1 ). The past medical history revrnlvd that tllcl paticwt Imd Wernickcsliorsakoffs syntlrome and *Chief Resident, Department of Oral Surgery, Boston City Hospital. ‘*Director, Department of Dentistry and Oral Surgery, koston City of Oral Surgery, Tufts University School of Dental Medicine. “**Professor and Chairman, Department of Oral Surgwy; Assistant Affairs, Tufts University School of Dental Mcdicinr.

184

IIospital; Dean

Professor for

Hospital

Volume r\Tumber

39 2

Squamous-cell

Pig.

Fig. midline. extending

1. Patient’s

initial

presentation

with

carckoma of floor of mouth

left

mandibular-buccal

185

swelling.

2. Intraoral view of lesion. The mandibular right canine is seen to the Necrotic-appearing leukoplakic tissue can be seen in the left floor of across the left residual ridge and up to the buccal mucosa.

left the

of the mouth,

Laennec’s cirrhosis, documented 7 years prior to admission, and a fracture of the left mandible 4 years prior to admission that was treated with ‘(a strap to my jaw” by a local physician. His social history revealed that, he had been smoking three packs of cigarettes a day for many years and that he drank alcohol-“as much as I can afford.” Physical examination revealed that he Jvas malnourished, seemingly older than his stated age of 53, and had a large left facial swelling cstending from the lateral mandible to the infraorbital region. The swelling was firm and tender, with an extraorally draining fist&a in the mental foramen area. He had anesthesia over the left mental nerve distribution. Examination of the neck revealed shoddy bilateral posterior cervical nodes and a small, tender, left submandibular node. The mandible deviated to the left when it opened. Intraorally, there mere only four mobile canine teeth remaining, and a large erythematous, necrotic-appearing swelling over the left floor of the mouth, residual ridge, and buccal mucosa. Palpation of that region

186

Rubir~, Malo7ley, a?td Dohc

Pig. 3. Posteroanterior foramen region to the approximation.

left

view. Loss eondylar

Fig. 4. Panographic examination of the left condylar head remaining.

of mandibular bone head. The mandibular

reveals

extent

can be seen from the right canines are seen without

of mandibular

erosion

with

and of the anterior mandible revealed soft to firm tissue without apparent (Fig. 2). The temperature was 100.2” F. orally, blood pressure 128/70, pulse 88, 18. Radiograhic examination revealed loss of mandibular bone from the right area to the left condylar head, with both mandibular canines “floating” in proximal bony edges were irregular and poorly defined (Figs. 3 and 4). Chest tion revealed interstitial changes with multiple old fractures of the ribs. Multiple biopsies of the area revealed infiltrating squamous-cell carcinoma (Fig. 5). Tomograms demonstrated possible tumor in the inferior portion of the

only

bony

mental bony

a portion

continuity

and respirations mental fornmen soft tissue. The x-ray examinain left

all side

sections of

tile

Volume Number

Squ,a,mous-cell

39 2

Fig. 5. Photomicrograph formation and background tion, x200.)

showing of chronic

infiltrating inflammation.

carcinoma

squamous-cell (Hematoxylin

of

floor of mouth

187

carcinoma with keratin pearl and eosin stain. Magnifica-

hard palate and bony destruction of the middle cranial fossa. Barium swallow was negative for carcinoma. Direct panendoseopy revealed a tumor extending up to the left nasopharynx: The lesion was classified as T4 NoMo. This indicated a tumor in the floor of the mouth that involved other anatomic structures, such as bone, muscles of the floor of the mouth, soft tissue of the neck, extending to more than one neighboring region, without nodal involvement. and lack of evidence of distant metastasis.:! The patient received CoGa 5,000 r external radiation, and at the time of this writing the original plan of a 2,000 r boost of megavoltage electrons was cancelled because of the over-all poor prognosis of his condition.

DISCUSSION

Certain elements in the history and examination of this patient need to be clarified. The history of a poorly treated mandibular fracture 4 years previously, the intermittent smelling, and the exacerbation of the pathologic condition since the self-extractions strongly suggested a chronic osteomyelitis. The absence of tumor adenopathy and the fluctuating febrile state of the patient were indications of an infection. The extent of the lesion, however, with the clisappearance of nearly three fourths of the mandible suggested carcinoma. Thus, in our original differential diagnosis, we considered tumor as well as chronic osteomyelitis. Oral cancer represents 5 per cent of all cancer in males? 4 and 2 per cent of all cancer in female@ and account,s for 70 per cent of all malignancies of the upper respiratory and alimentary passages.” This occurs with the highest frequency in males in the fifth decade and

I. Percentage S-year survival rate in floor-of-the-mouth carcinonla according to Ash,‘2 using Richard’s classification

Table

Stage <

c-rite&z

1.5 cm.

%

suwi?;al

5.Ynnr 70.7 61.0

<

3.0

>

3 cm:invading other structures Massive regional involvement and extension to adjacent structures or hone:

em.

41.1 !?;. 6

in females in the sixth decade of lift.” Smoking and alcoholic intake arc well known to be among t.hc most like])- ctiologic factors.JT W) According to most reports, 15 per cent of all oral cancer occurs in the floor of the mouth 4. i* ‘(’ sc~~mtlonl,v in incidcncc to lesions in the tongnc.“~ i Pain and tenderness a& uncommon initial symptoms. I1 As the tumor spreads, thcrc may 1~ superficial slough, infection, and local discomfort.7 Tlatcral spread is quite frcquently seen, and these tumors often spread rapidly to hccomc~atlhcrcnt to the inner aspect of the mandible. Holland and Frci!’ report mandiblllar involrcment, with orocntaneous fistulization seen as a late event. The lymphatic drainage is eontinuons with that of the tongue and therefore empties into the submandibular nodes ant1 the anterior jugular ch8in.l Bilateral metastases arc frequently seen, even whrn the primary lesion appears to l)v confined to one side.” The more anterior the l&on, the lower the drainage usually owurs in the ne~lr.~~ According to Scalon,’ regional l,vmph noclc metastasis is noted in about one third of the patients with C~IIII)C~~~ of the floor of the mouth at the time of admission. Avkcrman ant1 dcl K
ilIT?

Table I’lYm

II. Percentage 5 and lo-year survival rate in floor-of-the-mouth using the A.JC system

cancer,

~1y111,2”

AJG

ftayr 1 2 3 4

Rurcieal

period 5 IO r 1: 5 10 5 10

PPl. mnt

survid 75 55 61 29 43 20 15 0

penetrates the alveolar hone, the marrow spacesare replaced by loose connective tissue which is infiltrated with chronic inflammatory cells, and cords and islands of malignant, epithelial cells. There is an irregular paripheral zone of osteogenesis which may be due to the pressure of the invading carcinoma, release of various enzymes by the metabolically active cells, or the adjacent inflammatory reaction produced by the invading tumor. The treatment of carcinoma of floor of the mouth, like that of other carcinomas, depends upon various factors. A few of the more important factors are size of the lesion; extension or nonextension into adjacent structures; cure rate; morbidity and mortality of radiation versus morbidity and mortality of surgery; functional and esthetic results; patient’s health and age; finances; capability of the surgeon and radiotherapist. ln recent years, significant improvement has been achieved in the treatment of oral cancer by both radiotherapy and surgery. Small lesions can be cured by either method, and advanced lesions are incurable by e&her method.” A combination of surgery and radiotherapy is frequently indicated for T2 and most T3 lesions.‘7 Because of extensive surgical excision with limited esthetic results, radiotherapy is often used for larger lesions. Generally, surgery is a better choice for elderly patients. Because of the secondary xerostomia and resulting discomfort, patients over 70 years of age do not tolerate well a prolonged course of irradiation. This easily leads them from a usually deficient diet to a state of debilitation.17 When surgery is employed with clinically detectable metastatic nodes, a radical neck dissection is usually performed along with removal of the primary lesion. When combined radiotherapy and surgery is the method of therapy, a radical neck dissection is often performed 5 to 6 weeks after radiation, especially when the pre-therapeutic nodes are larger than 3 cm.l* This is often necessary becausethe center of nodes of this size is hypoxic and relatively resistant to radiotherapy. With the use of CoGO(gamma) radiation or megavoltage electron radiation, the effectiveness of radiation is improved with tissue oxygenation. On larger lesions, the innermost cells are relatively anoxic. This problem may be avoided in the future with the potential use of neutron irradiation which has a lower oxygen enhancement ratio (OER) , effective against cells with low oxygen content as well as normally oxygenated cells.19-21 Correa and associates”reported that extensive local lesions with invasion of

190

Oral February,

Ruhin, Hnloney, and Doku

III. American Reporting System”3 Table

Hurg. 1975

Joint Committee for Cancer Staging and End Results

ClasHication

TlS-carcinoma in situ Tl 2 cm. or h%S ‘t’:! > 2 cm. but 5 4 cm. ‘1’3 >

4 cm,.

Stnging Stage J Stage II Stage III

Stage &y Any

IV T with

No-no clinical disease Xl-single node 5 3 cm. SB-single ipsilateral > 3 em. or multiple ipsllnteral nodes X3-fixed ipsilateral or contralateral or bilateral nodes MO-no distant metastasis Ml--rlinicnl and/or radiographic evidence of metastasis other than to cervical nodes TlNoMo T2NoMo T3NoMo (Tl Nl (T2 Nl (T3 Nl

N2 or N3

T or N with

Ml

(Tl (T2 (T3

N2 N2 N2 or

and MO) MO) MO)

all NI

MO Tl MO T2 MO T3 any T or

N3 N3 N3 N

MO) MO) MO) category

and MI

bone, even in the absence of lymph node involvement, as in the case presented, arc practically never cured. Ash’” reported survival of 5 pears for patients with carcinoma of the floor of the mouth according to Richards’ classification (see Table I). Flynn and associates*” reported on survival of patients with cancer of the floor of the mouth according to the clinical system (TNM) of the American *Joint Committee for Cancer Staging and End Results Reporting (set Table II). See Table III for TNM and staging. SUMMARY

A case is presented to demonstrate the value of a proper differential diagnosis. On the basis of history alone, the patient seemed to have a chronic osteomyelitis; the radiographs were consistent with tither an extensive chronic osteom,velitis or carcinoma involving thr mandible. Only the biopsy report made possible a definite diagnosis of squamous-cell carcinoma. REFERENCES

1. Freyer, P. J.: Two Successful Cases of Excision of the Lower Jam for Myeloid Tumour, With Remarks, Indian Med. Gaz. 14: 10-13, 1879. 2. International Union Against Cancer. (“ommittrr on Professional Education : Clinical Oncology, Berlin, 1973, gpringer-Verl&, 1,. 135. 3. American Cancer Society: Cancer Statistics, 1974.\Vorltlwitle Epidemiology, -. &--A Cancer Journal for Clinicians 2k: 2-5, 1974. 4. Ackerman, L. V., and delRegato, J. A., Canwr-Diagnosis, Treatment and Prognosis, ed. 4, St. Louis, 1970, The C. V. Mosby Company, pp. 214-219. 5. American Cancer Society, Massachusetts Division : Canwr-A Manual for Practitioners, cd. 4, 1968, pp. 119.129. 6. Correa, J. N., Bosch, A., and Marcial, V. A. : Carcinoma of the Floor of the Mouth; R,eview of Clinical Factors and Results of Treatment, Am. .T. Roentgenol. 99: 302-312, 1967.

Volume

Number

39

2

Squamous-cell

carcinoma

of floor

of mouth

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T. F., Jr.: Management of the Patient With Cancer, Philadelphia, lQ65, W. B. 7. Nealon, Saunders Company, pp. 355400. Etiological Aspects of Squamous Cancers of the Head and Neck, 8. Wynder, E. L.: J.A.M.A. 215: 452453, 1971. 9. . Holland, J. F., and Frei, E., 111 : Cancer Medicine, Philadelphia, 1973, Lea & Febiger, pp. 1437-1450. W. G., Hines, M. R., and Levy, B. M.: A Textbook of Oral Pathology, ed. 2, 10. Shafer, Philadelphia, 1463, W. B. Saunders Company, p. 105. Il. Martin, H. E., and Sugarbaker, E. D.: Cancer of the Floor of the Mouth, Surg. Gynecol. Obstet.‘71: 347.359, 1940. G. E.. and Hendrick. J. W.: Tumors of the Head and Neck, Baltimore, 1950, Wil12. Ward. liams’& Wilkins Company, pp. 271-304. G. H., Burg, E. A., and Levy, D. M.: A Case of Multiple Primary Carcinomas of 13. Franke, the Head and Neck, Wis. Med. J. 70: 242-245, 19’71. 14. Rahausen, A., and Sayago, C.: Cancer of the Floor of the Mouth, Am. J. Roentgenol. 75: 515-518, 1956. H. M. : Principles and Practice of Oral R,adiographic Interpretation, Chicago, 1963, 15. Worth, Yearbook Medical Publishers, Inc., pp. 549-552. 16. Schwartz, S., and Shklar, G.: Reaction of Alveolar Bone to Invasion of Oral Carcinoma, ORAL SURG. 24: 33-37. 1967. W. S:, and Fletcher, G. H.: Cancer of the Head and Neck, Baltimore, 1967, 17. MacComb, Williams & Wilkins Company, pp. 123-133. 18. Fletcher, G. H., MacComb, W. S., Ballantyne, A. J., Shalek, R. J., and Stovall, M. S.: Radiation Therapy in the Management of Cancers of the Oral Cavity and Oropharynx, Springfield, Ill., 1962, Charles C Thomas, pp. 117-124. J. T.: Fast Neutrons for Radiation Therapy, _. Radiol. Clin. North Am. 7: 3% 19. Brennan, 374, 1969. 20. Gray, L. H., Conger, A. D., Elbert, M., Hornsey, S., Scott, 0. C. A.: Concentration of Oxygen Dissolved in Tissues at Time of Irradiation as a Factor in Radiotherapy, Br. J. Radiol. 26: 638-648, 1953. 21. Bewley, D. K.: Radiobiological Research With Fast Neutrons and the Tmplications for Radiotherapy, Radiology 86: 251-257, 1966. 22. Ash, C. L. : Oral Cancer: A Twenty-five Year Study, Am. J. Roentgenol. 87: 417-430, 1962. 23. Flynn, M. H., Mullina, F. X., and Moore, C.: Selection of Treatment in Squamous Carcinoma of the Floor of the Mouth, Am. J. Surg. 126: 477-481, 1973. Reprint requests to: Dr. R.onald Lee Rubin Chief Resident Department of Oral Surgery Boston City Hospital Boston. Mass. 02118