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Squamous cell carcinoma of the oral tongue in patients less than thirty years of age
Squamous Cell Carcinoma of the Oral Tongue in Patients Less Than Thirty Years of Age Robert M. Byers, MD, Houston, Texas
Squamous cell carcinoma of tbe oral tongue in patients less than thirty years of age is quite unusual. The alleged etiologic factors, that is, tobacco, alcohol, and chronic irritation from dental appliances, associated with most squamous cell carcinomas of the oral cavity, have not usually been operative long enough to be considered important. The selection of therapy by the treatment team is based on many emotional considerations due to the young age of the patient. Therefore, the usual rational therapeutic approaches that apply to other patients are often compromised. The purpose of this report is to put into focus the various tumor factors with the different modalities of treatment in an attempt to answer several perplexing questions. 1. How does local control of the tumor and’surviva1 of these young patients compare with those in older patients with the same type and stage of tongue lesions? 2. Is the biologic behavior of squamous cell carcinoma of the oral tongue in patients under the age of thirty any more aggressive than the type of tongue cancer seen in older patients? 3. How much control of the primary lesion and neck metastases can be expected with our current methods and concepts of treatment in these young patients? 4. Can we determine the best course of therapy for these patients on the basis of a limited experience with this rare disease?
Material and Methods The medical records of eleven patients under thirty years of age who presented with squamous cell carcinoma of the oral tongue at the M. D. Anderson Hospital between 1966 and 1973 were analyzed. (Table I.) During the same period, 407 patients over thirty years of age with squamous cell carcinoma of the oral tongue were seen at the M. D. Anderson Hospital. The pathologists at M. D. Anderson Hospital indicated a diagnosis of squamous cell carcinoma on the basis of tissue specimens in all patients. All patients were followed up a minimum of two years or until death. Since 80 to 90 per cent of all local recurrences appear within two years, this follow-up period was thought to be adequate. Follow-up data were obtained through routine clinic visits or personal communication. The seven male and four female patients averaged twenty-three years of age, with a range of seventeen to twenty-nine years. Four of them were less than twenty years of age. A history of heavy smoking or alcohol intake was absent, and the dental status of all the patients was considered good to excellent. Only one patient had associated intraoral leukoplakia. Every one of the patients had a two to twelve month history of an ulcer or sore on the tongue, usually with pain. Referred ear pain was present in only one of the patients. The primary lesion was stage Ti or Ts in nine patients whereas in the remaining two patients the primary lesion was Ts. Six of the eleven patients were observed to have clinically positive nodes on admission, stage N1 [I]. No patient was found to have positive results on the serologic test for syphilis. None of the eleven patients had received any radiation to the head and neck region during childhood.. Results
From the Head and Neck Service, Department of Surgery, The University of Texas System ,Cancer Center, M. D. Anderson Hospital, Houston, Texas. Reprint requests should be addressed to Robert M. Byers, MD, 6723 Bertner D&e, Houston, Texas 77025. Presented at the Combined Meeting of the James Ewing Society and the Society of Head and Neck Surgeons, New Orteans. Louisiana, March 25-29. 1975.
Vdume 130, octeber 1975
Six of the eleven patients (55 per cent) had regional control (primary lesion and neck). Five of the eleven (45 per cent) were alive at the time of the analyses which compares with an absolute two year survival of 65 per cent (265/407 patients) in
475
Combined
Radiation
Surgery
Treatment
TABLE I
3
23
27
74928
30778 1
3
2 2 X 2
19
19 28 27 22
84419 87911 80701 68921
2 1
1 2
Tumor
Clinical
72902
19 29
17 27
97639 21787
99707 100080
Case Number
Ageof Patient (yr)
1 I
III
0
I III III II
III II
II II
III
disease) disease)
Histologic Grade
1 (N2~ disease)
1 1 0 0
1 0
O(N,n 1 (N,
Nodes
State of Disease
X
To Primary Lesion Only
X (surgery, radiation postoperatively) X (surgery, radiation postoperatively X (radiation to ,primary lesion, surgery to nodes
X
X X X
X
X
X
To Primary Lesion and Nodes
First Therapy
x
x
Primary
X
x
x
X
x
X
Nodes
x
X
Distant Metastases
Site of Recurrence
Radiation
None
Commando None
Commando Radical neck dissection
Radiation
Therapy for Failure
Treatment and Results in Eleven Patients Less Than Thirty Years of Age with Squamous Cell Carcinoma of the Oral Tongue ______-
X
X
X
X
X
ease
No Evidence of Dis_
X
X
X
X
X
X
ease
Of DIS-
Dead
Status
Dead of Other Causes
Carcinoma of Tongue
older patients with similarly staged cancers of the oral tongue [2]. To better analyze the results, the patients were divided into three categories on the basis of the initial modality of treatment to the primary lesion. Surgery Alone. Two patients with Ts lesions were treated primarily by surgery. The neck of one patient had Ni staging, but the pathologist reported the nodes as negative. The other patients had stage No disease of the neck, but five of thirtyeight nodes examined showed metastatic squamous cell carcinoma. Neither lesion was classified as grade III on pathologic examination. The primary lesion of the tongue was treated in one instance by intraoral excision and neck dissection in discontinuity. The other patient had hemiglossectomy combined with mandibulectomy and radical neck dissection. This patient, who had positive nodes, had a recurrence in the neck, received radiation for the obvious recurrence, and died with residual cancer in the neck. Both patients had local control of the lesion of the tongue. Radiation Alone. Six patients were treated primarily with radiation alone, one with a radium implant alone and five with external radiation followed by a radium implant. All of these patients had lesions that were either Tr or Ts. The one patient treated with an implant alone had negative cervical nodes. Three of the five patients treated with both external and interstitial radium implants had Nr stage disease of the neck. Local control of the primary lesion and necknodes in those patients with negative cervical nodes was 67 per cent (two of three patients). The one patient in whom treatment failed did not have treatment of the neck since the primary lesion was treated with a radium implant only. Despite this, the neck metastasis that evolved was treated by radical neck dissection and the patient is free of disease fifteen years later. Of those patients with Ni disease of the neck, local control and survival was 33 per cent (one of three patients). Both of these patients in whom treatment failed had histologically classified grade III poorly differentiated squamous cell carcinoma. The overall local control of cancer of the tongue in these patients was 67 per cent (four of six patients). The absolute two year survival was 50 per cent (three of six patients). A surgical salvage procedure was attempted in two of these three patients, both with Ni disease of the neck, and was unsuccessful. Three of the six patients had grade III poorly differentiated lesions. Only one of these three patients had local control of the primary lesion of the tongue and none survived.
vohmlo 130, octobw 1975
Planned Combined Treatment. Three patients were treated with a combination of radiation and surgery in a planned sequence. Two patients were treated with combined resection of the tongue, mandible, and neck followed by radiation therapy immediately after the wound had healed. Both had stage Ts disease and had histologically classified grade III poorly differentiated squamous cell carcinoma. One patient had clinical and pathologic No disease; the other had clinical stage Ni disease which eventually proved to be Nsn disease on pathologic examination of the surgical specimen. In the immediate postoperative period, radiation was given to the primary area and both sides of the neck to a dose of 6,000 r in six weeks. Neither patient survived; however, both had local control of the primary lesion. Both had treatment failure in the neck (one in the tracheostomy scar; the other in the contralateral side of the neck). The third patient had a TrNi lesion 11 which the planned course of treatment consisted of a radium implant to the lesion of the tongue followed by preplanned radical neck dissection. There were no positive nodes in the surgically dissected neck specimen. This patient has remained free of disease for thirteen years. Comments Several articles in the world’s literature document the occurrence of squamous cell carcinoma of the tongue in young people [3-71. However, none of the reports explains in detail the rationale for the therapeutic approach used. In addition, the lack of significant numbers of patients from any one institution usually means that the articles appear as case reports. The eleven patients in this study represent 3 per cent of all patients with squamous cell carcinoma of the oral tongue seen at the M. D. Anderson Hospital between 1956 and 1973. Although any meaningful statistical interpretation of the results of eleven patients is impossible, some conceptual points as to the diagnosis and treatment emerge from this study. The failure of physicians to vigorously investigate a persistent ulcer of the tongue in a patient less than thirty years of age resulted in considerable delay in diagnosis in many of these patients. Whether this delay adversely affected the ultimate outcome is speculative in these specific cases, but the data showed that two of three patients with Ti disease and three of five patients with Ts disease survived. None of the patients with larger lesions remained alive. Thus, a clinician should keep a high index of
477
Byers
suspicion of cancer when an ulcer has been present on the tongue longer than three weeks. The correct clinical interpretation of the presence or absence of cancer in cervical nodes of young people can be unreliable, because most of them have nodes associated with reactive hyperplasia. Since the therapeutic indications are significant if the nodes in question are indeed histologically positive for cancer, it seems important to verify this factor prior to treatment. The histologic classification of the primary lesion has the most significant relationship to local control of the lesion and survival of the patient. The treatment of patients with grade I or II squamous cell carcinoma (25 to 50 per cent mitoses per high power microscopic field) is good, with 67 per cent local control and survival (4/6 patients). In contrast, only one of the patients who had grade III squamous cell carcinoma (75 per cent or more mitoses per high power microscopic field) had control of the lesion above the clavicle and all five patients with this histologic classification died of cancer. In addition, the proportion of grade III lesions in these patients less than thirty years of age is higher than it is in older persons (48 per cent [5/11] versus 22 per cent [90/407]) [2]. Thus, anaplastic squamous cell carcinoma of the oral tongue appears to have a higher incidence in persons less than thirty years of age and behaves biologically in a virulent or agressive manner. With these facts in mind, the selection of treatment can be conceived more clearly. If the initial lesion is small (Ti to Te), grade I to grade II histologically, and no nodes are palpable in the neck, intraoral excision or adequate irradiation combining external beam and interstitial radium appears to have equal success in local control of the tumor and survival of the patient. If the lesion is ‘Ta to Tq, with or without palpable nodes, and is classified histologically as grade III squamous cell carcinoma, the prognosis is grave regardless of the type of therapy, and treatment should be considered palliative. The most aggressive therapy, that is, combined surgery and radiation, should be reserved for those patients who present with histologically grade I or grade II primary lesions, staged Ts or Ts, with clinical evidence of mobile clinical metastases. The sequence of treatment is debatable. Since control of the primary lesion is usually good with either modality alone, control of the cervical metastases takes priority. Since the clinical diagnosis of positive cervical nodes in young people is unreliable, it seems logical to plan first a limited surgical dissection of the neck. If the suspect-
478
ed node is negative, the primary lesion is treated with radiation alone (external plus implant or implant alone) or is intraorally excised if technically feasible. If the node proves to be pathologically involved with squamous cell carcinoma, the primary lesion, dissected neck, and contralateral side of the neck are treated with radiation (external to 6,000 r in six weeks with a radium implant as a boost to the primary lesion). If treatment of the primary lesion fails, the recurrence can possibly still be resected for ultimate salvage. Hopefully, this therapeutic approach will enable the best of both modalities of treatment, that is, surgery and radiation, to be combined in a preplanned sequence to produce the greatest number of survivors of this aggressive disease.
Summary Eleven patients less than thirty years of age who had squamous cell carcinoma of the oral tongue were treated at the M. D. Anderson Hospital from 1956 to 1973. The overall survival was 45 per cent. Many of the usual concomitant factors, such as heavy smoking, drinking, and poor dental hygiene, were absent. Poorly differentiated, or grade III, squamous cell carcinoma was present in 48 per cent of the patients and indicated a poor prognosis regardless of the type of treatment. The primary lesion of the tongue was controlled in nine of the eleven patients. Recurrent cancer of the neck was observed in four patients. The selection of treatment in each case must be based on the various factors such as the size of the primary lesion, its histologic aspects, and the presence of nodal disease, and not on any emotional or subjective factors.
References 1. MacComb WS. Fletcher GH: M. D. Anderson Hospital, T and N staging. Cancer of the Head and Neck. Baltimore, Williams 8 Wilkins, 1967. 2. Unpublished data, M. D. Anderson Hospital experience with squamous cell carcinoma of the oral tongue. 3. Bhaskar SN: Oral tumors in infancy and chiklhood. J Pediatr 63: 195, 1963. 4. Dowd JF: A case of squamous cell carcinoma of the oral cavity in a ten year old boy. P&t Reconstr Surg 13: 109, 1954. 5. Frank LW. EnfiiM CD, Miller AJ: Carcinoma of the tongue in a newborn child: report of a case. Am J Cancer 22: 766, 1934. 6. Salieby GW: Cancer of the tongue in young subjects. Am J Cancer 38: 257.1940. 7. Merrifiiki FW, Daiiich WW, Steiner MM: Epidermoid carcinoma of the tongue and floor of the mouth in infancy and childhood. Am JDis ChM89: 281, 1955.
The American Journal ol sUr9rwy
Squamous cell carcinoma of tbe oral tongue in patients less than thirty years of age is quite unusual. The alleged etiologic factors, that is, tobacco, alcohol, and chronic irritation from dental appliances, associated with most squamous cell carcinomas of the oral cavity, have not usually been operative long enough to be considered important. The selection of therapy by the treatment team is based on many emotional considerations due to the young age of the patient. Therefore, the usual rational therapeutic approaches that apply to other patients are often compromised. The purpose of this report is to put into focus the various tumor factors with the different modalities of treatment in an attempt to answer several perplexing questions. 1. How does local control of the tumor and’surviva1 of these young patients compare with those in older patients with the same type and stage of tongue lesions? 2. Is the biologic behavior of squamous cell carcinoma of the oral tongue in patients under the age of thirty any more aggressive than the type of tongue cancer seen in older patients? 3. How much control of the primary lesion and neck metastases can be expected with our current methods and concepts of treatment in these young patients? 4. Can we determine the best course of therapy for these patients on the basis of a limited experience with this rare disease?
Material and Methods The medical records of eleven patients under thirty years of age who presented with squamous cell carcinoma of the oral tongue at the M. D. Anderson Hospital between 1966 and 1973 were analyzed. (Table I.) During the same period, 407 patients over thirty years of age with squamous cell carcinoma of the oral tongue were seen at the M. D. Anderson Hospital. The pathologists at M. D. Anderson Hospital indicated a diagnosis of squamous cell carcinoma on the basis of tissue specimens in all patients. All patients were followed up a minimum of two years or until death. Since 80 to 90 per cent of all local recurrences appear within two years, this follow-up period was thought to be adequate. Follow-up data were obtained through routine clinic visits or personal communication. The seven male and four female patients averaged twenty-three years of age, with a range of seventeen to twenty-nine years. Four of them were less than twenty years of age. A history of heavy smoking or alcohol intake was absent, and the dental status of all the patients was considered good to excellent. Only one patient had associated intraoral leukoplakia. Every one of the patients had a two to twelve month history of an ulcer or sore on the tongue, usually with pain. Referred ear pain was present in only one of the patients. The primary lesion was stage Ti or Ts in nine patients whereas in the remaining two patients the primary lesion was Ts. Six of the eleven patients were observed to have clinically positive nodes on admission, stage N1 [I]. No patient was found to have positive results on the serologic test for syphilis. None of the eleven patients had received any radiation to the head and neck region during childhood.. Results
From the Head and Neck Service, Department of Surgery, The University of Texas System ,Cancer Center, M. D. Anderson Hospital, Houston, Texas. Reprint requests should be addressed to Robert M. Byers, MD, 6723 Bertner D&e, Houston, Texas 77025. Presented at the Combined Meeting of the James Ewing Society and the Society of Head and Neck Surgeons, New Orteans. Louisiana, March 25-29. 1975.
Vdume 130, octeber 1975
Six of the eleven patients (55 per cent) had regional control (primary lesion and neck). Five of the eleven (45 per cent) were alive at the time of the analyses which compares with an absolute two year survival of 65 per cent (265/407 patients) in
475
Combined
Radiation
Surgery
Treatment
TABLE I
3
23
27
74928
30778 1
3
2 2 X 2
19
19 28 27 22
84419 87911 80701 68921
2 1
1 2
Tumor
Clinical
72902
19 29
17 27
97639 21787
99707 100080
Case Number
Ageof Patient (yr)
1 I
III
0
I III III II
III II
II II
III
disease) disease)
Histologic Grade
1 (N2~ disease)
1 1 0 0
1 0
O(N,n 1 (N,
Nodes
State of Disease
X
To Primary Lesion Only
X (surgery, radiation postoperatively) X (surgery, radiation postoperatively X (radiation to ,primary lesion, surgery to nodes
X
X X X
X
X
X
To Primary Lesion and Nodes
First Therapy
x
x
Primary
X
x
x
X
x
X
Nodes
x
X
Distant Metastases
Site of Recurrence
Radiation
None
Commando None
Commando Radical neck dissection
Radiation
Therapy for Failure
Treatment and Results in Eleven Patients Less Than Thirty Years of Age with Squamous Cell Carcinoma of the Oral Tongue ______-
X
X
X
X
X
ease
No Evidence of Dis_
X
X
X
X
X
X
ease
Of DIS-
Dead
Status
Dead of Other Causes
Carcinoma of Tongue
older patients with similarly staged cancers of the oral tongue [2]. To better analyze the results, the patients were divided into three categories on the basis of the initial modality of treatment to the primary lesion. Surgery Alone. Two patients with Ts lesions were treated primarily by surgery. The neck of one patient had Ni staging, but the pathologist reported the nodes as negative. The other patients had stage No disease of the neck, but five of thirtyeight nodes examined showed metastatic squamous cell carcinoma. Neither lesion was classified as grade III on pathologic examination. The primary lesion of the tongue was treated in one instance by intraoral excision and neck dissection in discontinuity. The other patient had hemiglossectomy combined with mandibulectomy and radical neck dissection. This patient, who had positive nodes, had a recurrence in the neck, received radiation for the obvious recurrence, and died with residual cancer in the neck. Both patients had local control of the lesion of the tongue. Radiation Alone. Six patients were treated primarily with radiation alone, one with a radium implant alone and five with external radiation followed by a radium implant. All of these patients had lesions that were either Tr or Ts. The one patient treated with an implant alone had negative cervical nodes. Three of the five patients treated with both external and interstitial radium implants had Nr stage disease of the neck. Local control of the primary lesion and necknodes in those patients with negative cervical nodes was 67 per cent (two of three patients). The one patient in whom treatment failed did not have treatment of the neck since the primary lesion was treated with a radium implant only. Despite this, the neck metastasis that evolved was treated by radical neck dissection and the patient is free of disease fifteen years later. Of those patients with Ni disease of the neck, local control and survival was 33 per cent (one of three patients). Both of these patients in whom treatment failed had histologically classified grade III poorly differentiated squamous cell carcinoma. The overall local control of cancer of the tongue in these patients was 67 per cent (four of six patients). The absolute two year survival was 50 per cent (three of six patients). A surgical salvage procedure was attempted in two of these three patients, both with Ni disease of the neck, and was unsuccessful. Three of the six patients had grade III poorly differentiated lesions. Only one of these three patients had local control of the primary lesion of the tongue and none survived.
vohmlo 130, octobw 1975
Planned Combined Treatment. Three patients were treated with a combination of radiation and surgery in a planned sequence. Two patients were treated with combined resection of the tongue, mandible, and neck followed by radiation therapy immediately after the wound had healed. Both had stage Ts disease and had histologically classified grade III poorly differentiated squamous cell carcinoma. One patient had clinical and pathologic No disease; the other had clinical stage Ni disease which eventually proved to be Nsn disease on pathologic examination of the surgical specimen. In the immediate postoperative period, radiation was given to the primary area and both sides of the neck to a dose of 6,000 r in six weeks. Neither patient survived; however, both had local control of the primary lesion. Both had treatment failure in the neck (one in the tracheostomy scar; the other in the contralateral side of the neck). The third patient had a TrNi lesion 11 which the planned course of treatment consisted of a radium implant to the lesion of the tongue followed by preplanned radical neck dissection. There were no positive nodes in the surgically dissected neck specimen. This patient has remained free of disease for thirteen years. Comments Several articles in the world’s literature document the occurrence of squamous cell carcinoma of the tongue in young people [3-71. However, none of the reports explains in detail the rationale for the therapeutic approach used. In addition, the lack of significant numbers of patients from any one institution usually means that the articles appear as case reports. The eleven patients in this study represent 3 per cent of all patients with squamous cell carcinoma of the oral tongue seen at the M. D. Anderson Hospital between 1956 and 1973. Although any meaningful statistical interpretation of the results of eleven patients is impossible, some conceptual points as to the diagnosis and treatment emerge from this study. The failure of physicians to vigorously investigate a persistent ulcer of the tongue in a patient less than thirty years of age resulted in considerable delay in diagnosis in many of these patients. Whether this delay adversely affected the ultimate outcome is speculative in these specific cases, but the data showed that two of three patients with Ti disease and three of five patients with Ts disease survived. None of the patients with larger lesions remained alive. Thus, a clinician should keep a high index of
477
Byers
suspicion of cancer when an ulcer has been present on the tongue longer than three weeks. The correct clinical interpretation of the presence or absence of cancer in cervical nodes of young people can be unreliable, because most of them have nodes associated with reactive hyperplasia. Since the therapeutic indications are significant if the nodes in question are indeed histologically positive for cancer, it seems important to verify this factor prior to treatment. The histologic classification of the primary lesion has the most significant relationship to local control of the lesion and survival of the patient. The treatment of patients with grade I or II squamous cell carcinoma (25 to 50 per cent mitoses per high power microscopic field) is good, with 67 per cent local control and survival (4/6 patients). In contrast, only one of the patients who had grade III squamous cell carcinoma (75 per cent or more mitoses per high power microscopic field) had control of the lesion above the clavicle and all five patients with this histologic classification died of cancer. In addition, the proportion of grade III lesions in these patients less than thirty years of age is higher than it is in older persons (48 per cent [5/11] versus 22 per cent [90/407]) [2]. Thus, anaplastic squamous cell carcinoma of the oral tongue appears to have a higher incidence in persons less than thirty years of age and behaves biologically in a virulent or agressive manner. With these facts in mind, the selection of treatment can be conceived more clearly. If the initial lesion is small (Ti to Te), grade I to grade II histologically, and no nodes are palpable in the neck, intraoral excision or adequate irradiation combining external beam and interstitial radium appears to have equal success in local control of the tumor and survival of the patient. If the lesion is ‘Ta to Tq, with or without palpable nodes, and is classified histologically as grade III squamous cell carcinoma, the prognosis is grave regardless of the type of therapy, and treatment should be considered palliative. The most aggressive therapy, that is, combined surgery and radiation, should be reserved for those patients who present with histologically grade I or grade II primary lesions, staged Ts or Ts, with clinical evidence of mobile clinical metastases. The sequence of treatment is debatable. Since control of the primary lesion is usually good with either modality alone, control of the cervical metastases takes priority. Since the clinical diagnosis of positive cervical nodes in young people is unreliable, it seems logical to plan first a limited surgical dissection of the neck. If the suspect-
478
ed node is negative, the primary lesion is treated with radiation alone (external plus implant or implant alone) or is intraorally excised if technically feasible. If the node proves to be pathologically involved with squamous cell carcinoma, the primary lesion, dissected neck, and contralateral side of the neck are treated with radiation (external to 6,000 r in six weeks with a radium implant as a boost to the primary lesion). If treatment of the primary lesion fails, the recurrence can possibly still be resected for ultimate salvage. Hopefully, this therapeutic approach will enable the best of both modalities of treatment, that is, surgery and radiation, to be combined in a preplanned sequence to produce the greatest number of survivors of this aggressive disease.
Summary Eleven patients less than thirty years of age who had squamous cell carcinoma of the oral tongue were treated at the M. D. Anderson Hospital from 1956 to 1973. The overall survival was 45 per cent. Many of the usual concomitant factors, such as heavy smoking, drinking, and poor dental hygiene, were absent. Poorly differentiated, or grade III, squamous cell carcinoma was present in 48 per cent of the patients and indicated a poor prognosis regardless of the type of treatment. The primary lesion of the tongue was controlled in nine of the eleven patients. Recurrent cancer of the neck was observed in four patients. The selection of treatment in each case must be based on the various factors such as the size of the primary lesion, its histologic aspects, and the presence of nodal disease, and not on any emotional or subjective factors.
References 1. MacComb WS. Fletcher GH: M. D. Anderson Hospital, T and N staging. Cancer of the Head and Neck. Baltimore, Williams 8 Wilkins, 1967. 2. Unpublished data, M. D. Anderson Hospital experience with squamous cell carcinoma of the oral tongue. 3. Bhaskar SN: Oral tumors in infancy and chiklhood. J Pediatr 63: 195, 1963. 4. Dowd JF: A case of squamous cell carcinoma of the oral cavity in a ten year old boy. P&t Reconstr Surg 13: 109, 1954. 5. Frank LW. EnfiiM CD, Miller AJ: Carcinoma of the tongue in a newborn child: report of a case. Am J Cancer 22: 766, 1934. 6. Salieby GW: Cancer of the tongue in young subjects. Am J Cancer 38: 257.1940. 7. Merrifiiki FW, Daiiich WW, Steiner MM: Epidermoid carcinoma of the tongue and floor of the mouth in infancy and childhood. Am JDis ChM89: 281, 1955.
The American Journal ol sUr9rwy