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The role of radical surgery and post-operative radiotherapy in the management of intra-oral carcinoma
Brilkh Journdof P/u.rrk Surgery (1985). 38, 3 lb320 C 1985 The Trustees of British Association ofPlastic
Surgeons
The role of radical surgery and post-operative radiotherapy in the management of intra-oral carcinoma A. G. ROBERTSON,
I. A. MCGREGOR, G. E. FLATMAN,
D. SOUTAR and P. BOYLE
Glasgow institute of Radiotherapeutics and Oncology, Western infirmary, Glasgow, the West of Scotland Plastic Surgery Unit, Canniesburn Hospital and the West of Scotland Cancer Surveillance Unit, Ruchill Hospital, Glasgow
Summary-The incidence rate for carcinoma of the tongue and floor of mouth has fallen in Scotland over the past 20 years (Fig. 1). Despite the fall in incidence rate and mortality rate many such tumours present late when the prognosis is poor (Pointon and Gleave, 1982; Decroix and Ghossein, 1981 a; Shaw 1982). Until relatively recently most centres treated such lesions either by surgery or by radiotherapy alone. Over the past decade a number of centres have adopted a dual treatment policy involving both surgery and radiotherapy. The head and neck oncologists at the Royal Marsden advocate pre-operative radiotherapy (Shaw, 1982) while Glasgow and the Memorial in New York (Vikram et al., 1980) have adopted the practice of post-operative radiotherapy. A combined plastic surgery/radiotherapy clinic has been run in Glasgow for the past ten years and over that time a treatment protocol has evolved. The results of treatment of all advanced tumours of the tongue and floor of mouth referred to the Glasgow Institute of Radiotherapeutics and Oncology are presented here. The results of planned combined therapy-radical surgery followed by radical radiotherapy-are compared with the results of treating similar lesions by minimal surgery plus radical radiotherapy and the advantages of combined radical treatment are discussed.
The Glasgow Institute provides a service for two thirds of the population of Scotland, the patients being domiciled in a region about a third of the area of Scotland. Between 1976 and 1982, 259 patients with carcinoma of the floor of mouth or tongue were referred to the Glasgow Institute for treatment, 185 had advanced lesions (see Table), 110 carcinoma of tongue and 75 carcinoma of floor of mouth. The age range for the two groups of patients was 25 to 93, the average age being 66. The ratio of males to females for carcinoma of the tongue was 1.5 to 1 and for carcinoma of floor of mouth 3 to 1. The age range and sex ratios are similar to those reported in other series (Morris, 1970; Binnie, 1976). This is essentially a retrospective study. All patients have been staged according to the 1978 rules of the IUCC. Patients who received radical surgery prior to their radiotherapy were staged according to both clinical and pathological findings-neural and periosteal involvement. Those who did not undergo radical surgery prior to treatment while having a histological diagnosis were staged clinically. This study is confined to patients with stage T2 NO MO and more advanced tumours (see Table).
Treatment policies, unfortunately, are often influenced by referral patterns. In an attempt to clarify the results the patients have been subdivided into two groups. The first group consists of patients seen at the combined plastic/radiotherapy clinic who are treated in a relatively uniform way. These patients underwent radical surgery which involved wide excision of the tumour together with either a radical or a functional neck dissection and immediate reconstruction by means of pedicle flaps initially (McGregor, 1963), and more recently using single stage methods such as myocutaneous flaps and free flaps (Soutar et al., 1983). These more recent flaps have their own blood supply and unlike skin grafts can tolerate a radical dose of radiotherapy. Four to 8 weeks (initially this time interval was longer (Fig. 2)) following surgery, patients start their post-operative radiotherapy. These patients receive 6000cGy in 30 fractions over six to eight weeks. A brisk intra-oral reaction often develops necessitating protraction of the treatment. A wedged pair set up is used to treat the oral cavity and a single anterior field is used to treat both anterior triangles of the neck, the midline is shielded (Fig. 3). The wedged pair set up used to treat the oral cavity reduces the total dose to the 314
315
THE ROLE OF RADICAL SURGERY AND POST-OPERATIVE RADIOTHERAPY
INCIDENCE OF CANCER OF THE FLOOR OF MOUTH AND THE TONGUE IN SCOTLAND. 1959.1980 ALL -AGES, AGE ~ANDARDISEDIN~IDE~E RATES PER 190,QW~MALES AND FEMALES.
1959
90
81
62
62
64
95
BB
67
69
69
70
71
72
73
74
75
---
Tongue
-
Flmr
of Mwth
77
78
7%
79
90
Yaw
Fig. 1 Figure l--Incidence
rates for carcinoma of tongue and carcinoma of floor of mouth in Scotland 1959 to 1980.
parotid on the unaffected side to about 2000 cGy. Such a dose does not destroy function and prevents the development of xerostomia, a very debilitating condition (Mira et al., 1981; Mossman et al., 1982; Cheng et al., 1981). This group is classified as having radical surgery followed by post-operative radical radiotherapy. The second group contains all other patients. All had a biopsy to establish the nature of the lesion and following this some had limited surgery with local excision, and occasionally a radical neck dissection. All received a radical course of radiotherapy receiving 6OOOcGy in 5 to 6 weeks but there was no specific time interval between excision and radiotherapy. This group is classified as having radical radiotherapy f surgery.
Results The results of treatment are presented in form of survival curves (Peto et al., 1977). The starting date of radiotherapy was taken as day 0 in both sets of patients (Figs. 49). In view of the small number of patients involved the groups were subdivided into those with nodal involvement and those without (Table). Where patients with squamous cell carcinoma of the tongue have received combined radical surgery followed by radical radiotherapy the j-year survival is 44%. For those receiving treatment involving radical radiotherapy plus a variety of surgical procedures the 5-year survival is 5% (Fig. 4). When the groups are subdivided into those with nodal in-
316 Table
BRITISH JOURNAL OFPLASTIC SURGERY TNM classjfication of patients with advanced squamous cell carcinoma of tongue and floor of mouth
Stage ofpatients with no nodal involvement Site
Tongue
Treatment Protocol
Radical surgery +XRT
Ffoar XRT rl:Surgery
ofmouth
Radical surgery +XRT
XRT f Surgery
Stage T2 NO T3 NO T4 NO
MO MO MO TXNO MO
I
7
5
1;
-
3 4
7 I
4
-
4
-
1
Stage ofpatients with nodal involvement Site
Tongtie
Treatment Protocol
Radical surgery +XRT
Stage T2N1 MO T2 N2 MO T2 N3 MO T3N1 MO T3 N2 MO T3 N3 MO T4 Nl MO T4 N2 MO T4 N3 MO TXNl MO TXN2 MO TXN3 MO
-
4
I 5 L
IO 1 -
1
volvement (Fig. 5) and those without (Fig. 6), in the group receiving combined radical treatment all those with no nodes involved are alive and well from 10 to 58 months after starting radiotherapy. The group is small-6 patients but 5 of them had T4 disease. Of those with nodal involvement (25 patients) the five year survival is 23%. All deaths occurred within 12 months of starting radiotherapy, with the exception of one patient who died 47 months after starting radiotherapy. Where the patients were not treated with combined radical treatment the 5-year survival of those with no nodal involvement is 9%. In the case of patients with lesions arising in the floor of mouth the 3-year survival for patients receiving combined radical treatment is 41%. The 3-year survival for the other group is 10% (Fig. 7). For patients with no nodal involvement treated by combination therapy the 2-year survival is 65%, that for the other group is 29% (Fig. 8). Where there is nodal involvement the 2-year survival drops to 35% and 4% respectively (Fig. 9).
&or XRT * Surgery
-
8
of mouih
Radical surgery +XRT
XRT f Surgery
-
6 1 2
2 6
2 8 2 6 10 I i
t I 2
-
: 7
1 2
The median delay between surgery and radiotherapy in those patients who are known to have died of disease is 7 months-signi~~antly larger (Mann-Whitney W = 1023,0, p 0.1 (Ryan et al., 1980)) than among those patients who remain alive-3 months (Fig. 2).
Patients with advanced oral tumours have a very poor prognosis. The major difficulty arises in controlling the primary (Westbu~, 1976) and neck metastases. Oral lesions rarely metastasise below the clavicle and deaths from metastases below the clavicle are extremely infrequent. Single agent therapy provides a satisfactory approach to the management of Tl NO MO lesions-the 5-year survival of such tumours of the tongue is about 80% (Decroix and Ghossein, 1981a), using radiotherapy or surgery alone-however the results for advanced lesions are much poorer ranging from 10 to 30% for T3 NO MO
THE ROLE OF RADICAL SURGERY AND POST-OPERATIVE RADIOTHERAPY l
20
l
15
l l
l l
IO
l * l l eee l
l
e*
e ee
5
eeeeee *e
PATENTS
l l
l
oeeeeeeeeee l
eee
e
l
l
e
l
l
ee
e
PATtENTSDUD
ALIVE
Fig. 2 Figure 2-Influence of time interval between surgery and radiotherapy on patients’ prognosis.
lesions (Decroix and Ghossein, 198lb; Pointon and Gleave, 1982) and those for more advanced lesions are obviously worse. In an attempt to improve control of the primary lesion and neck metastases various combinations of the three treatment modahties-surgery, radiotherapy and chemotherapy-have been introduced. To date we have not seen any advantage in routinely using chemotherapy. There has always been controversy over pre- and post-operative radiotherapy (Moss, 1982; Fletcher and Jesse, 1977). The combined technique of radical surgery and post-operative radiotherapy has many advantages over pre-operative radiotherapy.
317
Surgery debulks the tumour removing approximately 99% of the mass prior to X-ray treatment. Modern t~hniques in r~onstructive surgery using well vascularised tissue enable rapid healing in a single stage. Patients are often able to be discharged home without a nasogastric tube 10 days after operation. This facilitates early postoperative radiotherapy (Fig. 2) and the tolerance of such vascularised tissue is similar to that of surrounding tissue unlike the older staged methods of intra-oral reconstruction. Furthermore radical surgery allows more accurate staging and an appropriate volume of tissue can be irradiated post-operatively. Pre-operative radiotherapy will only control about 25% of bulky tumours (Vermund et al., 1982). It will downstage a tumour if surgery is carried out soon after treatment and if the surgical margins are too small there is no alternative treatment left, furthermore pre-operative radiotherapy delays surgery. The life table results (Figs. 4-9) presented, indicate that there is a dramatic improvement in survival where there is a planned radical approach to treatment. The age range in the two groups (Table) is approximately the same. In the group treated by radical surgery and radiotherapy age was not a contra-indication to treatment. Obviously patients who were not expected to survive the operation were not accepted but each patient was judged on his own merits and age was not an excluding factor. The two groups were obviously staged differently. The group receiving radical surgery has been staged pathologically while the other group has been staged clinically, following histologi~l veriiication of disease. This means that in the clinically staged group some of the cases will have been understaged with respect to the primary where it is difficult to determine bone and neural extension but may have been overstaged with respect to the nodes. Not all clinically palpable nodes have tumour present. Some are enlarged due to reactive change only. The difference in staging procedures is not critical in this analysis but any advantage should therefore be with the clinically staged groups as a percentage of the Nl cases will not have tumour in the nodes. The numbers in the groups treated with combined radical treatment are small and the time period over which the study has been conducted is short. The trends would suggest that combined radical treatment greatly improves the chances of survival. The six patients with carcinoma of the tongue who did not have nodal involvement were
BRITISH
JOURNAL
OF PLASTIC
SURGERY
Fig. 3 Figure 3-Radiotherapy
fields used to treat oral cavity and anterior
triangles
of neck.
carcinoma of Tongue of
Carcinoma Stages
%
12-X
Stages
Tz-X
NO MO
Tongue
No-3
MO
1
T“__
-_ --_
--_
I
Y....
._--______
__-- _. .----
-_ _ _..
--+SWW _____,__,
.-_--._----__________
Fig. 6 Figure 4-Actuarial advanced squamous
survival curve for all cell carcinoma of tongue.
patients
with
Figure bActuaria1 survival curve for patients with advanced squamous cell carcinoma of tongue with no nodal involvement.
Carcinoma SlagesT2-x
% r .._ ..
Floor of Mouth No-3
MO
too
: 2
“2
e 2 fj
-xl-
.... -
-
4
4
-‘.1..... ._--__
._____--------_____
Radical sulgwy
___ -
Rldiolhuwv
-
Rdi*Sulry
---_ _________________
nd
win
126pmno,. IW_,.
I 10
20 30 40 50 MONMSSINCEITARTOF RAlxOTHERU”
64
70
Fig. 5 Figure S-Actuarial survival curve for patients with advanced squamous cell carcinoma of tongue with node metastases.
Figure 7-Actuarial advanced squamous
survival curve for all patients cell carcinoma of floor of mouth.
with
THE ROLE OF RADICAL
SURGERY
Carcinoma Floor of Stages
% loo-
T2 -X
AND POST-OPERATIVE
319
RADIOTHERAPY Carcinoma
Mouth
NO MO
Stage8
% 100.
Floor
T2-x
of Mouth
Nl-2
MO
.__ ___ ; 5
-p
9
..
$ 50. 4 2
-sumnd~~,I~,.
___ _ _ _ _ _ _. ____________________------~--
-fs+mw 112pan,.
--. --_ --.. :____________ M
xl .-SINCE
30
u)
-~(Pmmmml 50
80
70
STARTOFIUDIMHEIIM
Fig. 8
Fig. 9
Figure 8-Actuarial survival curve for patients with advanced squamous cell carcinoma of floor of mouth with no nodal involvement.
Figure 9-Actuarial survival curve for patients with advanced squamous cell carcinoma of floor of mouth with nodal metastases.
all alive and well at the time of study from 12 to 55 months after starting the X-ray part of their treatment. The 5-year survival for the group receiving the alternative treatment (33 patients) is 9% (Figs. 5 and 6). The majority of patients who relapsed did so within 18 months. Where there was nodal involvement the results were poorer. The 3-year survival for the 25 patients treated by combined radical therapy is 46% and the 5-year survival is 23%. For the other group the 3-year survival is 24% and the 5-year survival is 9%. The results show a similar trend for patients with tumours of the floor of mouth (Figs. 7-9).Where there was no nodal involvement, the 2-year survival was 65% for the eight patients treated by combined therapy and 29% for the 12 patients in the other group (Fig. 8). Nodal involvement at the time of presentation worsens the prognosis. The 3-year survivals are 35% and 4% for the two groups respectively (Fig. 9). All recurrences presented within 2 years, this is in keeping with the findings of Porter (1971) who noted that the vast majority of recurrences appeared within 2 years and a few presented later. It could be claimed that patients with stage T2 NO MO disease and more advanced were being over treated when they received radical radiotherapy after radical surgery. This may be the case in patients with carcinoma of the tongue where all patients are still alive. The numbers however are small and a larger series will have to be built and analysed before a policy change-possibly watching T2 NO MO and treating T3 NO MO and T4 NO MO-is introduced. It must be appreciated
that if the disease is not controlled initially then the chances of cure are greatly diminished (Fig. 2). Not all patients with carcinoma of floor of mouth with no evidence of nodal involvement are cured. Of the eight patients treated by combined treatment only 65% are alive at 2 years compared with 29% of those treated conventionally. Clearly prophylactically irradiating the neck in this group of patients is not an excessive form of treatment though it should be noted that in the small group of eight patients, seven had stage T4 NO MO. Perhaps if patients had less advanced disease the neck would not need to be irradiated. Radical irradiation of the floor of the mouth and neck usually results in xerostomia which can be very debilitating. The set up used in the series of patients treated by combination therapy is shown in Figure 3. The dose to the contralateral parotid is reduced to 2000 cGy over 6 weeks. Subjectively the incidence and severity of xerostomia is much reduced by this procedure (Mira et al., 1981; Cheng et al., 1981). In conclusion the treatment techniques used in this study of the management of patients with advanced intra-oral lesions will greatly improve their quality of life. The treatment policy of radical excision followed by planned radiotherapy 4 to 8 weeks post surgery will improve the patients’ survival. Acknowledgements We wish to thank Mrs S. Harvey and Mrs J. Geddes for assistance in preparing this manuscript and the Medical Illustrations Department, Western Infirmary, Glasgow for the preparation of figures and tables.
320 References Bin&, W. H. (1976). Epidemiology and etiology of oral cancer in Britain. Proceedings of the Royal Society of Medicine, 69, 737. Cheng,V.S.T.,Do~J.,Herbert,D.andAramany,M.(1981). The function of the parotid gland following radiation therapy for head and neck cancer. International Journal of Radiation Oncology, Biology, Physics. (New York) 7,253. DecroIx, Y. and Gbossein, N. A. (198 la). Experience of the Curie Institute in treatment of cancer of the mobile tongue. I. Treatment policies and results. Cancer, 47,496. DecreII Y. and Ghossein. N. A. (1981bl. Exnerience of the Curie Institute in treatmen; of ca&er 0; the’ mobile tongue. II. Management of the neck nodes. Cancer, 47,503. FIetcher, G. H. and Jesse, R. I-I. (1977). The place of irradiation in the management of the primary lesion in head and neck cancers. Cancer, 39,862. McGregor, I. A. (1963). The temporal flap in intra-oral cancer: its use in repairing the post excisional defect. British Journal of Plastic Surgery, 16,3 18. Minx, J. G., Wescatt, W. B., Star&e, E. N. and Shannon, I. L. (1981). Some factors influencing salivary function when treating with radiotherapy. International Journal of Radiation Oncology, Biology, Physics. (New York) 7,535. Morris, S. (1970). A seven year survey of changing treatment in carcinoma of tongue. Clinical Radiology, 21,43 1. Mos+ W. T. (1982). The integration of irradiation and surgery as the treatment for selected cancers: International Journal of Radiation Oncology, Biology, Physics. (New York) 8, 1373. Mossman, K., Shatyman, A. and ChenchM, J. (1982). Long term effects of radiotherapy on taste and salivary function in man. International Journal of Radiation Oncology, Biology, Physics. (New York) 8,991. Pete, R., Pike, M. C., Amitage, P., Brcslow, N. E., Cox, D. R., Howard, S. N., Mantel, N., McPkersoo, K., Peto, J. and Smith, P. G. (1977). Design and analysis of randomised clinical trials requiring prolonged observation of each patient. British Journal of Cancer, 35,l. Pointoa, R. C. S. and Cleave, N. (1982). Lips and oral cancer. In Treatment of Cancer. Edited by K. E. Halnan, London: Chapman and Hall. Porter, E. H. (1971). The local prognosis after radical radio-
BRITISH JOURNAL OF PLASTIC SURGERY therapy for squamous carcinoma of the alveolus and of the floor of the mouth. Clinical Radiology (London). 22,139. Ryan, T. A., Joiner, B. L. and Ryi, %. F. (1980). Minitab Reference Manual, Penn State University. Shaw, H. J. (1982). Head and neck tumour surgery. Hospital Update, 8, 1069. Soutar, D. S., Scbeker, L. R., Tanner, N. S. B. and McGregor, I. A. (1983). The radical forearm flap: a versatile method for in&a-oral reconstruction. British Journal of Plastic Surgery, 36, 1. UICC 1978. TNM, Classification of malignant tumours. Third Edition. Vemund, H., Bremkovd, I. O., Kaalkus, 0. and Poppe, E. (1982). Pre-operative radiation therapy in squamous cell carcinoma of the anterior two thirds of the tongue at the Norwegian Radium Hospital. International Journal of Radiation Oncology, Biology, Physics. (New York) 8, 1263. Vikram, B., Strong, E. W., Shah, J. and Spiro, E. H. (1980). Elective post operative radiation therapy in stages III and IV epidermoid carcinoma of the head and neck. American Journal of Surgery, 14,580. Westbury, G. (1976). Oral cancer: general strategy of the management. Proceedings of the Royal Society of Medicine, 69, 749.
The Authors A. G. Robertson, PhD, MB, ChB, FRCR, Consultant Radiotherapist, Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary, Glasgow. I. A. McGregor, CkM, FRCS, FRACS.(Hon), Director, Plastic Surgery Unit, Canniesbum Hospital, Glasgow. G. E. FIalman, MD, FRCS, FRCR, FACR.(Hon), Director, Radiotherapy Institute, Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary, Glasgow. D. S. !%ahr, FRCSKd, Consultant Plastic Surgeon, Plastic Surgery Unit, Cannieabum Hospital, Glasgow. P. Boyle, BSc, Chief Statistician, West of Scotland Cancer Surveillance Unit, Ruchill Hospital, Glasgow. Requests for reprints to: Dr A. G. Robertson, Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary, Glasgow G 116NT.
Surgeons
The role of radical surgery and post-operative radiotherapy in the management of intra-oral carcinoma A. G. ROBERTSON,
I. A. MCGREGOR, G. E. FLATMAN,
D. SOUTAR and P. BOYLE
Glasgow institute of Radiotherapeutics and Oncology, Western infirmary, Glasgow, the West of Scotland Plastic Surgery Unit, Canniesburn Hospital and the West of Scotland Cancer Surveillance Unit, Ruchill Hospital, Glasgow
Summary-The incidence rate for carcinoma of the tongue and floor of mouth has fallen in Scotland over the past 20 years (Fig. 1). Despite the fall in incidence rate and mortality rate many such tumours present late when the prognosis is poor (Pointon and Gleave, 1982; Decroix and Ghossein, 1981 a; Shaw 1982). Until relatively recently most centres treated such lesions either by surgery or by radiotherapy alone. Over the past decade a number of centres have adopted a dual treatment policy involving both surgery and radiotherapy. The head and neck oncologists at the Royal Marsden advocate pre-operative radiotherapy (Shaw, 1982) while Glasgow and the Memorial in New York (Vikram et al., 1980) have adopted the practice of post-operative radiotherapy. A combined plastic surgery/radiotherapy clinic has been run in Glasgow for the past ten years and over that time a treatment protocol has evolved. The results of treatment of all advanced tumours of the tongue and floor of mouth referred to the Glasgow Institute of Radiotherapeutics and Oncology are presented here. The results of planned combined therapy-radical surgery followed by radical radiotherapy-are compared with the results of treating similar lesions by minimal surgery plus radical radiotherapy and the advantages of combined radical treatment are discussed.
The Glasgow Institute provides a service for two thirds of the population of Scotland, the patients being domiciled in a region about a third of the area of Scotland. Between 1976 and 1982, 259 patients with carcinoma of the floor of mouth or tongue were referred to the Glasgow Institute for treatment, 185 had advanced lesions (see Table), 110 carcinoma of tongue and 75 carcinoma of floor of mouth. The age range for the two groups of patients was 25 to 93, the average age being 66. The ratio of males to females for carcinoma of the tongue was 1.5 to 1 and for carcinoma of floor of mouth 3 to 1. The age range and sex ratios are similar to those reported in other series (Morris, 1970; Binnie, 1976). This is essentially a retrospective study. All patients have been staged according to the 1978 rules of the IUCC. Patients who received radical surgery prior to their radiotherapy were staged according to both clinical and pathological findings-neural and periosteal involvement. Those who did not undergo radical surgery prior to treatment while having a histological diagnosis were staged clinically. This study is confined to patients with stage T2 NO MO and more advanced tumours (see Table).
Treatment policies, unfortunately, are often influenced by referral patterns. In an attempt to clarify the results the patients have been subdivided into two groups. The first group consists of patients seen at the combined plastic/radiotherapy clinic who are treated in a relatively uniform way. These patients underwent radical surgery which involved wide excision of the tumour together with either a radical or a functional neck dissection and immediate reconstruction by means of pedicle flaps initially (McGregor, 1963), and more recently using single stage methods such as myocutaneous flaps and free flaps (Soutar et al., 1983). These more recent flaps have their own blood supply and unlike skin grafts can tolerate a radical dose of radiotherapy. Four to 8 weeks (initially this time interval was longer (Fig. 2)) following surgery, patients start their post-operative radiotherapy. These patients receive 6000cGy in 30 fractions over six to eight weeks. A brisk intra-oral reaction often develops necessitating protraction of the treatment. A wedged pair set up is used to treat the oral cavity and a single anterior field is used to treat both anterior triangles of the neck, the midline is shielded (Fig. 3). The wedged pair set up used to treat the oral cavity reduces the total dose to the 314
315
THE ROLE OF RADICAL SURGERY AND POST-OPERATIVE RADIOTHERAPY
INCIDENCE OF CANCER OF THE FLOOR OF MOUTH AND THE TONGUE IN SCOTLAND. 1959.1980 ALL -AGES, AGE ~ANDARDISEDIN~IDE~E RATES PER 190,QW~MALES AND FEMALES.
1959
90
81
62
62
64
95
BB
67
69
69
70
71
72
73
74
75
---
Tongue
-
Flmr
of Mwth
77
78
7%
79
90
Yaw
Fig. 1 Figure l--Incidence
rates for carcinoma of tongue and carcinoma of floor of mouth in Scotland 1959 to 1980.
parotid on the unaffected side to about 2000 cGy. Such a dose does not destroy function and prevents the development of xerostomia, a very debilitating condition (Mira et al., 1981; Mossman et al., 1982; Cheng et al., 1981). This group is classified as having radical surgery followed by post-operative radical radiotherapy. The second group contains all other patients. All had a biopsy to establish the nature of the lesion and following this some had limited surgery with local excision, and occasionally a radical neck dissection. All received a radical course of radiotherapy receiving 6OOOcGy in 5 to 6 weeks but there was no specific time interval between excision and radiotherapy. This group is classified as having radical radiotherapy f surgery.
Results The results of treatment are presented in form of survival curves (Peto et al., 1977). The starting date of radiotherapy was taken as day 0 in both sets of patients (Figs. 49). In view of the small number of patients involved the groups were subdivided into those with nodal involvement and those without (Table). Where patients with squamous cell carcinoma of the tongue have received combined radical surgery followed by radical radiotherapy the j-year survival is 44%. For those receiving treatment involving radical radiotherapy plus a variety of surgical procedures the 5-year survival is 5% (Fig. 4). When the groups are subdivided into those with nodal in-
316 Table
BRITISH JOURNAL OFPLASTIC SURGERY TNM classjfication of patients with advanced squamous cell carcinoma of tongue and floor of mouth
Stage ofpatients with no nodal involvement Site
Tongue
Treatment Protocol
Radical surgery +XRT
Ffoar XRT rl:Surgery
ofmouth
Radical surgery +XRT
XRT f Surgery
Stage T2 NO T3 NO T4 NO
MO MO MO TXNO MO
I
7
5
1;
-
3 4
7 I
4
-
4
-
1
Stage ofpatients with nodal involvement Site
Tongtie
Treatment Protocol
Radical surgery +XRT
Stage T2N1 MO T2 N2 MO T2 N3 MO T3N1 MO T3 N2 MO T3 N3 MO T4 Nl MO T4 N2 MO T4 N3 MO TXNl MO TXN2 MO TXN3 MO
-
4
I 5 L
IO 1 -
1
volvement (Fig. 5) and those without (Fig. 6), in the group receiving combined radical treatment all those with no nodes involved are alive and well from 10 to 58 months after starting radiotherapy. The group is small-6 patients but 5 of them had T4 disease. Of those with nodal involvement (25 patients) the five year survival is 23%. All deaths occurred within 12 months of starting radiotherapy, with the exception of one patient who died 47 months after starting radiotherapy. Where the patients were not treated with combined radical treatment the 5-year survival of those with no nodal involvement is 9%. In the case of patients with lesions arising in the floor of mouth the 3-year survival for patients receiving combined radical treatment is 41%. The 3-year survival for the other group is 10% (Fig. 7). For patients with no nodal involvement treated by combination therapy the 2-year survival is 65%, that for the other group is 29% (Fig. 8). Where there is nodal involvement the 2-year survival drops to 35% and 4% respectively (Fig. 9).
&or XRT * Surgery
-
8
of mouih
Radical surgery +XRT
XRT f Surgery
-
6 1 2
2 6
2 8 2 6 10 I i
t I 2
-
: 7
1 2
The median delay between surgery and radiotherapy in those patients who are known to have died of disease is 7 months-signi~~antly larger (Mann-Whitney W = 1023,0, p 0.1 (Ryan et al., 1980)) than among those patients who remain alive-3 months (Fig. 2).
Patients with advanced oral tumours have a very poor prognosis. The major difficulty arises in controlling the primary (Westbu~, 1976) and neck metastases. Oral lesions rarely metastasise below the clavicle and deaths from metastases below the clavicle are extremely infrequent. Single agent therapy provides a satisfactory approach to the management of Tl NO MO lesions-the 5-year survival of such tumours of the tongue is about 80% (Decroix and Ghossein, 1981a), using radiotherapy or surgery alone-however the results for advanced lesions are much poorer ranging from 10 to 30% for T3 NO MO
THE ROLE OF RADICAL SURGERY AND POST-OPERATIVE RADIOTHERAPY l
20
l
15
l l
l l
IO
l * l l eee l
l
e*
e ee
5
eeeeee *e
PATENTS
l l
l
oeeeeeeeeee l
eee
e
l
l
e
l
l
ee
e
PATtENTSDUD
ALIVE
Fig. 2 Figure 2-Influence of time interval between surgery and radiotherapy on patients’ prognosis.
lesions (Decroix and Ghossein, 198lb; Pointon and Gleave, 1982) and those for more advanced lesions are obviously worse. In an attempt to improve control of the primary lesion and neck metastases various combinations of the three treatment modahties-surgery, radiotherapy and chemotherapy-have been introduced. To date we have not seen any advantage in routinely using chemotherapy. There has always been controversy over pre- and post-operative radiotherapy (Moss, 1982; Fletcher and Jesse, 1977). The combined technique of radical surgery and post-operative radiotherapy has many advantages over pre-operative radiotherapy.
317
Surgery debulks the tumour removing approximately 99% of the mass prior to X-ray treatment. Modern t~hniques in r~onstructive surgery using well vascularised tissue enable rapid healing in a single stage. Patients are often able to be discharged home without a nasogastric tube 10 days after operation. This facilitates early postoperative radiotherapy (Fig. 2) and the tolerance of such vascularised tissue is similar to that of surrounding tissue unlike the older staged methods of intra-oral reconstruction. Furthermore radical surgery allows more accurate staging and an appropriate volume of tissue can be irradiated post-operatively. Pre-operative radiotherapy will only control about 25% of bulky tumours (Vermund et al., 1982). It will downstage a tumour if surgery is carried out soon after treatment and if the surgical margins are too small there is no alternative treatment left, furthermore pre-operative radiotherapy delays surgery. The life table results (Figs. 4-9) presented, indicate that there is a dramatic improvement in survival where there is a planned radical approach to treatment. The age range in the two groups (Table) is approximately the same. In the group treated by radical surgery and radiotherapy age was not a contra-indication to treatment. Obviously patients who were not expected to survive the operation were not accepted but each patient was judged on his own merits and age was not an excluding factor. The two groups were obviously staged differently. The group receiving radical surgery has been staged pathologically while the other group has been staged clinically, following histologi~l veriiication of disease. This means that in the clinically staged group some of the cases will have been understaged with respect to the primary where it is difficult to determine bone and neural extension but may have been overstaged with respect to the nodes. Not all clinically palpable nodes have tumour present. Some are enlarged due to reactive change only. The difference in staging procedures is not critical in this analysis but any advantage should therefore be with the clinically staged groups as a percentage of the Nl cases will not have tumour in the nodes. The numbers in the groups treated with combined radical treatment are small and the time period over which the study has been conducted is short. The trends would suggest that combined radical treatment greatly improves the chances of survival. The six patients with carcinoma of the tongue who did not have nodal involvement were
BRITISH
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Fig. 3 Figure 3-Radiotherapy
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Figure bActuaria1 survival curve for patients with advanced squamous cell carcinoma of tongue with no nodal involvement.
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Fig. 5 Figure S-Actuarial survival curve for patients with advanced squamous cell carcinoma of tongue with node metastases.
Figure 7-Actuarial advanced squamous
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THE ROLE OF RADICAL
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319
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Figure 8-Actuarial survival curve for patients with advanced squamous cell carcinoma of floor of mouth with no nodal involvement.
Figure 9-Actuarial survival curve for patients with advanced squamous cell carcinoma of floor of mouth with nodal metastases.
all alive and well at the time of study from 12 to 55 months after starting the X-ray part of their treatment. The 5-year survival for the group receiving the alternative treatment (33 patients) is 9% (Figs. 5 and 6). The majority of patients who relapsed did so within 18 months. Where there was nodal involvement the results were poorer. The 3-year survival for the 25 patients treated by combined radical therapy is 46% and the 5-year survival is 23%. For the other group the 3-year survival is 24% and the 5-year survival is 9%. The results show a similar trend for patients with tumours of the floor of mouth (Figs. 7-9).Where there was no nodal involvement, the 2-year survival was 65% for the eight patients treated by combined therapy and 29% for the 12 patients in the other group (Fig. 8). Nodal involvement at the time of presentation worsens the prognosis. The 3-year survivals are 35% and 4% for the two groups respectively (Fig. 9). All recurrences presented within 2 years, this is in keeping with the findings of Porter (1971) who noted that the vast majority of recurrences appeared within 2 years and a few presented later. It could be claimed that patients with stage T2 NO MO disease and more advanced were being over treated when they received radical radiotherapy after radical surgery. This may be the case in patients with carcinoma of the tongue where all patients are still alive. The numbers however are small and a larger series will have to be built and analysed before a policy change-possibly watching T2 NO MO and treating T3 NO MO and T4 NO MO-is introduced. It must be appreciated
that if the disease is not controlled initially then the chances of cure are greatly diminished (Fig. 2). Not all patients with carcinoma of floor of mouth with no evidence of nodal involvement are cured. Of the eight patients treated by combined treatment only 65% are alive at 2 years compared with 29% of those treated conventionally. Clearly prophylactically irradiating the neck in this group of patients is not an excessive form of treatment though it should be noted that in the small group of eight patients, seven had stage T4 NO MO. Perhaps if patients had less advanced disease the neck would not need to be irradiated. Radical irradiation of the floor of the mouth and neck usually results in xerostomia which can be very debilitating. The set up used in the series of patients treated by combination therapy is shown in Figure 3. The dose to the contralateral parotid is reduced to 2000 cGy over 6 weeks. Subjectively the incidence and severity of xerostomia is much reduced by this procedure (Mira et al., 1981; Cheng et al., 1981). In conclusion the treatment techniques used in this study of the management of patients with advanced intra-oral lesions will greatly improve their quality of life. The treatment policy of radical excision followed by planned radiotherapy 4 to 8 weeks post surgery will improve the patients’ survival. Acknowledgements We wish to thank Mrs S. Harvey and Mrs J. Geddes for assistance in preparing this manuscript and the Medical Illustrations Department, Western Infirmary, Glasgow for the preparation of figures and tables.
320 References Bin&, W. H. (1976). Epidemiology and etiology of oral cancer in Britain. Proceedings of the Royal Society of Medicine, 69, 737. Cheng,V.S.T.,Do~J.,Herbert,D.andAramany,M.(1981). The function of the parotid gland following radiation therapy for head and neck cancer. International Journal of Radiation Oncology, Biology, Physics. (New York) 7,253. DecroIx, Y. and Gbossein, N. A. (198 la). Experience of the Curie Institute in treatment of cancer of the mobile tongue. I. Treatment policies and results. Cancer, 47,496. DecreII Y. and Ghossein. N. A. (1981bl. Exnerience of the Curie Institute in treatmen; of ca&er 0; the’ mobile tongue. II. Management of the neck nodes. Cancer, 47,503. FIetcher, G. H. and Jesse, R. I-I. (1977). The place of irradiation in the management of the primary lesion in head and neck cancers. Cancer, 39,862. McGregor, I. A. (1963). The temporal flap in intra-oral cancer: its use in repairing the post excisional defect. British Journal of Plastic Surgery, 16,3 18. Minx, J. G., Wescatt, W. B., Star&e, E. N. and Shannon, I. L. (1981). Some factors influencing salivary function when treating with radiotherapy. International Journal of Radiation Oncology, Biology, Physics. (New York) 7,535. Morris, S. (1970). A seven year survey of changing treatment in carcinoma of tongue. Clinical Radiology, 21,43 1. Mos+ W. T. (1982). The integration of irradiation and surgery as the treatment for selected cancers: International Journal of Radiation Oncology, Biology, Physics. (New York) 8, 1373. Mossman, K., Shatyman, A. and ChenchM, J. (1982). Long term effects of radiotherapy on taste and salivary function in man. International Journal of Radiation Oncology, Biology, Physics. (New York) 8,991. Pete, R., Pike, M. C., Amitage, P., Brcslow, N. E., Cox, D. R., Howard, S. N., Mantel, N., McPkersoo, K., Peto, J. and Smith, P. G. (1977). Design and analysis of randomised clinical trials requiring prolonged observation of each patient. British Journal of Cancer, 35,l. Pointoa, R. C. S. and Cleave, N. (1982). Lips and oral cancer. In Treatment of Cancer. Edited by K. E. Halnan, London: Chapman and Hall. Porter, E. H. (1971). The local prognosis after radical radio-
BRITISH JOURNAL OF PLASTIC SURGERY therapy for squamous carcinoma of the alveolus and of the floor of the mouth. Clinical Radiology (London). 22,139. Ryan, T. A., Joiner, B. L. and Ryi, %. F. (1980). Minitab Reference Manual, Penn State University. Shaw, H. J. (1982). Head and neck tumour surgery. Hospital Update, 8, 1069. Soutar, D. S., Scbeker, L. R., Tanner, N. S. B. and McGregor, I. A. (1983). The radical forearm flap: a versatile method for in&a-oral reconstruction. British Journal of Plastic Surgery, 36, 1. UICC 1978. TNM, Classification of malignant tumours. Third Edition. Vemund, H., Bremkovd, I. O., Kaalkus, 0. and Poppe, E. (1982). Pre-operative radiation therapy in squamous cell carcinoma of the anterior two thirds of the tongue at the Norwegian Radium Hospital. International Journal of Radiation Oncology, Biology, Physics. (New York) 8, 1263. Vikram, B., Strong, E. W., Shah, J. and Spiro, E. H. (1980). Elective post operative radiation therapy in stages III and IV epidermoid carcinoma of the head and neck. American Journal of Surgery, 14,580. Westbury, G. (1976). Oral cancer: general strategy of the management. Proceedings of the Royal Society of Medicine, 69, 749.
The Authors A. G. Robertson, PhD, MB, ChB, FRCR, Consultant Radiotherapist, Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary, Glasgow. I. A. McGregor, CkM, FRCS, FRACS.(Hon), Director, Plastic Surgery Unit, Canniesbum Hospital, Glasgow. G. E. FIalman, MD, FRCS, FRCR, FACR.(Hon), Director, Radiotherapy Institute, Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary, Glasgow. D. S. !%ahr, FRCSKd, Consultant Plastic Surgeon, Plastic Surgery Unit, Cannieabum Hospital, Glasgow. P. Boyle, BSc, Chief Statistician, West of Scotland Cancer Surveillance Unit, Ruchill Hospital, Glasgow. Requests for reprints to: Dr A. G. Robertson, Glasgow Institute of Radiotherapeutics and Oncology, Western Infirmary, Glasgow G 116NT.