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What is the preferred initial method of treatment for squamous carcinoma of the tongue?
What is the Preferred Initial Method of Treatment for Squamous Carcinoma of the Tongue?
Dan White, MD, La Grange, Texas Robert M. Byers, MD, Houston, Texas
This study of patients with squamous cell carcinoma of the oral tongue presents results of treatment with surgery, radiation or a combination of both. Since the primary plan of treatment is chosen by the surgeon in a nonrandomized selection process, the statistician’s usual objections to any conclusions drawn from the data can be raised. Yet, no matter how the treatment plan was chosen, retrospective analysis of the patients’ medical records provides certain data that are useful in determining the future planned treatment for patients with this disease.
Material and Methods From 1970 through 1975, the medical records of 152 patients seen consecutively with squamous carcinoma of the tongue were reviewed. Only patients treated entirely at The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute were considered. A tissue diagnosis of invasive squamous carcinoma was confirmed by the hospital pathologists in all cases. All evaluable patients were followed up for at least 2 years or until death (Table I). Follow-up information was obtained through clinic visits and personal communication with the patient, the patient’s family or the referring physician. The 1978 American Joint Committee for Cancer Staging and End Results Reporting TNM classification was used retrospectively in all cases [I]. For statistical analysis, a different staging system was used, as follows: group A, TiNa; group B, TsNs; group C, Ts and TdNs; and group D, any T stage with clinically positive nodes. The patients’ ages ranged from 17 to 84 years (median 57). There were 98 men and 54 women (male to female ratio 1.8 to 1). Factors such as the use of tobacco and alcoholic beverages, dental status, presence of mandibular tori, associated leukoplakia and nutritional status were analyzed From the Department of Head and Neck Surgery, the Unwersity of Texas System Cancer Center, Anderson Hospital and Tumor Institute, Houston, Texas. ReqmStS for reprints should be addressed to, Robert M Byers, MD, 6723 Sertner Drive. Houston. Texas 77030 Presented at the 26th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California. May 14-17, 1980
Volume 140, October 1990
to determine whether they had any hearing on the selection of treatment. Surgery was more likely to be selected as the initial treatment of choice in patients with associated mandibular tori, leukoplakia or poor nutritional status. Eighty-one percent of the patients smoked two packs of cigarettes a day or more and 47 percent were alcoholics. Twelve percent of the patients never used alcohol or tobacco. The tumor factors that were evaluated as to their role in the selection of treatment were: the degree of histologic differentiation (tumor grade), tumor size (T staging) and the presence or absence of cervical nodal metastasis (N staging). One hundred forty-seven of the 152 patients had tumors histologically classified as grade I or II; the remainder were either grade III or spindle squamous carcinoma. The T staging was as follows: Ti, 47 lesions; Ts, 67 lesions; Ts, 32 lesions; and Tq, 6 lesions. Thirty-five (23 percent) of the 152 patients had clinically positive nodes; 20 were found on first observation and 15 appeared later. Five of these patients developed contralateral nodes, two initially and three subsequently.
Results Surgery alone: A surgical procedure was selected as the initial definitive method of treatment for 81 patients. Fifty-seven of the patients (70 percent) were staged in groups A and B and 24 (30 percent) in groups C and D. Fifty-seven (70 percent) of the 81 patients were alive and free of cancer at 2 years. Twenty-one (26 percent) had recurrence above the clavicle, which was successfully controlled with subsequent treatment in 15 of the 21 patients. In 54 (93 percent) of the patients in groups A and B and 21 (87 percent) of those in groups C and D, cancer above the clavicle was controlled. Intraoral resection without neck dissection was considered adequate treatment in 56 patients. Five patients had local recurrence, but subsequent treatment saved three of them. Eleven patients subsequently developed cervical metastasis, which was controlled by further treatment in 9. In four
553
White and Byes
TABLE I
Status at 2 Years in 152 Patients
Status
Surgery
No evtdence of disease Dead; primary failure Dead; neck failure Dead; primary and neck failure Dead; distant metastasis only Dead; distant metastasis and local-regional recurrence Dead; intercurrent disease Dead; second primary Living; local and regional disease Living; distant metastasis Living: second primary Lost to follow-up
57
Tntal
0 2 2
Radiation Therapy
Combined
32 6 2 5 2
11 2 2
8 1 3
2 1 0
2 0
81
63
0
0
patients treatment above the clavicles ultimately failed. Combined resection was selected as initial treatment for 25 patients. One patient had a recurrence of the primary lesion only but was not saved by subsequent treatment. Neck dissection was included in the initial treatment because of clinically positive nodes in 8 patients and for elective or technical reasons in 17 patients. The initial surgical resection successfully controlled the metastatic cervical cancer in seven of these eight patients staged N+, and the one failure was saved with subsequent treatment. Three of the 17 patients developed a recurrence limited to the neck, two of which occurred in the undissected contralateral side. Two of these patients were saved with further treatment. One patient had recurrences in both the primary site and the neck and was saved with further treatment. Sixteen tongue cancers were resected with a pull-through or discontinuity resection. Four of these patients’ tumors were classified as Ti, seven as Tz and five as T3. In nine patients a complete segment of the mandible was included with the resection of the tongue cancer. Two of these patients had tumors staged Ts; five were T3 and two Tq. Radiation alone: Radiation therapy was selected as adequate treatment for 63 patients. Forty-four (70 percent) of these patients were in groups A and B and 19 (30 percent) in groups C and D. Thirty-two (50 percent) had cancer-free survival at 2 years. Thirty-six (57 percent) had initial failure above the clavicles. The cancer was successfully controlled with subsequent treatment in 18 patients. Thirty-eight (86 percent) of the patients in groups A and B and 8 (42 percent) in groups C and D had control of the cancer above the clavicle.
554
Localized radiation, either with an interstitial source or small external fields, was used as definitive treatment for 15 patients with no failure at the primary site. Four of these patients subsequently developed clinically positive nodes within 2 years and were saved with further treatment. Forty-eight patients were treated with radiation to the tongue with external fields that included a portion of the neck or the entire neck, and in 39 of these patients a boost was given to the tongue cancer with insterstitial implants. In 18 (62.5 percent) of the 48 patients, cancer above the clavicle was ultimately controlled. Thirty-six patients had recurrence above the clavicle: 12 in the tongue, 15 in the neck and 9 in both the tongue and the neck. Of the 15 patients in whom recurrence in the neck was the only manifestation of treatment failure, 6 had recurrence in the radiated portion of the neck. Only half of the 36 patients could be saved by subsequent treatment. Four patients whose neck was staged N+ were treated initially with radiation; three of them developed recurrent disease in the treated portion of the neck and only one could be saved. Combined therapy: All eight patients in this group had staging in groups C and D (Ts and TdNc or TN+). In six patients cancer above the clavicles was controlled. The ultimate 2 year disease-free survival rate was 37.5 percent (three of eight). Six of the patients were treated with surgery and postoperative radiation and two had radiation followed by surgical excision. There were no recurrences in the tongue; however, three of the eight patients had recurrence in the treated neck.
Comments The number of previously untreated patients seen with squamous carcinoma of the tongue in the early stages is increasing. This may reflect a more aggressive attitude by referring physicians and dentists in recognizing oral cancer and perhaps a greater awareness on the part of the patients themselves in seeking medical attention sooner. The present report is, in a way, a critique of the selection process. Since the head and neck surgeon at the M.D. Anderson Hospital selects the treatment plan according to his opinion and experience in treating a large number of similar patients, it is interesting that the tumor factors did not play a significant role in the selection of treatment since the distribution of the patients in groups A, B, C and D is fairly uniform in both the radiation and the surgery groups. As expected, the patients treated with a planned, sequential combination had more advanced lesions. Close follow-up was important because if a
The American Journal of Surgery
Squamous
cancer is going to recur locally, after having had radiation treatment as an initial modality, it will do so within the first 2 years of follow-up. In contrast, in patients treated with surgery alone, a longer followup period may be necessary since only 68 percent of the failures developed within the first 2 years. Elective radical neck dissection in patients whose neck is staged No appears unjustified since most nodal metastasis occurring after initial surgery can be successfully controlled with further treatment. If a composite or pull-through approach is appropriate in order to resect the primary cancer, modified neck dissection is suggested. Only 13 percent of failures in the neck were in the surgically dissected area. The incidence of false-negative staging in the neck, that is, patients who were initially staged No but were actually N+ pathologically, was 25 percent. The incidence of false-positive staging was 23 percent. For the patients who failed primary treatment, a salvage procedure was usually successful except in patients with advanced lesions of the tongue in which radiation alone was selected as the initial modality of treatment. Using the data obtained from this retrospective analysis, the plan of treatment for carcinoma of the oral tongue can be formulated. If the patient presents with a TiNc carcinoma of the tongue, treatment with either intraoral surgical excision or a localized dose of radiation is equally effective in controlling the tongue cancer (Table II). The length of treatment time, financial concern, associated medical problems and the choice of the patient may dictate which treatment plan is preferred. The neck need not be treated initially unless there are clinically positive nodes. For lesions staged Ts, intraoral excision is the proper initial treatment since the local and regional recurrences can be handled adequately in 96 percent of the patients (Table II). The intraoral procedure requires only a few hospital days, and the effect on the speech and swallowing is negligible. Surgery should also be the initial treatment in patients with lesions staged Ts or Tq (Table II). The surgical procedure should be tailored to adequately remove the gross and microscopic disease, if possible. Postoperative radiation is indicated if there is extension of disease into the pterygoid area, large nerves or multiple cervical nodes. Gross tumor cut through at the time of surgery or proven microscopic residual disease in small nerves, lingual musculature or adjacent mucosa after repeated reexcision with frozen-section
volume 140, October 1990
TABLE II
Carcinoma
of the Tongue
Initial Treatment: Results of Surgery Versus Radiatlon
Primary Failure No. %
Initial Neck Ultimate Failure Failure % No No. %
Ti Radiation therapy Surgery
O/8’ 3141’
0 7.3
l/8’ 7141’
12 17
O/8’ 2141’
0 4.9
Radiation therapy Surgery T3 to T4 Radiation therapy Surgery
9/38t 1126t
24 4
14138 5126
37 19
7138 7126
ta 4
121 l7t 31147
70.5 21
9117 4114
56 29
loll7 3174
59 21
T2
Correlations not statistically significant (p >0.05) t Correlations statistically significant (p <0.05). l
analysis are also criteria for immediate postoperative radiation. Whether or not the mandible is removed depends on whether cancer is invading periosteum or bone. Perhaps with the judicious use of surgery and postoperative radiation, neck recurrences can be decreased in patients presenting with nodes staged 2A, 2B or 3A. From the data, it appears that radiation therapy is not the proper choice as the initial method of treatment for squamous carcinomas of the tongue in cancers staged Ts, Ts or T4 (Table II). The rate of initial failure in the tongue is unacceptably high, and the results of additional treatment of recurrences are discouraging. Summary The medical records of 152 previously untreated patients with squamous carcinoma of the tongue were reviewed. Radiation, surgery and the combination of both were analyzed with respect to the stage of disease treated, local and regional failure and ultimate salvage. The plan of treatment for a prospective patient is formulated based on the data. Surgery appears to be the best initial treatment for cancers staged Ts, Ts and Tq. Ti lesions can be treated with either radiation or surgery, and selection should be determined by the pertinent patient factors. Reference 1. The American Joint Committee for Cancer Staging and End Results Reporting: Manual for staging of cancer Chicago: t977:57
555
Dan White, MD, La Grange, Texas Robert M. Byers, MD, Houston, Texas
This study of patients with squamous cell carcinoma of the oral tongue presents results of treatment with surgery, radiation or a combination of both. Since the primary plan of treatment is chosen by the surgeon in a nonrandomized selection process, the statistician’s usual objections to any conclusions drawn from the data can be raised. Yet, no matter how the treatment plan was chosen, retrospective analysis of the patients’ medical records provides certain data that are useful in determining the future planned treatment for patients with this disease.
Material and Methods From 1970 through 1975, the medical records of 152 patients seen consecutively with squamous carcinoma of the tongue were reviewed. Only patients treated entirely at The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute were considered. A tissue diagnosis of invasive squamous carcinoma was confirmed by the hospital pathologists in all cases. All evaluable patients were followed up for at least 2 years or until death (Table I). Follow-up information was obtained through clinic visits and personal communication with the patient, the patient’s family or the referring physician. The 1978 American Joint Committee for Cancer Staging and End Results Reporting TNM classification was used retrospectively in all cases [I]. For statistical analysis, a different staging system was used, as follows: group A, TiNa; group B, TsNs; group C, Ts and TdNs; and group D, any T stage with clinically positive nodes. The patients’ ages ranged from 17 to 84 years (median 57). There were 98 men and 54 women (male to female ratio 1.8 to 1). Factors such as the use of tobacco and alcoholic beverages, dental status, presence of mandibular tori, associated leukoplakia and nutritional status were analyzed From the Department of Head and Neck Surgery, the Unwersity of Texas System Cancer Center, Anderson Hospital and Tumor Institute, Houston, Texas. ReqmStS for reprints should be addressed to, Robert M Byers, MD, 6723 Sertner Drive. Houston. Texas 77030 Presented at the 26th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California. May 14-17, 1980
Volume 140, October 1990
to determine whether they had any hearing on the selection of treatment. Surgery was more likely to be selected as the initial treatment of choice in patients with associated mandibular tori, leukoplakia or poor nutritional status. Eighty-one percent of the patients smoked two packs of cigarettes a day or more and 47 percent were alcoholics. Twelve percent of the patients never used alcohol or tobacco. The tumor factors that were evaluated as to their role in the selection of treatment were: the degree of histologic differentiation (tumor grade), tumor size (T staging) and the presence or absence of cervical nodal metastasis (N staging). One hundred forty-seven of the 152 patients had tumors histologically classified as grade I or II; the remainder were either grade III or spindle squamous carcinoma. The T staging was as follows: Ti, 47 lesions; Ts, 67 lesions; Ts, 32 lesions; and Tq, 6 lesions. Thirty-five (23 percent) of the 152 patients had clinically positive nodes; 20 were found on first observation and 15 appeared later. Five of these patients developed contralateral nodes, two initially and three subsequently.
Results Surgery alone: A surgical procedure was selected as the initial definitive method of treatment for 81 patients. Fifty-seven of the patients (70 percent) were staged in groups A and B and 24 (30 percent) in groups C and D. Fifty-seven (70 percent) of the 81 patients were alive and free of cancer at 2 years. Twenty-one (26 percent) had recurrence above the clavicle, which was successfully controlled with subsequent treatment in 15 of the 21 patients. In 54 (93 percent) of the patients in groups A and B and 21 (87 percent) of those in groups C and D, cancer above the clavicle was controlled. Intraoral resection without neck dissection was considered adequate treatment in 56 patients. Five patients had local recurrence, but subsequent treatment saved three of them. Eleven patients subsequently developed cervical metastasis, which was controlled by further treatment in 9. In four
553
White and Byes
TABLE I
Status at 2 Years in 152 Patients
Status
Surgery
No evtdence of disease Dead; primary failure Dead; neck failure Dead; primary and neck failure Dead; distant metastasis only Dead; distant metastasis and local-regional recurrence Dead; intercurrent disease Dead; second primary Living; local and regional disease Living; distant metastasis Living: second primary Lost to follow-up
57
Tntal
0 2 2
Radiation Therapy
Combined
32 6 2 5 2
11 2 2
8 1 3
2 1 0
2 0
81
63
0
0
patients treatment above the clavicles ultimately failed. Combined resection was selected as initial treatment for 25 patients. One patient had a recurrence of the primary lesion only but was not saved by subsequent treatment. Neck dissection was included in the initial treatment because of clinically positive nodes in 8 patients and for elective or technical reasons in 17 patients. The initial surgical resection successfully controlled the metastatic cervical cancer in seven of these eight patients staged N+, and the one failure was saved with subsequent treatment. Three of the 17 patients developed a recurrence limited to the neck, two of which occurred in the undissected contralateral side. Two of these patients were saved with further treatment. One patient had recurrences in both the primary site and the neck and was saved with further treatment. Sixteen tongue cancers were resected with a pull-through or discontinuity resection. Four of these patients’ tumors were classified as Ti, seven as Tz and five as T3. In nine patients a complete segment of the mandible was included with the resection of the tongue cancer. Two of these patients had tumors staged Ts; five were T3 and two Tq. Radiation alone: Radiation therapy was selected as adequate treatment for 63 patients. Forty-four (70 percent) of these patients were in groups A and B and 19 (30 percent) in groups C and D. Thirty-two (50 percent) had cancer-free survival at 2 years. Thirty-six (57 percent) had initial failure above the clavicles. The cancer was successfully controlled with subsequent treatment in 18 patients. Thirty-eight (86 percent) of the patients in groups A and B and 8 (42 percent) in groups C and D had control of the cancer above the clavicle.
554
Localized radiation, either with an interstitial source or small external fields, was used as definitive treatment for 15 patients with no failure at the primary site. Four of these patients subsequently developed clinically positive nodes within 2 years and were saved with further treatment. Forty-eight patients were treated with radiation to the tongue with external fields that included a portion of the neck or the entire neck, and in 39 of these patients a boost was given to the tongue cancer with insterstitial implants. In 18 (62.5 percent) of the 48 patients, cancer above the clavicle was ultimately controlled. Thirty-six patients had recurrence above the clavicle: 12 in the tongue, 15 in the neck and 9 in both the tongue and the neck. Of the 15 patients in whom recurrence in the neck was the only manifestation of treatment failure, 6 had recurrence in the radiated portion of the neck. Only half of the 36 patients could be saved by subsequent treatment. Four patients whose neck was staged N+ were treated initially with radiation; three of them developed recurrent disease in the treated portion of the neck and only one could be saved. Combined therapy: All eight patients in this group had staging in groups C and D (Ts and TdNc or TN+). In six patients cancer above the clavicles was controlled. The ultimate 2 year disease-free survival rate was 37.5 percent (three of eight). Six of the patients were treated with surgery and postoperative radiation and two had radiation followed by surgical excision. There were no recurrences in the tongue; however, three of the eight patients had recurrence in the treated neck.
Comments The number of previously untreated patients seen with squamous carcinoma of the tongue in the early stages is increasing. This may reflect a more aggressive attitude by referring physicians and dentists in recognizing oral cancer and perhaps a greater awareness on the part of the patients themselves in seeking medical attention sooner. The present report is, in a way, a critique of the selection process. Since the head and neck surgeon at the M.D. Anderson Hospital selects the treatment plan according to his opinion and experience in treating a large number of similar patients, it is interesting that the tumor factors did not play a significant role in the selection of treatment since the distribution of the patients in groups A, B, C and D is fairly uniform in both the radiation and the surgery groups. As expected, the patients treated with a planned, sequential combination had more advanced lesions. Close follow-up was important because if a
The American Journal of Surgery
Squamous
cancer is going to recur locally, after having had radiation treatment as an initial modality, it will do so within the first 2 years of follow-up. In contrast, in patients treated with surgery alone, a longer followup period may be necessary since only 68 percent of the failures developed within the first 2 years. Elective radical neck dissection in patients whose neck is staged No appears unjustified since most nodal metastasis occurring after initial surgery can be successfully controlled with further treatment. If a composite or pull-through approach is appropriate in order to resect the primary cancer, modified neck dissection is suggested. Only 13 percent of failures in the neck were in the surgically dissected area. The incidence of false-negative staging in the neck, that is, patients who were initially staged No but were actually N+ pathologically, was 25 percent. The incidence of false-positive staging was 23 percent. For the patients who failed primary treatment, a salvage procedure was usually successful except in patients with advanced lesions of the tongue in which radiation alone was selected as the initial modality of treatment. Using the data obtained from this retrospective analysis, the plan of treatment for carcinoma of the oral tongue can be formulated. If the patient presents with a TiNc carcinoma of the tongue, treatment with either intraoral surgical excision or a localized dose of radiation is equally effective in controlling the tongue cancer (Table II). The length of treatment time, financial concern, associated medical problems and the choice of the patient may dictate which treatment plan is preferred. The neck need not be treated initially unless there are clinically positive nodes. For lesions staged Ts, intraoral excision is the proper initial treatment since the local and regional recurrences can be handled adequately in 96 percent of the patients (Table II). The intraoral procedure requires only a few hospital days, and the effect on the speech and swallowing is negligible. Surgery should also be the initial treatment in patients with lesions staged Ts or Tq (Table II). The surgical procedure should be tailored to adequately remove the gross and microscopic disease, if possible. Postoperative radiation is indicated if there is extension of disease into the pterygoid area, large nerves or multiple cervical nodes. Gross tumor cut through at the time of surgery or proven microscopic residual disease in small nerves, lingual musculature or adjacent mucosa after repeated reexcision with frozen-section
volume 140, October 1990
TABLE II
Carcinoma
of the Tongue
Initial Treatment: Results of Surgery Versus Radiatlon
Primary Failure No. %
Initial Neck Ultimate Failure Failure % No No. %
Ti Radiation therapy Surgery
O/8’ 3141’
0 7.3
l/8’ 7141’
12 17
O/8’ 2141’
0 4.9
Radiation therapy Surgery T3 to T4 Radiation therapy Surgery
9/38t 1126t
24 4
14138 5126
37 19
7138 7126
ta 4
121 l7t 31147
70.5 21
9117 4114
56 29
loll7 3174
59 21
T2
Correlations not statistically significant (p >0.05) t Correlations statistically significant (p <0.05). l
analysis are also criteria for immediate postoperative radiation. Whether or not the mandible is removed depends on whether cancer is invading periosteum or bone. Perhaps with the judicious use of surgery and postoperative radiation, neck recurrences can be decreased in patients presenting with nodes staged 2A, 2B or 3A. From the data, it appears that radiation therapy is not the proper choice as the initial method of treatment for squamous carcinomas of the tongue in cancers staged Ts, Ts or T4 (Table II). The rate of initial failure in the tongue is unacceptably high, and the results of additional treatment of recurrences are discouraging. Summary The medical records of 152 previously untreated patients with squamous carcinoma of the tongue were reviewed. Radiation, surgery and the combination of both were analyzed with respect to the stage of disease treated, local and regional failure and ultimate salvage. The plan of treatment for a prospective patient is formulated based on the data. Surgery appears to be the best initial treatment for cancers staged Ts, Ts and Tq. Ti lesions can be treated with either radiation or surgery, and selection should be determined by the pertinent patient factors. Reference 1. The American Joint Committee for Cancer Staging and End Results Reporting: Manual for staging of cancer Chicago: t977:57
555