Carcinoma of the Lip and Oral Cavity -A Retrospective Investigation of 113 Patients

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1 THE KURUME MEDICAL JOURNAL Vol. 29, Supplement, P. S61-S78, 1982 Carcinoma of the Lip and Oral Cavity -A Retrospective Investigation of 113 Patients HIROSHI OHKUBO, TATSUO MAEDA, MINORU HIRANO, SHIGEJIRO KURITA AND SHIGENOBU MIHASHI Department of Otolaryngology, Kurume University, School of Medicine, Kurume 830, Japan Received for publication April 10, 1982 Summary: During the 10 years from January 1, 1971 to December 31, 1980, 113 patients with histologically proven carcinoma of the lip and oral cavity were treated at the Department of Otolaryngology, Kurume University Hospital. Among the entire 113 cases, the site of the primary lesion was the lip in 3, the buccal mucosa in 7, the upper alveolus and gingiva in 6, the lower alveolus and gingiva in 6, the hard palate in 9, the tongue in 65, the floor of the mouth in 17 cases. The results of treatments were discussed chiefly for those patients who had not been previously treated and underwent curative treatment. They can be summarized as follows : (1) In 54 patients of carcinoma of the tongue who underwent curative treatments, the 3- and 5-year cumurative survival rates were 72.5 % and 61.4 %, respectively. Of the 19 patients who died, the cause of death was primary lesion in 3 (16%), neck metastasis in 6 (32%), distant metastasis in 1 (5 %), complication in 2 cases (11 %). (2) In 16 patients of carcinoma of the floor of the mouth who underwent curative treatments, both 3- and 5-year cumurative survival rates were 50%. The more advanced the disease was, the lower the survival rate. Of the 8 patients who died, the cause of death was primary lesion in 4, neck metastasis in 1, distant metastasis in 1, and surgical and other complications in 2. (3) In 21 patients of carcinoma of the other sites who underwent curative treatments, the 3- and 5-year cumurative survival rates were 60 % and 40% for the buccal mucosa, 66.7% and 66.7% for the upper alveolus and gingiva, 58.4% and 58.4% for the lower alveolus and gingiva, 25% and 25% for the hard palate, respectively. Key words: carcinoma of lip - carcinoma of oral cavity - carcinoma of tongue - carcinoma of floor of mouth - survival rate - cause of death Introduction Carcinoma of the oral cavity is the third most frequent malignant neoplasm in the head and neck region in Japan. In the oral cavity, the tongue is the commonest site for carcinoma. Ichikawa et al. (1976) reviewed 34 cases of carcinoma of the tongue treated at our hospital in , presenting an estimated 5-year survival rate of 41 %. On the basis of analyses of these cases, we have employed a basic program that consisted of pre -operative irradiation and local chemotherapy followed by an extensive removal for the primary tumor and radical neck dissection (RND) for carcinoma of the tongue since The same program has been applied also to carcinoma of the floor of the mouth. Hirano et al. (1979) reviewed 40 cases of carcinoma of the tongue treated in The basic program was applied to most cases and S61

2 S 62 OHKUBO, ET AL. proved to have contributed to the improvement of the survival rate. They reported a 5-year survival rate of 65% calculated by the actuarial method. The purpose of this paper is to review the cases of carcinoma of the tongue treated with basically the same program in and to review the cases of carcinoma of the other sites in the oral cavity and those of the lip. Materials and Methods During the 10 years from January 1, 1971 to December 31, 1980, 113 patients with histologically proven carcinoma of the lip and oral cavity were treated at the Department of Otolaryngology Kurume University Hospital. There were 72 males and 41 females. Their age ranged from 27 to 84 years with a mean age of 60 years. There were 7 previously treated patients in this series. For data analyses, we adopted the classification of the region, TNM ca - tegorization and stage grouping which were based on the UICC TNM classification (UICC, 1978). Table 1 presents the distribution of the 113 patients by site and sex. The site was the lip in 3, the buccal mucosa in 7, the upper alveolus and gingiva in 6. the lower alveolus and gingiva in 6, the hard palate in 9, the tongue in 65, the floor of mouth in 17 cases. Thus, the number of patients was greatest for the tongue with respect to the site. Except for the upper alveolus and gingiva, the incidence was greater for males than for females. F ollow-up examinations were indicated twice a month during the first 6 months, once a month during following 6 months, once every 2 months during the second year, once every 3 months during the third year, once every 1/2-1 year after the third year. Questionaries were used to determine the status of those patients who did not return to follow - up examinations. Analysis of the results of the treatments was based on the status on May 31, The cumulative survival rate was cal - culated by the actuarial method (UICC, 1974). The onset chosen to compute sur - vival is the date of hospitalization which coincided within several days of initiation of treatment. The cause of death was classified and defined as follows : (1) Death from the tumor present (a) Death from primary lesion (T). Pa - tients who died with primary lesion uncon- Distribution TABLE 1 of 113 subjects by site and sex * Number of patients who were previously treated is shown in parentheses.

3 CARCINOMA OF LIP AND ORAL CAVITY S 63 trolled with or without neck and/or distant metastasis were classified into this category. (b) Death from neck metastasis (N). Patients who died with neck metastasis uncontrolled, with primary lesion controlled with or without distant metastasis were classified into this category. (c) Death from distant metastasis (M). Patients who died with distant metastasis with primary and neck controlled were classified into this category. (d) Surgical death. Patients who died within 30 days after major surgical treat - ment were classified into this category. (e) Death from complication. Patients who died of complications caused by any therapeutic intervention were classified into this category. Surgical death is one kind of death resulting from complications. In this paper, surgical death is described separately from those occurring from other complications. (f) Unknown. Dead patients of whom no information about the cause of death was available were classified into this ca - tegory. (2) Death from intercurrent disease. Patients who died of intercurrent disease and had no evidence of the carcinoma pre - sent were classified into this category. In instances when a patient had evidence of the carcinoma present, he (she) was classified as dead with tumor even if the direct cause of death was obviously an intercur - rent disease. These definition is primarily based on the proposal by the Japan Society of Head and Neck Tumor (1981). The deaths from primary, neck metastasis and distant metastasis were defined according to Hirano et al. (1976). Results I. Carcinoma of the lip All of the 3 patients underwent curative treatments. Fig. 1. presents an outline of these patients. In histological classification, 2 patients were squamous cell carcinoma and 1 was spinocellular carcinoma. With respect to TNM classification, there was 1 T2NOMO (stage II) and 2 T3NOMO (stage III ). For the initial treatment, radiation therapy was applied in one case and extensive surgical removal were made in two. In one of the surgical cases, pre-operative local injection of Bleomycin (52 mg in total) was applied. Of these 3 patients, the radiation case died from the tumor present whereas Fig. 1. Outline of patients of carcinoma of the lip C=commissure, L. L. =lower lip, S.C. C. =squamous cell carcinoma, R. N. D. =radical neck dissection, Rad=radiotherapy, BLM=Local injection of Bleomycin, Pre-operative

4 S 64 OHKUBO, ET AL. the 2 surgical cases are currently alive for 1 year and 3 months and 1 year and 2 months with no evidence of recurrent tumor. TABLE 2 Distribution of 64 patients of carcinoma of the tongue by T and N categories II. Carcinoma of the tongue The results will be presented chiefly for those patients who had not been previously treated and underwent curative treatment. The results of palliative treatments and the results of treatments for previously treated cases will be described separately in the latter part of each section. Table 2-3 present the distribution by T and N categories and stage grouping. With respect to T category, there were 25 Ti (39%), 24 T2 (37%), 12 T3 (19 %) and 3 T4 (5%) cases. Fifty-four cases (84%) were NO, 7 (11 %) were N1, 2 (3 %) were N2, and 1 (2 %) was N3. One case of T4NO was Ml (lung metastasis) case whereas all the other cases were MO. With respect to stage grouping, there were 23 cases (36 %) of stage I, 21 cases (33 %) of stage II, 15 cases (23 %) of stage III and 5 cases (8%o) ofstage IV. One case of T4N0 was MI case whereas all the others were M0. One previously treated case is excluded. TABLE 3 Distribution of 64 patients of carcinoma of the tongue by stage grouping One previously treated case is excluded. 1. Survival rate Of the entire 64 patients, 54 underwent curative treatments. The cumulative survival rate of these 54 patients is presented in Fig. 2. The 3 - and 5-year cumulative survival rates were 72.5 o and 61.4 o, respectively. Table 4 compares 3 - and 5-year survival rates by T category, N category and stage grouping. With respect to T category, the 5-year survival rate for T1 group was lower than that for T2 group. There were more cases withdrawn alive in the T1 group than in the T2 group. Concerning N category, the survival rate for NO group was higher than that for N1 and N2 groups. With respect to stage grouping, stages I and II presented higher survival rates than stages III and N. Fig. 2. Cumulative survival rate caluculated by the actuarial method. 54 cases of carcinoma of the tongue treated in

5 CARCINOMA OF LIP AND ORAL CAVITY S65 TABLE 4 Three-and 5-year cumulative survival rates (in %) calculated by the actuarial method for 54 patients of carcinoma of the tongue curatively treated for the first time between 1971 and 1980 * There was no patient of T4 category ** There was no patient of N3 category 2. Cause of death Table 5 shows the cause of death of 19 patients. Sixteen (84 %) died of the tumor present and 3 (16 %) died of intercurrent disease. The cause of death was primary lesion in 3 (16 %), neck metastasis in 6 (32 %), distant metastasis in 1 (5 %), complication in 2 (11 %), and unknown in 4 cases (21 %). Six patients (32 %) died within 1 year and 12 (63 %) within 2 years. One patient died with neck metastasis 5 years and 2 months after the onset of treatment. Table 6 presents distribution of the cause of death by T and N categories and stage grouping. Death from primary lesion was not related to the degree in the T category. It should be noted that 4 patients in NO died of neck metastasis. One patient (TINO) died with distant metastasis (lung) 3 years and 11 months after the onset of treatment. Death from complications were not related to the degree of pathology. 3. Control of primary tumor Table 7 presents the type of treatment for the primary tumor by frequency of local recurrence and the cause of death. There were 17 cases of local recurrence. In thirteen (76 %) of the 17 cases, local recurrence occured within 1 year after the onset of treatment. One exceptional case developed local recurrence 4 years and 3 months TABLE 5 Cause of death by number of years of survival for 19 patients of carcinoma of the tongue undergoing curative treatment * Year after the onset of treatment T : Death from primary lesion N : Death from neck metastasis M ; Death from distant metastasis

6 S66 OHKUBO, ET AL. TABLE Cause of death by T and N categories F and stage grouping TABLE 7 Type of initial treatment for the primary tumor, frequency of local recurrence and cause of death in 54 curative treatment * Number in parentheses indicate number of patients where death occured within 1 year from causes other than primary tumor and patients who withdrew alive within 1 year are excluded. (Ten patients in total are thus excluded). ** Radiation was accompanied by local chemotherapy Eby means of intraarterial infusion when catheterization *** Excision by laser. was possible.

7 CARCINOMA OF LIP AND ORAL CAVITY S67 after the onset of treatment. In order to present meaningful data on the rate of local recurrence, cases dead within 1 year from causes other than local recurrence and surviving cases withdrawn within 1 year should be excluded. Consequently, in Table 7, the number of patients after these exclusions is indicated in parentheses. It should be noted that local recurrence took place in 6 of the 10 T1 radiation cases and in all of the 4 cryosurgery cases. Three of the 17 patients who developed local recurrence died from the primary lesion and 8 of the 17 patients is alive with the local recurrence controlled. 4. Control of neck metastasis As shown in Table 8, there was evidence of cervical lymphnode involvement in 8 patients on the affected side and in 2 of the same patients also on the unaffected side. In all patients with evidence of node involvement except one (TIN2MO), radical neck dissection (RND) were executed. In this case who did not ungergo RND in the initial treatment, bilateral cervival lymph - node swelling completely disappered after pre - operative radiation. RND was also done in 22 of the 46 patients who presented no TABLE 8 Condition of cervical lymph nodes in 54 patients of carcinoma of the tongue and execution of RND RND=radical neck dissection * The same patient evidence of node involvement on the of - fected side. In only 1 of the 52 patients who had no evidence of node involvement on the unaffected side was RND performed. Table 9 presents frequency of cervical recurrence. On the affected side, 3 patients developed cervical recurrence after RND. Since there was no recurrence at the primary site; these cases were regarded as RND failure. Three patients who had no RND at the initial treatment developed cervical recurrence later. Since there was no recurrence at the primary site in these Recurrence TABLE 9 of cervical lymphnodes * These 3 cases are regarded as RND failure. ** These 4 cases should have had latent neck metastasis the unaffected side, 3 on the affected side and 1 on

8 S 68 OHKUBO, ET AL. cases, it was suggested that there was latent neck metastasis at the time of the initial treatment. On the unaffected side, 2 patients developed cervival recurrence following RND associated with recurrence at the primary site. In these cases, it could not be determined if they were RND failure or if the neck metastsis resulted from the recurrent primary tumor later. One patient who had not had RND developed cervival recurrence without having recurrent primary tumor. It was suggested that, in this case, there was latent neck metastasis on the unaffected side at the time of the onset of treatment. The interval between the onset of treat - ment and the cervical recurrence was less than 1 year in 8 (89%) and 1 to 2 years in 1 (11 %). Thus, 89% of the cervical recurrence occurred within 1 year. One of the ways to estimate the rate of occult neck metastasis is to examine the incidence of cervical recurrence without local recurrence in the patient who had negative nodes and did not undergo RND. In this case, the patients who died or withdrew within 1 year without having neck recurrence should be excluded from the data. The rate of latent neck metastasis estimated in this way was 3 out of 18 (17 %) on the affected side and 1 out of 40 (3%) on the unaffected side. Another way to estimate the rate of occult neck metastasis is to examine the incidence of histologically positive nodes in the RND specimens obtained from clinically negative node cases. The rate of occult neck metastasis estimated in this way was 11 out of 22 (50%) on the affected side and none out of 1 on the unaffected side. 5. Analysis of distant metastasis There were 4 patients who developed distant metastasis. Fig. 3. presents outline of these patients. The metastasis was de - termined by histological examination in 3 and by X-ray examination in 1 patient. The location of metastasis was the lung in 3, the trachea and skin in 1 patient. One patient developed the distant metastasis without local and cervical recurrence. In other 2 patients, the distant metastasis was preceded by local and cervival recurrences which were surgically uncontrolled. In the other patient, the distant metastasis was preceded by a cervical recurrence which were surgically uncontrolled. The interval from the onset of treat - ment to the first recognition of the distant metastasis ranged from 11 months to 5 years. The interval from the onset of treatment to the death ranged from 1 year to 5 years and 2 months. Fig. 3. Outline of patients of carcinoma of the tongue who developed distant metastasis Local inf. =local infusion chemotherapy, Hemiglos. =hemiglossectomy, RND=radical neck dissection, Rad=radiation.

9 CARCINOMA OF LIP AND ORAL CAVITY S Analysis of fatal complications There were 2 patients who died of treatments complication. However, there was no surgical death. Fig. 4. presents the out - line of the 2 patients. One patient died of pneumonia and the other of renal insufficiency. 7. Analysis of fatal intercurrent disease Three patients died of an intercurrent disease. An outline of these patients is presented in Fig. 5. The fatal intercurrent disease was bronchopneumonia in 1, esophageal cancer with lung metastasis in 1 and liver cirrhosis in 1 patient. The interval from the onset of the treatment to the death ranged from 11 months to 3 year and 4 months. 8. Analysis of palliative cases For various reasons, 9 of the 64 patients were treated palliatively : Four patients were inoperable because of the advanced lesion; four patients refused curative surgery; and 1 patient died of an intercurrent diease (hepatoma) after pre-operative radiation and chemotherapy followed by curative surgery and prior to planned surgery for recurrent cervical lymphnode. Of the 8 patients who were inoperable cases or re - f used surgery, 6 received palliative radiation and local chemotherapy by infusion, 1 palliative radiation alone, and the other Bleomycin (135 mg in total) alone. Of these 8 patients, 5 died from the tumor present whereas 3 are alive. One of the surviving cases was T1N0M0, received Bleomycin alone, and is alive for 9 years and 10 months after the treatment. Another surviving case was T2N0M0, was treated with radiation (3000 rad) and local chemotherapy, and is alive for 8 years and 9 months. The other case was T3N0M0, Fig. 4. Outline of patients of carcinoma of the tongue who died from complications Cryo=cryosurgery, Hemiglos=hemiglossectomy, BLM=bleomycin, RND=radical neck dissection, Fig. 5. Outline of patients of carcinoma of the tongue who died from intercurrent disease Cryo=cryosurgery, Local inf. =local infusion chemotherapy, Hemighos.=hemiglossectomy, RND=radical neck dissection

10 S 70 OHKUBO, ET AL. was treated with radiation (6000 rad) and local chemotherapy, and is alive for 6 years and 8 months. One of the 64 patients was not treated at our hospital for a geographic reason but was referred to another hospital. No further information was available. TABLE 11 Distribution of 16 patients of carcinoma of the floor of the mouth by T and N categories 9. Analysis of previously treated case There was a patient who had been pre - viously treated with radiation at another hospital and developed recurrence later. He was a case of rt1nomo and underwent pre-operative radiation and local chemotherapy followed by hemiglossectomy and RND in our hospital. He is alive for 8 years and 8 months. All cases were M0. One previously treated case is excluded. TABLE 12 Distribution of 16 cases of carcinoma of the floor of the mouth by stage grouping III. Carcinoma of the floor of the mouth Table 10 presents histological types of the 17 cases of carcinoma of the floor of the mouth. There were 13 squamous cell carcinomas, 1 adenocarcinoma, 1 mucoepi - dermoid carcinoma, and 2 malignant pleo - morphic adenomas. Tables present the distribution by T and N categories and stage grouping. With respect to T category, there were 3 T1 (19%), 8 T2 (50%) and 5 T4 (31%) cases. Nine cases (56 %) were staged NO, 5 (31%) were N1 and 2 (13%) were N3. All cases were MO. With respect to stage grouping, there were 1 case (6 %) of stage On previously treated case is excluded. TABLE 13 Three-and 5-year cumulative survival rates (in %) calcurated by the actuarial method for 16 patients of carcinoma of the floor of the mouth curatively treated for the first time between 1971 and 1980 TABLE 10 Histological types of 17 cases of carcinoma of the floor of the mouth * Previously treated case.

11 CARCINOMA OF LIP AND ORAL CAVITY S71 I, 6 cases (38%) of stage II, 4 cases (25%) of stage III and 5 cases (31%) of stage IV. 1. Survival rate All of the 16 patients who had had no previous treatment underwent currative treatments. Both 3 - and 5-year cumulative survival rates were 50 %. Table 13 compares 3 - and 5-year sur - vival rates by T category, N category and stage grouping. With respect to T and N categories and stage grouping, the more advanced the disease, the lower the sur - vival rate. 2. Cause of death Table 14 shows the cause of death of 8 patients. All patients died from the tumor or its treatment complication. The cause of death was primary lesion in 4, neck metastasis in 1, distant metastasis in 1, and surgical and other complications in 2. Four patients died within 1 year and 7 pa - tients within 2 years. Table 15 presents distribution of the TABLE 14 Cause of death by number of years of survival for 8 patients of carcinoma of the floor of the mouth * Year after the onset of treatment T : Death from primary lesion N : Death from neck metastasis M : Death from distant metastasis TABLE 15 Cause of death by T and N categories and stage grouping

12 S 72 OHKUBO, ET AL. cause of death by T and N categories and stage grouping. Four of 5 T4 patients died from primary lesion. One patient (T2N0) died with distant metastasis (lung) 2 years and 9 months after the onset of treatment. 3. Control of primary tumor Table 16 presents the type of initial treatment for the primary tumor by frequency of local recurrence and the cause of death. There were 5 cases of local recurrence. In all of the 5 cases, local recurrence took place within 1 year after the onset of treatment. In order to present meaningful data on the rate of local recur - rence, cases dead within 1 year from causes other than local recurrence and surviving cases withdrew within 1 year should be excluded. Consequently, in Table 16, the number of patients after exclusions is indicated in parentheses. Four of the 5 T4 patients who developed local recurrence died from the primary lesion. The fifth T4 pa - tient is alive without local recurrence for 3 years and 2 months. One T2 patient who developed local recurrence died of neck me - tastasis with the local recurrence controlled. 4. Control of neck metastasis As shown in Table 17, there was evidence of cervical lymphnode involvement in 7 patients on the affected side and in 1 of the same patients also on the unaffected side. Six of the 7 patients with evidence of node involvement underwent radical neck dissection (RND) on the affected side. The other patient died of treatment complication after preoperative radiation but prior to surgical treatments. RND was also done in all of the 9 patients who presented no evidence of node involvement on the affected TABLE 17 Condition of cervical lymphnodes in.16 patients and execution of RND RND=radical neck dissection TABLE 16 Type of initial treatment for the primary tumor, frequency of local recurrence and cause of death in.16 curative treatments * Number in parentheses indicate number of patients where death occured within 1 year from causes other than primary tumor and patients who withdrew alive within 1 year are excluded. (One patient is thus excluded) ** Radiation was accompanied by local chemotherapy with the use of intra-arterial infusion in most cases.

13 CARCINOMA OF LIP AND ORAL CAVITY S 73 side. One who presented evidence of node involvement on the unaffected side died from the primary lesion with lung metestasis without undergoing RND. In 1 of the 15 patients who had no evidence of node involvement on the unaffected side was RND performed. None of the patients who underwent RND developed cervical recurrence. On the unaffected side, one patient who had not had RND developed cervival recurrence associated with recurrence at the primary site. RND had been done on the affected side in this case. It could not be determined if there was neck metastasis on the unaffected side at the time of initial treatment or if the neck metastasis resulted from the recurrent primary tumor later. He died from the primary lesion with neck metastasis. Another patient developed cervical recurrence on the unaffected side without having recurrent primary tumor. It was suggested that there was latent neck metastasis on the unaffected side at the time of the onset of treatments. He died from surgical complication. The incidence of histologically positive nodes in the RND specimens obtained from clinically negative node cases were 1 out of 9 (11 %) on the affected side and none out of on the unaffected side. 5. Analysis of distant metastasis There were 3 patients who developed distant metastasis. Fig. 6. presents outline of these patients. The location of metastasis was the lung and the metastasis was determined by X-ray examination in all of the 3 patients. One patient developed the distant metastasis without local and cervical recurrence. Bleomycin was administered for the distant metastasis. He survived for 2 years and 1 month from the first recogni - tion of the distant metastasis. In this case, Bleomycin seemed to be useful for a pallia - tive purpose. In the other 2 patients, the distant metastasis was detected simultaneously with local recurrence. They died with the local recurrence uncontrolled. 6. Analysis of previously treated case There was I patient who had been pre - viously treated with surgery and radiation at another hospital and developed recur - rence. He was a case of rt4nomo (mucoepidermoid carcinoma) and underwent removal of the tumor with partial mandibulectomy and RND. He is currently alive for 8 years and 3 months. Fig. 6. Outline of patients of carcinoma of the floor of the mouth who developed distant metastasis * Case D-2 was malignant pleomorphic adenoma histologically while the other two was squamous cell carcinoma.,

14 S 74 OHKUBO, ET AL. N. Carcinoma of the other sites Table 18 presents histological types of carcinema of miscellaneous sites of the oral cavity. Of the 28 patients, 23 were squa - mons cell carcinoma, 1 adenocarcinoma, 3 adenoid cystic carcinoma, and 1 malignant pleomorphic adnoma. Tables 19, 20 and 21 present the distribution of the 28 patients by T and N ca - tegories and stage grouping. With respect to T category, such advanced cases as T4 occupyed 75 % With respect to N category, nineteen cases (68 %) were staged NO whereas 9 cases (32 %) presented clinically involved lymph nodes. One case of hard palate carcinoma was Ml (pulmonary me - tastasis) but all the other cases were MO. With respect to stage grouping, there was 21 cases (75 %) of stage N. Of the entire 28 patients, 21 underwent curative treatment. Of these 21 patients, 5 were buccal mucosa, 6 upper alveolus and gingiva, 6 lower alveolus and gingiva, and 4 hard palate carcinomas. Three - and 5- year cumulative survival rates were 60% and 40% for the buccal mucosa, 66.7% and 66.7% for the upper alveolus and gingiva, 58.4% and 58.4 % for the lower alveolus and gingiva, and 25 % and 25% for the hard palate. Type of initial treatment was preoperative radiation and surgery in most cases. Table 22 shows the cause of death by site of lesion for 11 patients. Seven patients died from the tumor or its treatment complication and 3, of intercurrent disease, and 1, of unknown cause. Six patients died within 1 year and 3 within 2 years. One patient died with intercurrent disease (carcinoma of the lung) 7 years and 4 months after the onset of treatment. TABLE 18 Histological types of 28 cases of carcinoma of miscellaneous sites of the oral cavity TABLE 19 Distribution of 28 patients with carcinoma of miscellaneous sites of the oral cavity by T category * One case in this category was Ml whereas all the others were M0. Number in parentheses presents number of patients who were previously treated.

15 CARCINOMA OF LIP AND ORAL CAVITY S75 TABLE 20 Distribution of 28 patients with carcinoma of miscellaneous sites of the oral cavity by N category * One case in this category was M1 whereas all the others were M0. Number in parentheses presents number of patients who were previously treated. TABLE 21 Distribution of 28 patients with carcinoma of miscellaneous sites of the oral cavity by stage grouping Number in parentheses presents number of patients who were previously treated. TABLE 22 Cause of death for 11 patients with carcinoma of miscellaneous sites of the oral cavity

16 S 76 OHKUBO, ET AL. Discussion Discussion will be made on carcinoma of the tongue and that of the floor of the mouth since the number of patients was relatively large for these pathologies. Carcinoma of the tongue The survival rates reported in recent literature are presented in Table 23. The 5-year survival rate for carcinoma of the tongue ranges from 40 to 60% The 5-year survival rate for carcinoma of the tongue treated in our hospital be - tween 1960 and 1970 was 41% (Ichikawa et al. 1976). Among 19 deaths, the cause of death was local recurrence in 11 and cervical metastasis in 6. Thus, there was a neccessity for improvements in managing the primary lesion and cervical lymphnodes. Since 1971 we have been basically using a program which includes preoperative ra - diation and local infusion chemotherapy followed by extensive removal of the primary lesion and radical neck dissection. In some patients, the basic program has been modified according to their condition. The five - year survival rate for 54 patient was 61.4% in the present review. In 1977, Ono reported that an excellent result was obtained with interstitial radium needle ther - apy, presenting a five-year survival rate of 60 o. Our result is comparable with his. The choice of treatment modalities should depend on the instrumentation and specialists in each hospital. Table 24 compares the causes of death between the eras and in our hospital. Death from primary lesion decreased after This is attributed to the improvement in managing the primary lesion. However, it should be noted that, of the 3 patients who died from primary TABLE 24 Comparison of cause of death between cases of and those TABLE 23 Survival rate reported in recent literature * Chiefly interstitial irradiation Surg : Surgery, Rad : Radiation

17 CARCINOMA OF LIP AND ORAL CAVITY S77 lesion between 1971 and 1980, 2 were T1 cases. The initial treatment was wide excision by LASER in one case and radiation and local infusion chemotherapy in the other. A more radical procedure should have been applied for these cases. There was no difference in the Ire - quency of death from neck metastasis be - tween the 2 eras. Adequate management for neck metastasis is one of the crucial factors to treat carcinoma of the tongue successfully (Ichikawa et al. 1976; Ono, 1977; Spiro and Strong, 1971). For this purpose, indication of elective RND for NO cases, which has been controversial, should be determined adequately. In the present review, the rate of occult neck metastasis on the affected side was estimated to be 14/40 (35 %). On the basis of this figure, one may hesitate as to whether he indicates RND for every NO cases or not. Therefore, we examined if the rate of occult neck metastasis differs according to the extent of the primary lesion. The result is shown in Table 25. The rate of occult neck metastasis was 3/17 (18%) for T1, 7/18 (39%) for T2 and 4/5 (80 %) for T3. One may conclude that elective RND is demanded for T2 and T3 whereas, for T1, elective RND is not always necessary provided that the patient can be carefully followed up. Carcinoma of the floor of month Recently, the use of combined therapy in treating carcinoma of the floor of the mouth has been increasing (Applebaum et al. 1980; Harrold, 1971; Inoue, 1977; Panje et al. 1980). Many reports lack to permit accurate comparisons of various treatment methods for each stage of carcinoma of the floor of the mouth. We have been using a program which includes preoperative ra - diation and local infusion chemotherapy followed by extensive removal of the primary lesion and radical neck dissection. This basic program was occasionally modif ied, according to individual conditions. Though this study did not have a large TABLE 25 Rate of occult neck metastasis by T category number of patients, the more advanced the disease was, the lower the survival rate tended to be. Earlier stage such as T1 and T2 lesions could be readily managed by our basic program. However, conservative surgery may prove disappointing (Applebaum et al. 1980). Applebaum et al. (1980) and Schramm et al. (1980) emphasized that more aggressive surgical therapy was warranted even for small lesions. Advanced lesions such as T3 and T4 have presented with low survival rates (Applebaum et al. 1980). This was also the case with our review. Recent advance in reconstructive surgery have provided with various modalities for reconstruction following extensive surgeries to minimize functional disorders. Therefore, we can employ larger surgical removal for advance lesions in order to improve the result of treatments. With respect to management of neck metastasis, we have performed RND on the affected side even for NO lesions. This appears to have resulted in minimum occurrence of death caused by neck metastasis. References APPLEBAUM, E. L., CALLINS, W. P. and BYTELL, D. E. 1980). Carcinoma of the floor of the mouth. Arch. Otolaryngol. 106, HARROLD, C. C. (1971). Management of cancer of the floor of the mouth. Am. J. Surg. 122, HIRANO, M., KURITA, S., MIHASHI, S., WATANABE, Y. and RI, S. (1979). Treatments for car-

18 S78 OHKUBO, ET AL. cinoma of the tongue. Pract. Otol., Kyoto. 72, ICHIKAWA, A., HIRANO, M., SHIN, T., MIHASHI, K., and HIR0T0, I. (1976). Long term results of treatments for carcinoma of the tongue. Otologia. Fukuoka. 22, INOUE, K. (1977). Management of cancer of the floor of the mouth. Pract. Otol. Kyoto. 70, KRAUSE, C. J., LEE, J. G. and MCCABE, B. F. (1973). Carcinoma of the oral cavity. Arch. Otolaryngol. 97, ONO, I. (1977). A study of the factors influencing prognosis of carcinoma of the tongue, J. Otolaryngol. Jpn. 80, PANJE, M. R., SMITH, B. and MCCABE, B. F. (1980). Epidermoid carcinoma of the floor of the mouth; Surgical therapy vs combined therapy vs radiation therapy. Otolaryngol Head Neck Surg 88, SCHRAMM, V. L., MYERS, E. N. and SIGLER, B. A. (1980). Surgical management of early epidermoid carcinoma of the anterior floor of the mouth. Laryngoscope, 90, SPIRO, R. H. and STRONG, E. W. (1971). Epidermoid carcinoma of the mobile tongue. Am. J. Surg. 122, UICC (1974). TNM. General rules. International Union Against Cancer, Geneva. UICC (1978). TNM. Classification of malignant tumors. International Union Against Cancer, Geneva. YARINGTON, C. T. (1980). A protocol for combined treatment of cancer of the oral cavity and tongue. Laryngoscope, 90,