Head and Neck Cancer A Brief Review of 852 Patients Treated in Kurume University Hospital During the 10 years from 1971 to 1980

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1 THE KURUME MEDICAL JOURNAL Vol. 29, Supplement, P. S1- S7, 1982 Head and Neck Cancer A Brief Review of 852 Patients Treated in Kurume University Hospital During the 10 years from 1971 to 1980 MINORU HIRANO Department of Otolaryngology, Kurume University School of Medicine, Kurume, 830 Japan Received for publication April 10, 1982 Summary: During the 10 years from 1971 to 1980, 852 patients of histologically proven head and neck cancer were treated at our inpatient clinic. The most frequent pathology was carcinoma of the larynx, being followed by carcinomas of the maxillary sinus and the oral cavity. The 5-year survival rate was high for carcinomas of the thyroid gland (76.8%), larynx (69.4%), tongue (61.4%) and nasal cavity (60%). It was low for carcinomas of the epipharynx (17.8%) and hypopharynx and cervical esophagus (25.4%). Key words: cancer head and neck head and neck cancer survival rate causes of death Introduction During the 10 years from 1971 to 1980, 852 patients of histologically proven head and neck cancer were treated at the inpatient clinic of the Department of Otolaryngology, Kurume University Hospital. This paper presents a brief status report on these patients. Details of each group of patients will be reported in the following articles in this booklet. Distribution of the Patients 1.Distribution by nature and site of lesion Table 1 presents distribution of the 852 patients by nature and site of the lesion. Right hundred patients were not previously treated whereas 52 patients were previously treated cases. Of the former 800, 726 patients underwent curative treatments while 74 were palliatively treated for various reasons, and, in the latter 52, 43 received curative treatments, while 9 had palliative treatments. Carcinoma of the larynx was the most frequent pathology (260/852, 30.5%), carcinoma of the maxillary sinus was the second most frequent (124/852, 14.6%), and carcinoma of the oral cavity was the third (110/852, 12.9%). Neoplasmas of epithelial origin were much more frequent than those of non-epithelial origin. 2.Distribution by staging Tables 2-5 present distribution of the patients of major groups of carcinoma by TNM classification and stage grouping. Those patients who had been previously treated before their admission to our hospital are excluded from these tables. With respect to T category, early cases were found most frequently for the larynx, then for the oral cavity, oropharynx, salivary glands and thyroid gland. On the other hand, advanced cases were frequent for the maxillary sinus, nasal cavity, naso- S1

2 TABLE1 Head and neck cancer Histologically Proven cases treated at Kurume University Hospital during 10 Years from 1971 to 1980.

3 HEAD AND NECK CANCER S3 pharynx, hypopharynx and cervical esophagus (Table 2). As regards neck metastasis, carcinoma of the nasopharynx presented the worst figure. Almost all patients of this group had clinically positive lymphonodes. Positive nodes were frequently palpated also for carcinoma of the oropharynx, hypopharynx and cervical esophagus. On the contrary, cervical metastasis was infrequent for carcinoma of the nasal cavity, maxillary sinus, lip and larynx (Table 3). Distant metastasis was rare in all groups as shown in Table 4. As to stage grouping, advanced stages were the most frequent for carcinoma of the epipharynx. All the cases of this pa thology were Stage III or IV. Cases of ad- TABLE 2 Distribution of patients by site and T category T classification is based on UICC classification (UICC, 1978) cxcept for the nasal cavity, maxillary sinus and major salivary gland. For the nasall cavity and maxillary sinus, Sakai classification (Sakai, 1970) is applied whereas AJC classification (AJC, 1977) is used for major salivary gland. TABLE 3 Distribution of patients by site and N category N classification is based on UICC classification (UICC, 1978).

4 S4 HIRANO vanced stages were also frequent for the nasal cavity, maxillary sinus, lip, oropharynx, hypopharynx and cervical esophagus (Table 5). Carcinomas of the salivary and thyroid glands are not included in Table 5 because no stage grouping has been re commended yet. TABLE 4 Distribution of patients by site and M category Results of Treatments 1.Five-year survival rate Table 6 compares the 5-year survival rate for different groups of cancer. Those groups which had a small number of pa tients are excluded. The 5-year survival rate was calculated by the actuarial method for the patients who had not been previ ously treated and underwent curative treat ments in our hospital. Therefore, those patients who had been previously treated in other hospitals and those patients who were palliatively treated are not included M classification is based on UICC classifi cation (UICC, 1978). TABLE 5 Distribution of patients by site and stage Stage grouping is based on UICC classification (UICC, 1978) except for the nasal cavity and maxillary sinus. For the nasal cavity and maxillary sinus, Sakai classification (Sakai, 1970) is applied. * Five Tis cases are excluded. ** One case of Hodgkin lymphoma is not included.

5 HEAD AND NECK CANCER S5 in this calculation. The 5-year survival rate was the greatest for carcinoma of the thyroid gland, especially for differentiated carcinoma. For the remainings, the survival rate became smaller in the order of the larynx tongue, nasal cavity, salivary glands, maxillary sinus, lymphoma, oropharynx, hypophar ynx and cervical esophagus, and naso pharynx. Fig.1 presents the relationship between the rate of the occurrence of Stage N and the 5-year survival rate. There was a tendency that the greater the rate of Stage N patients was the smaller the survival rate. Stage N cases were minimum for carcino mas of the tongue and larynx and the sur vival rate was high for them, whereas the survival rate was minimum for carcinoma of the nasopharynx which included many Stage N cases. Fig.2 shows the relationship between the rate of the occurrence of Stages III and N and the survival rate. In this figure, there was an obvious separation of the car cinomas investigated into two groups. The first group consisted of carcinomas of the TABLE 6 Five-year survival rate in her cent calcu lated by the actuarial method larynx, tongue, nasal cavity and maxillary sinus, presenting high survival rates. The second group consisted of carcinomas of the epipharynx, oropharynx, hypopharynx and cervical esophagus, showing low sur vival rate. Within each of the two groups, there was a tendency that the greater the rate of the occurrence of Stage III and N was the lower the survival rate. The results shown in Fig.1 and 2 in- Fig.1. Relationship between rate of occurrence of Stage IV and 5-year survival rate * Values for differentiated carcinoma ** Non-Hodgkin lymphoma Fig.2. Relationship between rate of occurrence of Stages III and IV and 5-year survival rate

6 S6 HTRANO dicate that Stage III cases of carcinomas of the larynx, tongue, nasal cavity and maxillary sinus can be more successfully treated than those of carcinomas of the pharynx and the cervical esophagus. 2.Cause of death Table 7 shows the cause of death for different major groups of cancer. Only those patients who had not been previously treated and underwent curative treatments were included in this study, excluding those patients who had been previously treated or who received only palliative treatments. The cause of death were classified as follows: (1) Death from the tumor present (a) Death from primary lesion (T). Pa tients who died with primary lesion un controlled 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 complication 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 se parately from those occuring 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. This definition is primarily based on the proposal by the Japan Society of Head and Neck Tumor (1981). The deaths from pri mary, neck metastasis and distant metas tasis were defined according to Hirano et al. (1976). Failures to control the primary lesion was a frequent cause of death for carcino mas of the nasopharynx, major salivary TABLE 7 Cause of death for curative treatment group Number in parenheses indicates per cent.

7 HEAD AND NECK CANCER S7 glands, and maxillary sinus. It was rare for carcinoma of the larynx. As regards cervical metastasis, failures in managing was a significant cause of death for car cinoma of the tongue, oropharynx, hypo pharynx and cervical esophagus. Distant metastasis was the cause of death in one fifth or more of the deaths for carcinomas of the oropharynx, hypopharynx and cer vical esophagus, larynx and salivary glands. It should be noted that surgical or other complications were a significant cause of death for carcinoma of the hypopharynx and cervical esophagus. For carcinoma of the larynx, more than half of the entire deaths resulted from intercurrent diseases. Coments It appears that early diagnosis of car cinomas of the nasal cavity, maxillary sinus, nasopharynx, oropharynx, hypopharynx and cervical esophagus is not frequently made. In particular, this accounts for the poor prognosis of carcinomas of the phar ynx and esophagus. A campaign for early diagnosis of these diseases may be de manded. Also, further effort should be made to improve treatment methods of these pathologies. Regardless of a high incidence of ad vanced cases, carcinomas of the nasal cavity and maxillary sinus presented with a fairly high survival rate. This can be attributed to a poor lymphatic flow from these sites and to the recent advancement of combined therapies. In the present review, carcinomas of the thyroid gland, larynx, tongue, nasal cavity, major salivary glands, and maxil lary sinus presented with a favorable prog nosis whereas those of the nasopharynx, hypopharynx and esophagus, and orophar ynx demonstrated a poor prognosis. Malig nant lymphoma was in between these two groups. For carcinomas of the larynx and tongue, the post-therapeutic function should be an important issue. Early detection of these pathologies is desired chiefly for a favorable functional result. Futher developments of reconstructive modalities are demanded for advanced cases of these diseases. References American Joint Committee for Cancer Staging and End-Results Reporting (AJC) (1977). Manual for staging of cancer. HIRANO, M., SHIN, T., MIHASHI, S., ICHIKAWA, A., MIHASHI, K. and HIROTO, I. (1976). Long term results of treatments for carcinoma of the larynx. Otologia (Fukuoka). 22, Japan Society of Head and Neck Tumor (1981). Unpublished report. SAKAI, S. (197). A proposal for TNM classifi cation of malignant neoplasms of the head and neck which are not classified at UICC. Unpublished report. UICC (1978). TNM Classification of Malignant Tumors. Geneva.