PLASTIC SURGERY IN RELATION TO RADIOTHERAPY FOR CANCER OF THE MOUTH. By GEORGE Joss, F.R.C.S.E.

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1 PLASTIC SURGERY IN RELATION TO RADIOTHERAPY FOR CANCER OF THE MOUTH By GEORGE Joss, F.R.C.S.E. From the Mount Vernon Centre for Plastic Surgery, Northwood, Middlesex OUR few weapons in the treatment of this disease remain those of destruction. The pendulum of current thinking vacillates between radiotherapy on the one hand and ablative surgery on the other. A more elegant form of destruction has been introduced in the newer cytotoxic agents ; but these as yet are neither sufficiently specific nor free from toxicity to have established a place in the treatment of oral cancer, where the field is unsuitable for a true isolation perfusion ; their value is mainly for palliation, especially of pain. Until combined radiotherapy and plastic surgery clinics are more widely available in this country the complementary use of these two disciplines will fall short of the ideal. Indeed, one still tends to see mainly the " failures " passed over from the " other " field. And yet during the last decade we have seen the introduction of supra-voltage irradiation, as the result of which the scope for treatment has been increased whilst the cost to the patient in terms of necrosis of bone or skin has been reduced. Recently Windeyer (1962) has discussed the complementary use of a 4,ooo,ooo-volt linear accelerator and a kilocurie Cobalt Unit in a review of over 4oo cases of malignant disease of the mouth and pharynx. He concluded that, in some instances, a prospect of cure could be offered with less risk of bone necrosis where previously not even control could be obtained. On the other hand, advances in ana:sthesia, intravenous therapy, and antibiotics have allowed surgical procedures, once inconceivable, to become commonplace. As redescribed by Kremen (I95I), the dissection of cervical neck glands en bloc with excision of the primary tumour is now widely practised. The plastic surgeon, with his reconstructive techniques, has an expanding role to play in this field and is increasingly called upon to carry out primary treatment. However, in the absence of sound convictions based on an extensive personal experience, the decision regarding choice of treatment in individual cases is often dictated by one's training, the more so because of the difficulty in drawing firm conclusions from a review of the literature. In their critical analysis of 653 cases of cancer of the tongue, Cade and Lee (I957) concluded that histological examination of biopsy specimens was unhelpful either in deciding upon management or in judging prognosis, although they found some relationship between the size of the primary and lymph node involvement, this correlation being therefore of some prognostic value. Their views accord with those of Moss (z 959) who, in an authoritative work on radiotherapy, considers histological grading to be of little value in deciding the type of treatment. However, he does refer to a relationship between the extent of infiltration and the degree of radiosensitivity of the tumour. On the other hand, some have attached importance to Broders' (1920) classification and, in a review of 217 cases of carcinoma of the tongue seen at the Mayo Clinic between the years 1949 and I953, Lash found a consistent correlation between histological grading and extent of infiltration of the 88

2 PLASTIC SURGERY IN RELATION TO RADIOTHERAPY FOR CANCER OF TIfE MOUTH 89 growth. As did Cade and Lee, Lash also found a relationship between the size of the primary and the presence or likelihood of metastases with therefore a bearing on prognosis (Table I). TABLE I Size of Primary Five years survival rate Over 2 cm. in diameter. 29 per cent. Under 2 cm. in diameter 57 per cent. This brief reference to three only of many works on the subject serves to emphasise that a decision regarding treatment is to be reached from a careful consideration of clinical rather than of laboratory findings. SURGERY OR RADIOTHERAPY.~ Whether our objective in the treatment of oral cancer be cure, control, or merely palliation, we aspire to leave the patient in reasonable comfort for a reasonable length of time, a longer life expectancy, but in a state of misery being as unacceptable as a short one at the end of a lengthy programme of reconstructive surgery. The patient himself rather than his disease must therefore be the guide in deciding the modality of treatment, the aim being to restore him expeditiously to a place, if possible his former place, in society. Cancer of the Lip.--Cancer of the lip is the commonest neoplasm (25 per cent.) of the oral cavity, and lesions in the lower lip, which carry a substantially better prognosis, are fifteen to eighteen times more frequently seen than in the upper lip. Treatment of these lesions tends to depend upon the size of the primary. For lesions involving one-third or less of the lip, most authorities agree that surgery and radiotherapy are equally effective and convenient to the patient. Extensive primaries are probably better treated by radiotherapy, not because the cure rate is higher but in consideration of the patient's comfort. Reconstruction of half or even the whole of a lip following surgical excision is perfectly feasible, but may be less convenient to the patient. In the treatment of primaries involving one-third to two-thirds of the lip the two disciplines will probably always overlap. Moss (1959) considers that 80 per cent. of all lesions of the lip are equally curable by surgery or radiotherapy. Lampe (1959) reviewed sixty-seven cases of advanced cancer treated by irradiation at the University of Michigan and compared the results with those obtained by the surgical treatment of comparable lesions by Ward and Hendrick (195o) in a previous paper. He found no significant difference between either method for previously untreated cases (Table II). TABLE Three-year survival-- Surgery. 49 per cent. Radiotherapy., 5o'8 per cent. Five-year survival-- Surgery.. 41 per cent. Radiotherapy. 42"6 per cent. The cure and the restoration of appearance and function without costing the patient some time and discomfort may be an objective more difficult to attain for II

3 90 BRITISH JOURNAL OF PLASTIC SURGERY the surgeon than for the radiotherapist, although the surgeon does have the advantage of being able to obtain histological confirmation of the adequacy of his treatment. Occasionally, however, reconstruction after radiotherapy will be required for very extensive lesions, and in such instances Moss recommends that a surgical excision be carried out first in order that non-irradiated tissues may be utilised in the reconstruction. Cancer of the Tongue, Floor of the Mouth and Alveolus.--In this particular field the surgeon and the radiotherapist usually walk their separate ways and neither from the literature nor from the statistician is the one likely to receive justification and the other condemnation. Small growths in the anterior two-thirds of the tongue and mobile lesions in the floor of the mouth provide no problem in reconstruction and may well be treated by surgical excision, provided that speech and deglutition will not thereby be impaired. Cancer of the posterior third of the tongue carries a uniformly bad prognosis whatever the method of treatment, but the mutilation and suffering inflicted by the surgeon in an attempt to ablate it can only rarely be justified. Without causing unreasonable discomfort, however, the radiotherapist is better equipped to obtain palliation in this disease and sometimes achieves good local control. There is a group in which surgical excision is almost certainly the treatment of choice and the patients in this group fall into the following categories :-- I. Those with lesions which involve the alveolus or the mandible. 2. Those with lesions in which syphilis or leukoplakia is an mtiological factor. 3. Young patients (i.e., those with a life expectancy of thirty years or more). 4- Those in whom follow-up is impossible. For patients falling into categories other than these it is impossible to generalise and a separate decision regarding radiotherapy or surgery must be made for each individual, the guiding maxim being " Aegro morbum posthabeas." THE PLACE AND TIMING OF RECONSTRUCTION Following the excision of an oral neoplasm the task of the plastic surgeon is to achieve the restoration of, first, function and, secondly, appearance. Whether he aims for a simple one-stage repair or whether he embarks upon a multistaged programme of reconstruction is a matter to be carefully considered upon the merits of each case ; here the prognosis is of paramount importance. The Neek Glands.--Involvement of the neck glands has an all-important prognostic significance. In cases which are clinically free from cervical metastases, the five-year control rate averages about 6o per cent., but this figure falls to 20 or 3 per cent. when the glands are involved. Since our aim is the rapid return of the patient to a place in society, an elaborate reconstruction is obviously contraindicated if the lymph nodes are involved when the patient is first seen. Furthermore, the management of the primary growth cannot be divorced from simultaneous consideration of the lymphatic drainage area. Twenty years ago it was the practice in many centres, particularly by Martin (I935), to carry out a block dissection of clinically uninvolved glands as a prophylactic measure~ after the primary lip or tongue turnout had been excised,

4 PLASTIC SURGERY IN RELATION TO RADIOTHERAPY FOR CANCER OF THE MOUTH 91 Some workers still advocate this regime, notably Tailhefer (1952, I958), who has reported on 182 cases of primary block dissection of clinically impalpable neck glands. He states that 43 per cent. are revealed to have metastatic involvement on subsequent histological examination, and he believes that his control rate for this 43 per cent. is improved as the result of his "prophylactic " operation, the figure being 26 per cent. MacFee (I959), in a smaller series, also tends to favour prophylactic block dissection in some cases, but the majority,of workers now on both sides of the Atlantic prefer to wait for a clear clinical indication before treating the lymphatic drainage area. This attitude is probably due mainly to the work of Hayes Martin, who published a statistical review of a very large series of his own cases treated during the period when he was practising prophylactic block dissection (Martin, I95!). Recently support for this more conservative approach has been forthcoming from a number of publications. Erich and Kragh (1959) reviewed lo2 cases treated at the Mayo Clinic in 1945 and I954 and found only 9 per cent. of histological carcinoma in impalpable neck glands treated by prophylactic block dissection; the figure became 65 per cent. when the glands were clinically palpable. Lyall and Grief (I96o) found only four cases of histological involvement in sixty-five neck dissections for impalpable nodes. It would seem that a conservative attitude should be adopted in most instances, but there is a case to be made out for the prophylactic treatment of the neck glands in those cases in which, by virtue of the exposure necessary for excision of the primary tumour, en bloc resection has been made possible without substantially extending the wound. A rational attempt to equate these two approaches to the problem has been made by Longacre et al. (I961). They employ the aid of an expert cytologist to examine frozen sections taken from all the cut surfaces at the time of the operation. In reviewing 239 cases of extensive head and neck cancer treated this way over a period of fifteen years, Longacre states that a more controlled and better ablation of the disease is obtained. Twenty-six per cent. of these cases had recurrence when first seen but, following treatment, the overall recurrence rate was stated to be as low as 6.2 per cent. On the basis of this figure, they are strongly in favour of immediate reconstruction. Some workers belong to the school of thought which believes that the first attack upon a cancer is the only one that counts. The ablative surgery is on the " all or none" principle and a full-scale reconstruction can be carried out, or initiated, at the same operation. Longacre's method seems to be a legitimate and acceptable way of following this school of thought by placing it on a rational and scientific basis. However, the majority of workers do not accept this rather gloomy basic surmise, are more conservative in their approach, and prefer a more simple repair operation. All surgeons seek to avoid the experience of watching a patient being overtaken by recurrent local disease before a reconstructive programme has been completed. It is reasonable to conclude therefore that in cases where the primary tumour exceeds 2 cm. in diameter or in which there are clinically palpable neck glands elaborate reconstruction is to be avoided. Instead an adequate repair (in one stage whenever possible) is the treatment of choice. Even large flaps of tissue can usually be imported in one stage if the pedicle is shaved down to the dermis, thereby avoiding a subsequent operation to close the deliberate fistula. If, after a reasonable interval, the patient remains free from secondary disease it would be reasonable to reconsider the possibility of a reconstructive procedure.

5 9 2 BRITISH JOURNAL OF PLASTIC SURGERY SURGERY FOLLOWING IRRADIATION A review has been carried out of the fifty cases of oral neoplasm treated at the Mount Vernon Centre for Plastic Surgery during the five-year period 1957 to Unfortunately, the proximity of this centre to the Mount Vernon Radium Institute, which has its own surgical staff, determined a highly atypical distribution of oral lesions undergoing plastic surgery. No useful statistical information could therefore be obtained. More than half of those referred to this centre were suffering from complicated cancers in which there was simultaneous involvement of the floor of mouth and alveolus with, in the majority, the tongue also. There were thirty such cases but, of these, three had undergone excisional surgery elsewhere and were referred for reconstruction only. Three other cases became operative or post-operative mortalities. There remained twenty-four patients who had an extensive excision within the mouth, having undergone resection of part of the tongue, the floor of the mouth and part of the mandible. One point emerged from this review and from the detailed analysis of these twenty-four cases which is considered worth reporting. It concerns the effect which previous irradiation had upon healing after surgery. Thirteen of the twenty-four patients had not received any previous radiotherapy and in eleven of these intra-oral and extra-oral healing took place primarily without incident. Of the two patients who failed to heal primarily, one developed a small and temporary intra-oral breakdown but with no fistula formation, in spite of block dissection having been carried out. In the other patient, the mucosa healed primarily but there was a skin breakdown where the flaps had been brought together over a steel bar, this having been used as a spacer between the mandibular remnants. Again no fistula occurred although block dissection had been carried out. None of the patients who had received previous irradiation healed primarily ; that is to say all eleven patients developed a breakdown of the intra-oral suture line, ten of them with fistula formation. In all seven patients ill whom a simultaneous block dissection was carried out when they had received radiotherapy previously, fistula formation occurred. In not one of nine patients who had a similar gland dissection did a fistula form when there was no history of previous X-ray treatment. Although this is a small series, it is felt that these observations are significant and they are summarised in Tables UI and IV. TABLE III TABLE IV Healed Breakdown Block Primarily of Suture Line Dissection I No previous II cases 2 cases X-rays Previous Radiotherapy o cases II cases (Io with fistula) Previous Radiotherapy Fistula Formation No previous 9 cases i o cases X-rays ] 7 cases [ 7 cases I

6 PLASTIC SURGERY IN RELATION TO RADIOTHERAPY FOR CANCER OF THE MOUTH 93 In four patients an attempt was made to repair the floor of the mouth by introducing local flap tissue. However, in each case the flap had been included in the radiotherapy field and breakdown of the suture line occurred just the same. In one instance the patient had previously received supravoltage irradiation through an area which was subsequently used as a flap, and this too broke down. One final observation is perhaps worth making. In two of the patients both lingual arteries were ligated in order to minimise ha:morrhage, but in both the anterior two-thirds of the tongue necrosed and subsequently separated. CONCLUSION It is not unreasonable to draw the conclusion that, in previously irradiated cases, when the local excision is to be extensive, tissue should be imported in the form of flaps from areas which have not been included in the field of irradiation. Flaps taken from areas which have shared in the radiotherapy are not successful. A block dissection of the neck, if this is deemed necessary, is better deferred until healing at the site of excision of the primary growth has taken place, unless flap tissue is introduced. This does not apply in patients who have received no previous X-ray treatment. In this regard, one can philosophise that devitalisation of tissue by X-rays has replaced the risk of infection which prompted Wilfred Trotter to advise against simultaneous block dissection (Trotter, I913). If the intra-oral defect is small, satisfactory flaps can often be obtained from one or both nasolabial lines, based on an inferior pedicle which may be shaved to eliminate a deliberate fistula. The apron "island" flap described by Desprez and Kiehn (I959) will yield more tissue but is more complicated. However, the hardiest and most adaptable is almost certainly the forehead flap described by McGregor (I963, but previously reported). The cost to the patient in terms of scarring is outweighed by the comfort of an immediate repair with primary healing in the mouth. The breakdown of the oral suture line is a complication to be avoided as strenuously as fistula. The protracted healing associated with contamination of a breakdown cavity by food debris adds considerably to the patient's discomfort and his period in hospital, and the ensuing fibrosis tethers the tongue which impairs swallowing and speech. Gardham (I962) has stressed the difficulty in swallowing which affects all patients undergoing extensive oral excisions. It is important therefore that attention be paid to obtaining primary healing in every case. SUMMARY A review of the literature indicates that when an oral cancer exceeds 2 cm. in diameter or where the neck glands are palpable, elaborate reconstruction should be deferred in favour of a simple one-stage repair. Most writers feel that block dissection for clinically impalpable glands is not indicated. An analysis of twenty-four of the cases treated in a recent five-year period at the Mount Vernon Centre for Plastic Surgery suggests that, following irradiation, serious consideration must be given to the importing of tissue for repair when the excisional surgery is to be extensive. Unless this is done in such cases, block dissection of the neck glands should be postponed until healing at the site of primary excision is complete.

7 94 BRITISH JOURNAL OF PLASTIC SURGERY I am indebted to my.former chief, Mr Rainsford Mowlem, for his inspiration ; to him and to Mr R. L. G. Dawson, Mr S. H. Harrison and to Mr I. F. K. Muir of the Mount Vernon Centre for Plastic Surgery for permission to review their cases. REFERENCES BRODERS, A. C. (192o). J. Amer. reed. Ass., 74, 656. CADE, S. and LEE, E. S. (1957). Brit. J. Surg., 44, 433- DSSVREZ, J. D. and KIH-IN, C. L. (1959). Plast. reconstr. Surg., 24, 238. ERICH, J. B. and KRAC-H, L. V. (1959). Arch. Surg. (Chicago), 79, 94. GARDHAM, A. J. (1962). J. R. Coll. Surg. Edinb., 7, 88. KREMEN, A. J. (1951). Surgery, 30, 227. LAMI'E, I. (1959). Plast. reconstr. Surg., 24, 34. LASH, H., ERICH, J. B. and DOCKERTY, M. B. (1961). Amer. J. Surg., lo2, 620. LONGACRE, J. J., DE STEFANO, G. A., HOLMSTRAND, K., LEICHLITER, J. W. and JOLLY, P. (1961). Plasr. reconstr. Surg.~ 28, 549. LYALL, D. and GRIER, W. R. N. (196o). Ann. Surg., x52, lo67. MACFEE, W. F. (1959). Ann. Surg., 149, 9o3. McGRECOR, I. A. (1963). Brit. J. plast. Surg., 16, 318. MARTIN, g. E. (1935). Amer. J. Surg., 3 o, (1958). Cancer, 4, 92. Moss, W. T. (1959). " Therapeutic Radiology." London : Henry Kimpton. TAILHEFER, A. (1952). Proc. R. Soc. Med., 45, (1958). Mere. Acad. Chir., 84, 609. TROTTER, W. (1913). Lancer, i, lo75, WARD, G. E. and HENDRICK, J. W. (195o). Surgery, 27, 321. WINDEYER, g. (1962). International Congress on Radiotherapy, Moscow. Submitted for publication, June 1963.