Malignant tumours of the buccal cavity: A clinical analysis of 970 cases

M A L I G N A N T T U M O U R S O F T H E B U C C A L C A V I T Y : A C L I N I C A L A N A L Y S I S O F 9 7 0 C A S E S

S. K. BHANSALI, M.S.(BOMBAY), F.R.C.S.(ENGLAND)

Royal Marsden Hospital, Fulham Road, London, S.W.3

THIS paper is a study of tumours occurring irt the buccal cavity which extends from the muco- cutaneous junctions of both the lips, backwards to the junction of the hard palate with the soft palate, the anterior faucial pillars, and the circumvallate papillae of the tongue.

Between 1936 and 1955, 1,155 malignant tumours of the buccal cavity were seen at the Royal Marsden Hospital. One hundred and eighty-five recurrent tumours have been excluded, leaving 970 cases for analysis.

The primary site.--Neoplasms in different anatomical sites in the buccal cavity differ in their behaviour, and their management differs cor- respondingly. The anatomical sites are listed in Table 1. It is felt necessary to define two sites, the palatoglossal sulcus and the buccinator sulcus. " T h e palatoglossal sulcus is the term applied to the junctional area between the lower end of the anterior faucial pillar and the posterior end of alveolingual sulcus . . . With the exception of the tumours of insertion of anterior pillar which should be considered buccopharyngeal, all palatoglossal neoplasms, when identifiable as such, should be allocated to the buccal cavity group of tumours" (Lederman 1956). " The buccinator sulcus is defined as the posterior part of cheek where the vestibule of the buccal cavity becomes continuous with the anterior faucial arch, across the inter- maxillary triangle " (Lederman).

Neoplasms in different sites may have some features in common. In the later part of this paper, certain sites are grouped together as follows : - -

1. Upper alveolus and hard palate. 2. Floor of mouth, inferior surface of tongue

and palatoglossal sulcus. 3. Buccal mucosa and buccinator sulcus. Age and sex.--The distribution of cases by age

and sex is not presented here in detail but the study confirmed that these tumours occur mostly in old people and that they are commoner in males than in females.

Staging of the disease.---The staging adopted here is that followed by Ledlie and Harmer (1950), which is based on that employed at the Christie Hospital and Holt Radium Institute, Manchester. Table 1 shows the distribution of these cases at various sites by clinical stages. Since the metastatic

involvement of regional lymph nodes has a pro- found influence on prognosis, it is convenient to group Stages I and II as " n o d e free " and Stages III and IV as " node involved." The " n o d e involved" group may also include art occasional case where the primary growth is too advanced, without any metastatic involvement of lymph nodes. Six cases where staging was not possible have been classified as " n o d e free." The largest percentage of " node involved" cases was seen when the primary tumour was in the lower alveolus or floor of mouth (Table 1). In the first group, including the upper alveolus and hard palate, there is a difference in the percentage of " n o d e involved" cases at the two sites. The smaller number o f " node involved" cases seen in the hard palate is partly accounted for by the fact that ten out of thirty-four tumours with positive histology were sialomas. Nine of these were " node free."

Excluding tumours of the lip, 53 per cent of cases had already reached Stage I l l or IV when first seen by the clinician. Table 2 compares by sex the number o f " node free " and " node involved" cases. Women seek advice at art earlier stage than men.

Histology.--In this series a positive histological diagnosis was made in 802 cases (83 per cent). Seven hundred and eighty-one (97 per cent) were squamous carcinomas. Table 3 shows the histological diagnosis in the remaining twenty-one cases. One hundred and sixty-eight cases were without a positive histological diagnosis. Of these, 129 were seen in the first ten-year period 1936-45, and thirty-nine were in the period 1946-55.

Multiple primaries.--In this series, 116 patients (12 per cent) had more than one malignant tumour. Thirty-five patients (30 per cent) had a second primary tumour irt the buccal cavity, and twenty- five patients had a second primary tumour in other parts of the upper respiratory and digestive tracts. This supports the suggestion that a common aetiological factor or factors may be operating over a wide area of mucosa so that the entire mucosa in that region has malignant propensities (Goodner and Watson 1956). Carcinomas of the buccal cavity and pharynx are sometimes associated with widespread leukoplakia.

299

300 C L I N I C A L R A D I O L O G Y

TABLE 1

CASES BY SITES AND CLINICAL STAGES

Site

1. Lip

2. Lower alveolus .

3. Uppe r a lveolus .

4. H a r d pa la te

5. F loo r of m o u t h .

6. Infer ior surface of tongue

7. Pa la tog lossa l sulcus

8. D o r s u m and borders of an- ter ior two- th i rds tongue

9. Buccal mucosa

10. Buccina tor sulcus

All sites

Al l sites except lip

Tota l No, of Stage Stage Stage

I 1l I I I cases

227 165 13 37

77 10 12 36

31 3 13 11

42 10 21 4

162 26 37 50

74 21 19 27

19 2 4 5

218 76 34 77

93 21 26 27

27 2 10 13

970 336 189 287

743 171 176 250

Stage StIage unknown

11 1

18 1

4

5 2

48 1

7

8

31

18 1

2

152 6

141 5

" N o d e " N o d e Percentage free" invo lved" in "node

involved"

179 48 21

23 54 70

16 15 48

33 9 21

64 98 60

40 34 46

6 13 68

110 108 50

48 45 d8

12 15 56

531 439 45

352 391 53

TABLE 2

COMPARISON BY SEX OF INCIDENCE OF " N O D E F R E E " AND " N O D E I N V O L V E D " G R O U P

Males Females

Site " N o d e " N o d e Percentage in " N o d e " N o d e Percentage in f ree" invo lved" " n o d e free" involved" "node

invo lved" involved"

Lip . 170 46 21 9 2 18

Sites o ther than l ip 253 326 56 99 65 40

All sites 423 372 43 108 67 38

T A B L E 3

HISTOLOGY OTHER THAN SQUAMOUS CARCINOMA, BY SITE

Site Ma l ignan t Lympho- Chondro- F ibro- R h a b d o - Basal cell s i a loma sa rcoma sa rcoma sa rcoma myosa rcoma carc inoma

Lip .

Lower alveolus .

Upper alveolus .

H a r d pa la te

F loo r of m o u t h .

Buccal mucosa .

m

I p lO

m

I

m

E

1

m

m

m

1 2

TOTAL . i 15 ] 1

I I

m

1

1

i

2

M A L I G N A N T T U M O U R S OF T H E B U C C A L C A V I T Y : A C L I N I C A L A N A L Y S I S

TABLE 4 CASES BY SEX IN THE TWO TEN-YEAR PERIODS

301

Period

1936-45 .

1946-55 .

Males

527

268

Al l sites

Females Rat io males / females

6.5

2'9

Males

371

208

All sites except l ip

[ Ra t io Females males / females

77

87

81

94

I 4"8 I I 2.4

Changing pattern of the disease.--The cases have been divided into two ten-year periods, 1936-45 and 1946-55. There were 608 cases in the first period, and 362 cases in the second period, a decrease which was more marked with tumours of the lip than with the other tumours.

Figure 1 shows in the form of a graph the percentage of cases in each of the five age groups in the two periods. The shift to the right in the peak age incidence is probably due to the increasing number of aged persons in the United Kingdom.

TABLE 5

pERCENTAGE OF CASES IN "NODE FREE" AND "NODE INVOLVED" GROUPS IN THE TWO TEN-YEAR PERIODS

Percentage in "node tYee"

Percentage in " n o d e involved"

All sites except lip

1936-45 1946-55

46 50

54 50

Lip only

1936--45 1946-55 [

75 88

25 12

There is a marked relative increase m the incidence of these tumours in the females in the second period (Table 4), due to a decrease in the number of male and an increase irt the number of female patients. A similar trend in sex incidence is reported from other centres irt this country. Russell (1955), in a morbidity survey of Cancer of Mouth, which included the base of the tongue, the soft palate, and the fauces, compared the periods 1935-39 and 1945-49. He found 1,077 males and 119 females in the first period and 777 males and 209 females irt the secortd period. Cade (1957) reported the ratio of male patients to female patients in Cancer of the Mouth and Tongue as 10:1 in 1925 and 2:1 in 1955. When the aetiological factors of a disease are uncertain, it is difficult to explain a changing pattern of the disease. Two factors which may be significant are the decrease in the incidence of syphilis and improved oral and dental hygiene.

Table 5 compares the cases in the two periods by stages. It is disheartening to note that even in

40 * o o

° Go°

30

/

~20

I0 ~ 1936-1945 e*oeoe 1946-1955

0 ~ . . . .

40 ~rs. 41-50 51-60 61-70 Over 70

under Age Groups

Fro. 1

Compar ing the percentage of cases in each a g e g r o u p in the two periods.

the second period one-half of the patients, excluding those with lip cancer, reached the clinician when the disease had already involved the .regional lymph nodes.

METHODS OF T R E A T M E N T In order to simplify an analysis of the methods

of treatment and the survival rates, the primary sites have been collected together into Treatment groups: cases Group 1 Group 2 Group 3 Group 4

Group 5

Group 6

Lip . 227 Lower alveolus . 77 Upper alveolus and hard palate 73 Floor of mouth, inferior surface of tongue and palatoglossal sulcus 255 Borders and dorsum of anterior two-thirds of tongue . 218 Buccal mucosa and buccinator sulcus 120

970

302

Since tumours of the lip differ considerably from those at other sites, they wiU be considered separately.

Tumours of the l ip.--Table 6 shows the methods of treatment employed in this series. Nearly two- thirds of the patients were treated with x-ray therapy, usually of low voltage. Other radio- therapeutic methods were used to treat a relatively small number of patients. Eight patients were not treated, five because of advanced disease and three refused treatment.

Sites other than l ip.--Table 7 shows the number of cases for which the three broad groups of treatment were employed. Over three-quarters of the patients were treated with radiotherapy alone: nearly half of these were treated by telecurie therapy (usually with a 5 gin. teleradium unit). Radiotherapy was used more frequently in late stages than in the early cases. Surgery was carried out twice as often in the " node f r ee" as in the " node involved " group. The problem of block dissection will be considered later on.

It is not intended to compare the various methods of treatment, as the material in each group is so dissimilar. The various methods of treatment must be considered as complementary to each other, and not competitive. The choice of arty

TABLE 6 METHODS OF TREATMENT. LIP. TREATMENT GROUP 1

227 CASES--8 NOT TREATED

C L I N I C A L R A D I O L O G Y

given method or combination of methods, will depend on the primary site and the extent of the lesion, and the personal bias of the individual clinician.

RESULTS Survival rates in arty analysis of malignant

tumours may be expressed either as crude survival rates or net survival rates. The crude survival rate considers a / / the new patients seen. It relates two irrefutable facts, the number known to be alive and the total number in the series. Net survival rates are computed by excluding the indeterminate group composed of (1) patients not treated; (2) patients dead of intercurrent disease or of a malignant turnout originating in another site, without there being arty evidence of the presence of the malignant tumour under consideration; and (3) patients lost trace of. Deaths occurring within three months of treatment, whatever may be the cause, are counted as turnout deaths. In this present survey, crude as well as net survival rates are presented. No attempt is made to present results according to the actuarial methods based on life table constructions.

Tumours of the l ip .~Table 8 shows the three-, five- and ten-year crude and net survival rates.

TABLE 7 METHODS OF TREATMENT. SITES OTHER THAN LIP

TREATMENT GROUPS 2 TO 6, 743 CASES--28 NOT TREATED

Method of treatment

Radiotherapy .

Surgery .

Radiotherapy and surgery.

All methods

All stages

194

11

14

219

"Node bee"

158

10

8

176

"Node involved"

36

1

6

43

Method of treatment

Radiotherapy .

Surgery .

Radiotherapy and surgery.

All methods

All stages

549

63

103

715

"Node free"

246

43

55

344

"Node involved"

303

20

48

371

TABLE 8

THREE-,' FIVE- AND TEN-YEAR SURVIVAL RATES

LIP CANCERS

Three-year survivals

Five-year survivals

Ten year survivals

Years

1936-55

1936-53

1936-48

All rages

227

218

185

All cases

"Node "Node bee" involved"

179 48

170 48

140 45

All stages

183

160

104

Net total

"Node t "Node L e e ' - - involved"

143 / 40

122 38

78 26

All "Node stages free"

66 73

56 63

34 43

Crude survival rate percentage

"Node ]involved"

40

29

Net survival rate percentage

All "Node "Node stages free" involved"

81 91 47'5

76 88 37

61 77 11-5

M A L I G N A N T T U M O U R S OF TH E B U C C A L C A V I T Y : A C L I N I C A L A N A L Y S I S

TABLE 9 THREE-YEAR SURVIVAL RATES. SITES OTHER THAN LIP

YEARS 1936--55. 743 CASES

303

Treatment group number

All groups

All cases

All "Node stages ~ee"

77 23

73 49

255 110

218 110

120 60

743 352

"Node involved"

54

24

145

108

60

391

Net total Crude survival rate percentage

All ! "Node stages[ flee"

74 22

65 45

227 94

188 93

102 49

656 303

I

"Node free"

48

51

57

45

48

51

"Node All involved" stages

52 34

20 38

133 34

95 29

53 34

353 33

"Node involved"

28

12'5

17

13

20

17



35 50 29

43 56 15

38 67 18

34 54 15

40 59 23

37 59 19

TABLE 10

FIvE-YEAR SURVIVAL RATES. SITES OTHER THAN LIP

YEARS 1936--53. 692 CASES


All groups

All stages

72

66

233

209

112

692

All cases

"Node "Node flee" involved"

21 51

42 24

100 133

105 104

56 56

324 368

Al l stages

66

60

197

174

93

590

Net total

"Node "Node All free" involved" stages

20 46 29

40 20 33

78 119 25

85 89 22

42 51 26

265 325 25


"Node f~ee' '

48

48

43

36

34

4O


"Node All "Node involved" stages flee"

22 32 50

8 37 50

11 29 55

8 26 45

18 31 45

12 30 49

"Node involved"

24

10

11

9

20

14

TABLE 11 TEN-YEAR SURVIVAL RATES. SITES OTHER THAN LIp

YEARS 1936-48. 558 CASES


All groups

All stages

66

53

175

175

89

558

All cases

"Node "Node free" involved"

18 48

36 17

69 106

90 85

46 43

259 299

All stages

56

44

136

139

65

440

Net total

"Node free"

16

3O

47

64

28

185

"Node involved"

40

14

89

75

37

255



14 33 6

17 19 12

12 25 4

14 22 5

9 13 5

13 22 5



16 37'5 7'5

20 23 14

15 36 4

17 31 5

12 21 6

16 30 6


The prognosis in lip cancer is relatively good and the ten-year net survival rate in the " node f r e e " group is 76 per cent. However, the outlook in patients with lymph node metastases is much worse. The three-year net survival rate in this group is only 47.5 per cent. The problem of lymph node metastases is discussed again below.

Sites other than the l ip.--These sites have been grouped as mentioned previously. Tables 9, 10 and 11 show the survival rates for the five groups and for all the groups together. The survival rates for each site are similar. The results of treatment of tumours of the dorsum and borders of the anterior two-thirds of the tongue are the worst. Amongst t h e " node involved," the best results were obtained in Groups 2 and 6. The overall results seem most promising in the upper alveolus and hard palate, but this is because nearly two-thirds of these cases were " node free." I f the " node free " and " node involved" are considered separately, the results at these sites are not the best amongst the five groups. This is surprising as there were at least ten histologically proved sialomas at these sites. The three- year net survival rate amongst thirty-one patients with tumours of the upper alveolus was 47 per cent in the " node free " and 21 per cent in the " n o d e involved." The three-year net survival rate amongst forty-two patients with tumours of hard palate was 60 per cent in the " node f r e e " group. No patient with involved nodes survived for three years. This group included ten with histologically proved sialoma. Nine of these were " node f r e e " and all survived for three years. One of the ten was in the " node involved" group and died of dis- seminated cancer in less than three years.

I t is impossible to compare these survival rates accurately with any reported in literature as the classification of the pr imary sites, and the sites

included under the heading " buccal cavity " or " oral c av i t y " differ from author to author.

Survival and sex.--Table 12 shows the survival rates by sex and stage of cases at primary sites other than lip. In the " node involved," the results are similar in the two sexes. In the "node free" the results are definitely better in women than in men. A similar observation has been recorded by Russell (1954).

Survival and methods of treatment.--It is not intended to compare the results obtained by various forms of treatment, but in order to indicate what can be achieved by different methods of treatment with a proper selection of cases, the three-, five- and ten-year survival rates obtained by various methods of treatment are analysed in Tables 13, 14 and 15. Cancer of the lip is not considered in these tables. The best results are obtained apparently by surgery alone but over two-thirds of the patients treated by this method were " node free," and were therefore the more favourable cases. More significant are the good results obtained by a combination of radiotherapy and surgery; some case selection occurs also in this group but nearly one-half were in the " node involved" group. The combination of methods usually implies either surgery for a residual primary tumour, block dissection of the neck after the primary has been controlled by radiotherapy, or surgery for the residual primary growth as well as a block dissection. Occasionally radiotherapy was given post-operatively for incomplete excision, but post-operative radiotherapy is less effective as the tolerance of tissues to irradiation is decreased by fibrosis and a diminished blood supply.

The encouraging results obtained by the com- bined methods of treatment indicate that the best approach to the problem at the moment is a judicious combination of radiotherapy and surgery.

Three-year survivals (1936-55)

Five-year survivals (1936-53)

Ten-year survivals (1936--48)

Males

Females

Males

Females

Males

Females

All stages

579

164

547

145

455

103

TABLE 12 SURVIVAL RATES BY SEX AND STAGE. SITES OTHER THAN LIP

All cases Net t o t a l

"Node free"

253

99

234

90

192

67

"Node A l l involved" stages

I 326 ] 502

65 154

313 458

55 ] 132

263 353

36 87

"Node "Node ~ee" involved"

212 290

91 63

185 273

80 52

131 222

54 33


"Node free"

46

62

36

51

17

34

All stages

3O

45

22

37

10

24

"Node involved"

17

18

12

15

5

6


All "Node "Node stages I free" Jinvolved"

34 55 19

47 67 19

26 45 14

41 57'5 15

13 25 6 I

29 34 6

M A L I G N A N T T U M O U R S OF THE B U C C A L C A V I T Y " A C L I N I C A L A N A L Y S I S

TABLE 13 THREE-YEAR SURVIVAL RATES BY METHODS OF TREATMENT. SITES OTHER THAN LIP

YEARS 1936-55• 743 CASES--28 NOT TREATED

305

Method of treatment

Radiotherapy .

Surgery .

Radiotherapy and surgery

All L stage

. - ~ 4 9

63

• 103

All cases Net total

i

"Node free"

43

55

"Node involved"

--5;;--03 20

48

All stage

5;Y 57

94


"Node free"

38

49

"Node All involved"[stages

289 30

19 49

45 48

"Node "Node free" involved"

i

T 15

25

58 ] 35

Net survivalrate I percentage

All ]"Node "Node stages I flee" involved" I

33 56 16

54 68 26

52 65 38

TABLE 14 FIvE-YEAR SURVIVAL RATES BY METHODS OF TREATMENT. SITES OTHER THAN LIP

YEARS 1936--53. 692 CASES--25 NOT TREATED

Method of treatment

Radiotherapy .

Surgery .


All stages

519

58

90

All cases Net total

"Node "Node All "Node ~ee" involved" stages I flee"

I

226 293 455 i 186

42 16 53

45 45 82 41


"Node All "Node involved" I stages I flee"

269 2l 36 i

38 15 48 6O

41 41 53


,,NoL-e I All involved" ] stages

10 24

19 53

29 45

"Node "Node free" linvolved '~

44 11

66 20

59 32

TABLE 15

TEN-YEAR SURVIVAL RATES BY METHODS OF TREATMENT. SITES OTHER THAN LIP

YEARS 1936--48. 558 CASES--22 NOT TREATED

Method of treatment

Radiotherapy .

Surgery .


All stages

439

46

51

All case2

"Node "Node ] A l l flee" involved" [ stages

33 13 40

28 23 44

total Crude survival rate I Net survival rate Net percentage I percentage

"Node "Node . . . . I - - "Node "Node All "Node ] "Node free'' involved" free" involved" stages l free" involved"

-134 222 ---17-- 4 ( S ~4 5 I

28 12 30 42 - - 35 50 - -

23 21 29 36 22 34 43 24 I

PROB LEM OF L Y M P H N O D E METASTASES

Metastatic involvement of the regional lymph nodes is the most important single event occurring during the natural history of these tumours, as it considerably alters the prognosis. Over one-fifth of the patients with tumours of the lip and more than one-half the cases of cancer arising in other sites had developed lymph node metastases when first seen by the clinician. Over one-eighth of the " node f r ee " patients with lip tumours and one- fourth of the " node free " patients with tumours

E (4)

at other sites develop lymph node metastases after successful t reatment of the primary. The problem of lymph node metastases has to be faced by the clinician in just under one-third of all patients with lip cancer and nearly two-thirds of all patients with cancer at other sites.

The treatment of choice for metastatic lymph nodes is a Crile's block dissection of neck, when- ever it is feasible. One hundred block dissections were carried out in this series. Fifty-three were done as a part of the initial treatment sequence and forty-seven for recurrences in lymph nodes. The


operation was performed on a relatively small number of patients, either because the lymph nodes were already fixed to other structures or because the primary growth could not be controlled. In cases where block dissection is impossible, radiotherapy gives useful palliation with occasional long survivals.

Tables 16 and 17 show the incidence of lymph node recurrences from the initially " node free " tumours arising from the lip, and from sites other than the lip. The majority of lymph node recurrences occur within three years. The irtcidence of recurrence in regional lymph nodes is lower in women thart in men. Tables 18, 19 and 20 analyse by sex the three-, five- and ten-year net survival rates respectively, in patients with lymph node recurrence and those without such recurrence. Table 21

summarises the net survival rates of the patients who had lymph node metastases at the first examination, the patients who developed lymph node

TABLE 16

LYMPH NODE RECURRENCE IN "NODE FREE" TUMOURS OF LIP

Y e a r s N u m b e r o f " n o d e f r ee"

cases

1936-55 179

1936-53 170

1936-48 140

L y m p h n o d e r ecu r r ence

Percentage o f N u m b e r o f cases " n o d e f r e e "

cases

(Wi th in 3 years) 22 12

(Wi th in 5 years) 22 13 l

(With in 10 years) 20 14

TABLE 17

LYMPH NODE RECURRENCE IN "NODE FREE" TUMOURS AT SITES OTHER THAN LIP (CASES ANALYSED BY SEX)

Y e a r s

1936-55

1936-53

1936-48

N u m b e r o f " n o d e f r ee" cases

Bo th sexes

Males Females

352 253 99

324 234 90

259 192 67

N u m b e r o f cases

Wi th in 3 years

Wi th in 5 years

Wi th in 10 yea r s

Bo th sexes

97

98

86

L y m p h n o d e r ecu r rence

Pe rcen tage o f " n o d e f r e e " cases

Females

21

24

19

Males

76

74

67

B o t h Males sexes

28 30

30 32

33 35

21

27

28

Fema le s

TABLE 18

THREE-YEAR SURVIVAL RATES, INFLUENCE (BY SEX) OF LYMPH NODE RECURRENCE IN "NODE FREE" GROUP SITES OTHER THAN LIP. YEARS 1936--55. 352 CASES--46 INDETERMINATE

L y m p h n o d e r e c u r r e n c e .

No l y m p h n o d e r ecu r r ence

N u m b e r o f " n o d e f r ee" cases

Bo th sexes

97

209

Males

76*

138

Fema le s

21~

71 i

N e t survival r a t e pe rcen tage

B o t h Males sexes

21 20

76 74

Females

25

79

* T w o died o f i n t e r cu r r en t disease a f t e r successful t r e a t m e n t o f l y m p h n o d e recur rence .

1" O n e d ied o f new p r i m a r y t u m o u r a f t e r successful t r e a t m e n t o f l y m p h n o d e recurrence .

TABLE 19

FIvE-YEAR SURVIVAL RATES. INFLUENCE (BY SEX) OF LYMPH NODE RECURRENCE IN "NODE FREE" GROUP SITES OTHER THAN LIP. YEARS 1936--53. 324 CASES--57 INDETERMINATE

L y m p h n o d e r e c u r r e n c e .

No l y m p h n o d e r ecu r r ence

N u m b e r o f " n o d e f r e e " cases

Bo th sexes

98

169

i Ma les t

7 4 *

i 113 I

Fema le s

24

56

N e t surv iva l r a t e pe r cen t age

Bo th Males sexes

19 15

66 65

Females

29

70

* O n e died o f a n i n t e r cu r r en t disease, a n d one died o f a n e w p r i m a r y t u m o u r , a f t e r successful t r e a t m e n t o f l y m p h n o d e recur rence .

M A L I G N A N T T U M O U R S OF T H E B U C C A L C A V I T Y : A C L I N I C A L A N A L Y S I S

TABLE 20

TEN-YEAR SURVIVAL RATES. INFLUENCE (BY SEX) OF LYMPH NODE RECURRENCE IN "NODE FREE" GROUP SITES OTHER THAN LIP. YEARS 1936--48. 259 CASES--69 INDETERMINATE

307

Lymph node recurrence.

No lymph node recurrence

Number of "node free" cases

Both sexes

86

104

Males

67*

67

Females

19t

37


Both Males sexes

10 6

46 43

Females

24

51

Two died of intercurrent disease, and one was lost trace of, after successful treatment of lymph node recurrence.

One died of an intercurrent disease, and one died of a new primary tumour, after successful treatment of lymph node recurrence.

metastases after the successful control of the primary and the patients who never developed lymph node metastases. Lip cancer is excluded from this table. Three facts emerge:--

1. The survival rate of patients who develop lymph node metastases, whatever the stage in the history of the disease, is roughly one-fourth of the survival rate of those patients who never develop them.

2. The survival rate of patients with lymph node metastases appearing for the first time after control of the primary growth is only slightly better than those who have involved lymph nodes at the first examination.

3. The survival rate is higher in women than in men in the group which develops lymph node recurrence after the control of primary, as well as in the group which never develops metastases. This contrasts with the more equal survival rates in the two sexes where the patients had lymph node metastases when first examined.

TABLE 21

INFLUENCE OF LYMPH NODE METASTASES ON SURVIVAL RATES

SITES OTHER THAN LIP

Three-year net survival rate percentage .

Five-year net survival rate percentage .

Ten-year net survival rate percentage .

Years

936-5

[936-5

L936-4

"Node involved"

19

14

"Node free"

L3 mph N o lymph I n ~de node

,'ct rrence recurrence

21 76

19 66

10 46

JE*06 )

COMPARISON OF SURVIVAL RATES IN TH E TWO TEN-YEAR PERIODS

A comparison has been made of the results in the two ten-year periods, tumours of the lip and tumours at sites other than lip being considered separately. The three-year survival rates of the cases seen from 1936 to 1945 are compared with those of the eases seen from 1946 to 1955. For comparing the five-year survival rates, cases seen in the years 1954 and 1955 have to be excluded. To make the series in the two periods comparable, cases seen in the years 1944 and 1945 are omitted. Similarly the ten-year survival rates of the cases seen from 1936 to 1938 are compared with those of the cases seen from 1946 to 1948.

This comparison is outlined in Tables 22, 23 and 24. At sites other than lip there is a significant improvement in the survival rates in the second period over the survival rates in the first period. The variations in the survival rates in cancer of the lip are of little significartce because of the small number of cases.

There are several factors which may be responsible for the improved survival rates : - -

1. Improved techniques of radiotherapy, surgery and artaesthesia, and the use of antibiotics.

2. The increased percentage of females in the second period. The better prognosis in women has been emphasised previously.

3. In the second period more patients were treated by a combination of radiotherapy and surgery (Table 25).

SUMMARY

1. Nine hundred and seventy cases of malignant tumours of the buccal cavity have been analysed. Over one-fifth of the lip cancers and more than one-half of the other buccal cavity turnouts had


TABLE 22

COMPARISON OF THREE-YEAR SURVIVAL RATES IN THE TWO PERIODS, 1936--45 AND 1946--55

Site

Lip

Sites other than lip

Years cases total

1936-4511~-0 131

1946-55 52

1936-45 448 400

1946-55 295 256

Crude Net All Net survival survival

total rate rate percentage percentage

66 80

67 66 85

31 34

37 43

TABLE 23

COMPARISON OF FIVE-YEAR SURVIVAL RATES IN THE PERIODS, 1936--43 AND 1946--53

Two

Site

Lip


Years

1936-43

1946-53

1936-43

1946-53

All ,~ase~

726 58

244

Crude Net Net I survival] survival total rate rate

pe_~centa e I percentage

78

23

37

COMPARISON

TABLE 24

OF TEN-YEAR SURVIVAL RATES IN THE TWO PERIODS, 1936--38 AND 1946-48

Site

Lip


All i Crude Ne t [ survival

Years total rate cases Fpercentage

1936-38 43 I

946-48 25 13 24

1936-38 131 106 10

1946-48 110 83 15

Net survival

rate percentage

i 44

46

12

19

metastasised to regional lymph nodes when first seen.

2. Most of the tumours were squamous carcinomas. Nearly one-fourth of the tumours arising f rom the hard palate were malignant sialomas.

3. The incidence of multiple primary tumours was 12 per cent. One-third of the second tumours occurred in the buccal cavity,

4. The incidence of buccal cavity cancer is decreasing and the proportion of women is becoming greater.

5. Tumours of the lip have an overall five-year net survival rate of 76 per cent. At other sites the results are roughly uniform and about one-third of the net cases survive for five years.

6. At the present time a combination of radiotherapy and surgery appears to hold out the best hope for the patient.

7. Regional lymph node involvement is of serious significance. About one-fourth of the " node free " patients develop lymph node metastases within three years, and prognosis in these cases is almost as bad as those in which lymph nodes are involved when the patient is first seen. In the absence of regional lymph node

TABLE 25

METHODS OF TREATMENT IN THE TWO TEN-YEAR PERIODS

SITES OTHER THAN LIP

YEARS 1936--45: FOURTEEN CASES NOT TREATED

YEARS 1946--55: FOURTEEN CASES NOT TREATED

1936-45

Method of Treatment Number

Radiotherapy . r ~ ° f ~

Surgery . . 27

Radiotherapy and surgery . . 30

1946-55 I

Percentage [Percentage of all : Number I of all cases I of cases cases

treated _ _ _ _ trea_ted I

- - 8 - ~ - 172 61

6 36 13

7 73 26

metastases the survival rate shows a four-fold improvement.

8. The prognosis in females is better than that in males.

9. The results in the period 1946 to 1955 are better than those in the period 1936 to 1945.

Acknowledgements . - -I am grateful to the members of the staff o f the Royal Marsden Hospital , pas t and present, for their kind permission to publish their clinical material . I wish to acknowledge my debt to D r M. Lederman and Mr M. H. Harmer , without whose help, guidance and encouragement this review would not have been possible. The help rendered by Miss Susan Taylor of the Records Depar tment in the collection of data has been invaluable; I am very thankful to her for this assistance.

R E F E R E N C E S CADE, S. (1957). Northw. Med. (Seattle), 56, 1,431. GOODNER, J. T., & WATSON, W. L. (1956). Cancer, 9, 1,248. LEDERMAN, M. (1956). Brit. J. Radiol. 29, 605. LEDLm, E. M., & HARMER, M. H. (1950). Brit. J. Cancer,

4, 6. RUSSELL, M. H. (1954). Brit. Ted. J. 1, 430. RUSSELL, M. H. (1955). Brit. Ted. J. 2, 823.

Malignant tumours of the buccal cavity: A clinical analysis of 970 cases

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