THE MANAGEMENT OF MOUTH CANCER

R. G. WILLIAMS T.D., F.R.C.S.

Consultant ENT Surgeon, Hull Royal Infirmary, East Yorkshire

CAN(ER 01F THE MOUTH is relatively rare in this country; about 36 new cases occur in a population of one million in a year'. In South-East Asia it is relatively common to find canlcer in the mouth; of 48,082 patients seen at the Tata Memorial Hospital, Paymaster2 found that 6,992 (150) had oral cancer. In Britain the tongue is the most frequent organ involved; in India and Pakistan it is the cheek or buccal mucosa. T'he first major study of oral cancer was made by Sir Henry Butlin in a classic monograph, Diseases of the 7'ongue, published in 1885'. Surgical interest in mouth cancer was sustained by Wilfred Trotter during the early decades of this cenitury; he stressed the central problem in clinical management namely, a method of effectively treating the average case, which was, and still is, the moderately advanced case'. To a limited extent a solution has been found in the past 20 years throuigh advances in surgery. A review of modern surgical niethods will form the main part of this lecture.
Irradiation therapy for mouth cancer Major strides have also been made in recent years in radiotherapy. Perhaps the most useful has belen the general availability of high-energy therapy usinig cobalt-60 in place of the older 250-kV radiotherapy plant. High-energy irradiation has a skin-sparing effect, but it does not affect the basic biological response of tumours to irradiation. ChurchillDavidson" has used hyperbaric oxygen therapy as a supplement to irradiation, in order to obtain an improved response. The possibilities of improved results through combining irradiation therapy with surgery have been described by Rush and Greenlaw', and the closer integration of surgery and radiotherapy probably olfers the best prospects of improving results in the future.

Chemotherapy for mouth cancer An entirely niew development has been intra-arterial chem)otherapy lor the control of advanced mouth cancer. Chemotherapy has been used alone7 aid in conljunlctioil with radiotherapys. It has also been eniployed as a supplement to surgery). Harrison1" has used hypothernlia as all
Postgraduate Lecture

(Ann. Roy. Coll. Surg. Engl. 1973, vol. 52) 49

R. G. WILLIAMS

adjunct to chemotherapy in order to protect the bone marrow from the inevitable leakage of the agent into the systemic circulation. With the chemotherapeutic agents available at present the results for advanced mouth cancer have not been good. Surgery for mouth cancer Postoperative infection in the mouth and lungs held up any hopc of progress in surgical treatment until the development of antibiotics in the 1940s. With the major advances in anaesthesia, there was then a new impetus to surgery. The results obtained during the following decades can now be analysed. Carcinoma of the tongue. Frazell and Lucas"1 reviewed a very large series of 1,554 patients with cancer of the tongue seen at Memorial Hospital, New York, between 1939 and 1952. Cervical lymph node metastases were present in 40%/, of cases when first seen. In the course of time two-thirds of the patients developed lymph node metastases. It is of interest that the initial complaint in 310/% of patients with carcinoma of the posterior third of the tongue was of development of a symptomless lump in the neck. After 1953 about 90%/O of these patients were treated by surgery. Partial glossectomy gave a 5-year survival rate of 57%/O (218/381). For the more advanced cases glossectomy combined with partial mandibulectomy and block dissection of the neck yielded a 5-year survival rate of 300/, (68/227). The most recent surgical development has been in techniques intended to maintain the mobility of the tongue following extensive ablative surgery. McGregor'2 used the versatile full-thickness forehead flap employed for many years in the reconstruction of the nose. He showed that a forehead flap could be introduced into the oral cavity through an incision below the zygomatic arch parallel with the branches of the facial nerve without causing facial paresis. Bakamjian" used a skin flap from the neck which included the underlying sternomastoid muscle in order to increase its blood supply. It was introduced into the oral cavity from the region of the angle of the mandible, after a partial mandibulectomy. This flap can resurface the posterior part of the tongue and tonsillar region. A method of restoring mobility to a tongue which has become tethered as a result of extensive surgery was described by Corso and Gerold'4. They draped a split skin graft round a mould which was buried under the mucosa of the tethered part of the tongue. The mould was subsequently removed, exposing the grafted area. Carcinoma of the gum. The results of treatment of 606 patients with cancer of the gum during the period 1942 to 1961 were reported 50

THE MANAGEMENT OF MOUTH CANCER

by Cady and Catlin15. Surgery was employed exclusively after 1946. Eighty per cent of the tumours were of the lower jaw gum. Lymph node involvement was present in 370/% of cases when they were first seen. The overall 5-year cure rate was 51.5%. Partial full-thickness resection of the mandible is often necessary in the surgical treatment of gum cancer. It results in a variable degree of mandibular swingover. Efforts are usually now made to restore mandibular continuity at the time of surgery. Cook"' has described metal implants used for this purpose. Mandibular implants sometimes become infected or exposed, and then have to be removed. If they are screwed or bolted on to the bony mandible, their removal becomes a major procedure (although simpler than the difficulties of removing metal mesil or gauze). A more simple method of stabilizing the mandible is to use a piece of stout Kirschner wire bent to the appropriate shape, as described by Sako and Marchetta1 7. The wire is thrust into the exposed medulla of the two cut surfaces of the mandible. If the need arises, it is easily removed. MacDougall"' has improved this technique by inserting a rib graft at a later stage.
Carcinoma of the floor of the mouth. Carcinoma of the floor of the mouth is very prone to spread both on to the adjacent mandibular guIml and into the substance of the tongue. Harrold19 found this was present in 77% of the 930 patients he reviewed. Bony involvement of the mandible had taken place in 15% of his cases. He found that cervical lymph node metastases were present at first examination in 39%/, of the patients. Cancer of the floor of the mouth often crosses the midline of the floor of the mouth, and contralateral metastases may appear. Harrold reported a 5-year survival rate of 75% when metastases were absent and 23% when they were present. A difficult problem arises when the body of the mandible, including the symphysial region, is resected. A stout Kirschner wire can be used in the manner described to anchor the tongue and to minimize the gross deformity that otherwise results. A more ingenious repair has been (lescribed by Millard20. Carcinoma of the cheek (buccal mucosa). Squamous cell carcinoma of the buccal mucosa is often associated with leukoplakia, and a wide excision is therefore necessary. Relining of the resulting defect can sometimes be achieved by simple advancement of the remaining buccal mucosa after extensive undermining posteriorly and superiorly. L3uccal mucosa has considerably natural elasticity. The alternative is to resurface the buccal surface with split skin grafts. Split skin grafts in the oral cavity take well if appropriate modifications of technique are employed as described by Slanetz and Rankow21, Fister and 51

R. G. WILLIAMS

Sharp22", and Helsper and Fister23. The old-fashioned antiseptic called BIPP (bismuth subnitrate and iodoform paste, B.P.C. 1954) can be used to impregnate the bolus or 'tie-over' dressings. A full-thickness resection of the cheek should be repaired at the same time as excision when possible, using a skin flap from the neck with internal lining from buccal mucosa advancement flaps24.
Role of the dental surgeon in management of mouth cancer The dental surgeon had a very important role in the rehabilitation of those patients with prostheses described by Geddes25. The diagnosis of mouth cancer by the dental surgeon has been discussed by Ward2.

Conclusion Although cancer of the mouth is a relatively uncommon disease in this country when compared with its incidence in South-East Asia, 93 new cases were seen in a 5-year period at a provincial general district hospital27. The best final results were undoubtedly in those patients who were successfully treated by radiotherapy. Unfortunately, many patients were first seen when the disease was already advanced, often with lymph node metastases present in the neck. It is for these cases that the surgical management of mouth cancer offers an increased prospect of cure.
REFERENCES worths. 3. BUTLIN, H. T. (1885) Diseases of the Tongue. London, Cassell. 4. TROTTER, W. (1913) Lancet, 1, 1075. 5. CHURCHILL-DAVIDSON, I. (1967) in Modern Trends in Radiotherapy, ed. T. J. Deeley and C. A. P. Wood, p. 73. London, Butterworths. 6. RUSH, B. F., and GREENLAW, R. H. (1968) Cancer Therapy by Integrated Radiation and Operation. Springfield, Ill., Thomas. 7. KLOPP, C. T., SMITH, D. F., and ALFORD, T. C. (1961) Amer. J. Surg., 102, 830. 8. FRIEDMAN, M., DE NARVAES, F. N., and DALY, J. F. (1970) Cancer, 20, 711. 9. DESPREZ, J. D., KIEHN, C. L., ScIoTTo, C., and RAMIREZ-GONZALES, M. (1970) Amer. J. Surg., 120,461. 10. HARRISON, D. F. N. (1969) Geriatrics, 24, 87. 11. FRAZELL, E. L., and LUCAS, J. C. (1962) Cancer, 15, 1085. 12. MCGREGOR, I. A. (1963) Brit. J. plast. Surg., 16, 318. 13. BAKAMJIAN, V. (1963) Plast. reconstr. Surg., 31, 103. 14. CORSO, P. F., and GEROLD, F. P. (1962) Amer. J. Surg., 104, 727. 15. CADY, B., and CATLIN, D. (1969) Cancer, 23, 551. 16. COOK, H. P. (1968) Ann. roy. Coll. Surg. Engl., 42, 233. 17. SAKO, K., and MARCHETTA, F. C. (1962) Amer. J. Surg., 104, 715. 18. MACDOUGALL, J. A. (1965) Amer. J. Surg., 110, 562. 19. HARROLD, C. C. (1971) Amer. J. Surg., 122, 487. 20. MILLARD, D. R., CAMPBELL, R. C., STOKLEY, P., and GARST, W. (1969) Amer. J. Surg., 118, 726. 21. SLANETZ, C. A., and RANKOW, R. M. (1962) Amer. J. Surg., 104, 721. 22. FISTER, H. W., and SHARP, G. S. (1963) Amer. J. Surg., 106, 709. 23. HELSPER, J. T., and FISTER, H. W. (1967) Amer. J. Surg., 114, 596. 24. RUSH, B. F., and HUMPHREY, L. (1967) Amer. J. Surg., 114, 592. 25. GEDDES, M. (1969) Ann. roy. Coll. Surg. Engl., 44, 334. 26. WARD, T. G. (1967) Ann. roy. Coll. Surg. Engl., 44, 334. 27. WILLIAMS, R. G., and WOODCOCK, F. R. (1969) Brit. J. oral Surg., 6, 181.
1. PETERSEN, N. C., BODENHAM, D. C., and LLOYD, 0. C. (1962) Brit. J. plast. Surg., 15, 49. 2. PAYMASTER, J. C. (1967) in Cancer of the Head and Neck, ed. J. Conley, p. 308. Washington, Butter-

52