Elliot W. Strong

Predictive value of tumor thickness in squamous carcinoma confined to the tongue and floor of the mouth

In this review of 105 consecutive patients who underwent operation for previously untreated, N0 squamous carcinomas arising in the oral tongue or the floor of the mouth, 86 percent of the determinate patients remained alive and well 2 years after treatment. Included were 48 patients, 49 patients, and 8 patients who had T1, T2, and T3 tumors respectively. Elective cervical lymphadenectomy was performed in about a third, but tumor staging did not facilitate selection of those who were most likely to have occult metastases. For this reason, we retrospectively assessed the impact of tumor thickness using an optical micrometer to measure the thickness in millimeters of the excised tumors in routinely prepared paraffin sections. Disease-related death appears to be unusual when oral tumors are thin (2 mm or less), regardless of the tumor stage. Multivariate analysis confirms that increasing tumor thickness, rather than tumor stage, had the best correlation with treatment failure and survival. These findings need to be verified in prospective studies involving a larger patient population and other head and neck sites, but they strongly suggest that measurement of tumor thickness may be a better way to select those oral cancer patients who are most likely to benefit from elective treatment of the N0 neck.

Adenoid cystic carcinoma of salivary origin. A clinicopathologic study of 242 cases.

In recent years, the term “adenoid cystic carcinoma” has won increasing acceptance as the one preferred for the unusual, malignant epithelial tumor that Billroth called “cylindroma” in 1856 [I-7]. Whatever the preference in nomenclature, neoplasms showing an adenoid cystic histologic pattern are quite uncommon and may arise in a variety of anatomic sites, including the paired salivary glands, the lacrimal gland [8,9], the mucous glands of the upper respiratory [IO] and digestive tracts [11,12], the skin [13,14], and the breast [15,16]. In this study, we shall focus on a sizable experience with adenoid cystic carcinoma arising in major and minor salivary (mucous) glands. Patients having similar tumors in the lacrimal glands or mucous glands of the trachea have been excluded, although other reports suggest that the clinical course is similar [8,10]. The designation of certain rare skin and breast tumors as “adenoid cystic” is somewhat misleading, inasmuch as the clinical course in such patients is quite different.

Granular cell myoblastoma

Ninety‐five patients with granular cell myoblastoma have been seen at Memorial Hospital from 1934‐1965. Their ages ranged from 11 months to 68 years, an average of 38.1 years. Symptoms were present from a few days to more than 5 years and principally consisted of the presence of a painless mass in 85 patients. The lesion is ubiquitous and of the 110 lesions, 51 arose in the head and neck, 19 in the arm, 24 in the chest wall and breast, 2 in the abdominal wall, 3 in the perineum, 7 in the leg, and 4 in miscellaneous sites. Multiple lesions were noted in 8 patients. Lesions varied from minute to 5.5 cm in diameter, with an average of 1.85 cm. Initial wide surgical excision was successful in 91 patients. Two more were salvaged by subsequent re‐excision. Three malignant lesions were encountered, one of which recurred and was cured by re‐excision. The other 2 failed all treatment. Follow‐up varied from 0 to 21 years with an average of 44.6 months. Granular cell myoblastoma is an uncommon lesion of uncertain histogenesis, almost universally benign and cured by adequate local resection.

Prognostic factors in differentiated carcinoma of the thyroid gland.

A retrospective review of a consecutive series of 931 previously untreated patients with differentiated thyroid carcinoma treated over a 50-year period was undertaken to analyze prognostic factors. Data pertaining to demographic status, clinical, operative, and pathologic findings, and survival were analyzed. Univariate statistical analysis was performed based on the Kaplan-Meier method and the log-rank test. Multivariate analysis was performed to assess the independent effect of these variables using the Cox model. There were 630 female and 301 male patients, with an average age of 43 years. A total of 532 patients were younger than 45 years. Seven hundred thirty-one patients had either pure or mixed papillary carcinoma, and 200 had follicular carcinoma. In 153 patients, lesions were larger than 4 cm. Extrathyroidal extension was noted in 71 patients. Multifocal lesions were present in 159 patients. Regional lymph node metastasis was present on admission in 451 patients, and distant metastases were noted on presentation in 45 patients. Determinate survival for all patients was 87% at 10 years. Favorable prognostic factors using univariate analysis included female gender, multifocal primary tumors, and regional lymph node metastases. Adverse prognostic factors included age over 45 years, follicular histology, extrathyroidal extension, tumor size exceeding 4 cm, and the presence of distant metastases. On multivariate analysis, the only factors that affected the prognosis were patient age, histology, tumor size, extrathyroidal extension, and distant metastases. These observations support findings of reports from the Mayo Clinic and Lahey Clinic regarding the significance of prognostic factors for differentiated carcinoma of the thyroid gland.

Significance of Positive Margins in Oral Cavity Squamous Carcinoma

Three hundred ninety-eight consecutive, previously untreated patients undergoing surgery for epidermoid carcinoma of the oral cavity from 1979 to 1983 were reviewed. One hundred twenty-nine patients were classified as having positive surgical margins. Of these, 83 patients had tumor within 0.5 mm of the surgical margin, 9 had premalignant changes at the margin, 9 had in situ carcinoma at the margin, and 28 had invasive cancer at the margin. The remaining 269 patients had uninvolved margins. The significance of positive margins relating to survival, subsequent clinical course, local recurrence, and patterns of treatment failure was examined, along with the impact of adjuvant postoperative radiotherapy on positive margins. The percentage of patients having positive margins progressively increased with increasing T stage: 21% in T1 versus 55% in T4 primary cancer. The overall 5-year survival for patients with negative margins was 60%. For patients with positive margins, 5-year survival was 52%. This difference was statistically significant. The incidence of local recurrence in patients having positive surgical margins was twice as much as in those with negative margins (36% versus 18%). Metastasis rates in the neck and at distant sites were not significantly influenced by the status of the surgical margin. Of the 129 patients with positive margins, 49 received postoperative radiotherapy. In those patients so treated, a trend toward lower recurrence rates was noted. Differences were not statistically significant. This retrospective review confirms the importance of adequate resection of the primary tumor as well as the relative ineffectiveness of adjuvant postoperative radiotherapy in the improvement of local control in patients with positive surgical margins.

The indications for elective treatment of the neck in cancer of the major salivary glands

To define the indications for elective neck treatment, the cases of 474 previously untreated patients were reviewed who had locally confined major salivary gland cancers treated between 1939 and 1982, Clinically positive nodes were present in 14% (67 of 474). Overall, clinically occult, pathologically positive nodes occurred in 12% (47 of 407). By univariate analysis, several factors appeared to predict the risk of occult metastases; however, multivariate analysis revealed that only size and grade were significant risk factors. Tumors 4 cm or more in size had a 20% (32 of 164) risk of occult metastases compared with a 4% (nine of 220) risk for smaller tumors [P < 0.00001). High‐grade tumors (regardless of histologic type) had a 49% (29 of 59) risk of occult metastases compared with a 7% (15 of 221) risk for intermediate‐grade or low‐grade tumors [P < 0.00001). In view of the low frequency of occult metastases in the entire group, routine elective treatment of the neck is not recommended. High‐grade tumors and larger tumors have a high rate of occult neck metastases, and treatment should be considered in this group.

Cervical node metastasis from epidermoid carcinoma of the oral cavity and oropharynx: A critical assessment of current staging☆

Abstract The clinical and histologic status of cervical lymph nodes has been correlated with the results of treatment in 1,069 consecutive patients who underwent radical neck dissection as part of the initial treatment of a primary epidermoid carcinoma arising in either the oral cavity or oropharynx. The influence on “cure” rates of size, number, location, and fixation of involved nodes, correlated with the specific site of origin within the oral cavity, was evaluated in determinate patients with proved nodal metastasis. As the extent of lymph node involvement increased from solitary to multiple ipsilateral and to bilateral enlarged nodes, cure rates dropped progressively. Survival was not invariably decreased in those whose involved nodes were large or considered fixed, and there was considerable variance among examiners when size and fixation were evaluated. These data suggest that the N system of staging presently advocated might be improved. Rather than designating contralateral or bilateral node involvement as N 2 , this category might be reserved for those with multiple ipsilateral cervical node metastases. Those with contralateral and bilateral as well as so-called fixed metastases might better be relegated to the N 3 category. The results of treatment were uniformly poor in the latter group of patients, provided the term “fixed” indicated immobility of involved lymph nodes and not merely the presumption that tumor had extended beyond the capsule of the node.

Carcinoma of the oral cavity: Factors affecting treatment failure at the primary site and neck☆

A retrospective review of the clinical records of patients with carcinoma of the oral cavity was undertaken, and several parameters were studied in terms of comparing two groups of patients: those who were controlled at the primary site and neck and others who failed locally or regionally following initial treatment. A comparative statistical analysis of the factors studied revealed that female patients who had a higher T status, a higher N status, and thus a higher stage of disease did poorly in terms of local and regional control of disease. Those patients whose primary tumors manifested deep invasion and those who had positive margins after surgical resection at the primary site had also a significantly high incidence of local/regional failure. Presence of extracapsular extension of disease in cervical lymph nodes and involvement of soft tissues in the neck as well as involvement of multiple lymph nodes at multiple levels also put the patients in a high risk category. We urge that these factors be considered as prognostic criteria and be used to select patients for treatment by additional modalities on an elective basis in hope of achieving better local and regional control of disease and perhaps better cure rates.

Ameloblastoma of maxilla and mandible

Results of various treatment modalities in 72 patients with ameloblastoma of mandible and 20 patients with ameloblastoma of maxilla are analyzed. Controversial methods of treatment are discussed to arrive at a semblance of rational management. It was found that: 1. Curettage was followed by local recurrence in 90% of mandibular and all maxillary ameloblastomas; 2. Subsequent resection could control 80% of mandibular but only a fraction of maxillary recurrences; 3. Marginal resection, in a few selected cases, might control primary cases of mandibular ameloblastoma but is not a useful procedure for recurrent mandibular ameloblastoma; 4. External radiation therapy was ineffective in controlling ameloblastoma but did not seem to adversely affect prognosis even after subsequent resection; and 5. Distant metastases, although rare, occurred in 7 patients.

Detailed quality of life assessment in patients treated with primary radiotherapy for squamous cell cancer of the base of the tongue

This study was conducted to evaluate quality of life in patients treated with primary radiotherapy (RT) for cancer of the base of tongue.