Carcinoma of the oral cavity

A Current Review of Machine Learning and Deep Learning Models in Oral Cancer Diagnosis: Recent Technologies, Open Challenges, and Future Research Directions

Cancer is a problematic global health issue with an extremely high fatality rate throughout the world. The application of various machine learning techniques that have appeared in the field of cancer diagnosis in recent years has provided meaningful insights into efficient and precise treatment decision-making. Due to rapid advancements in sequencing technologies, the detection of cancer based on gene expression data has improved over the years. Different types of cancer affect different parts of the body in different ways. Cancer that affects the mouth, lip, and upper throat is known as oral cancer, which is the sixth most prevalent form of cancer worldwide. India, Bangladesh, China, the United States, and Pakistan are the top five countries with the highest rates of oral cavity disease and lip cancer. The major causes of oral cancer are excessive use of tobacco and cigarette smoking. Many people's lives can be saved if oral cancer (OC) can be detected early. Early identification and diagnosis could assist doctors in providing better patient care and effective treatment. OC screening may advance with the implementation of artificial intelligence (AI) techniques. AI can provide assistance to the oncology sector by accurately analyzing a large dataset from several imaging modalities. This review deals with the implementation of AI during the early stages of cancer for the proper detection and treatment of OC. Furthermore, performance evaluations of several DL and ML models have been carried out to show that the DL model can overcome the difficult challenges associated with early cancerous lesions in the mouth. For this review, we have followed the rules recommended for the extension of scoping reviews and meta-analyses (PRISMA-ScR). Examining the reference lists for the chosen articles helped us gather more details on the subject. Additionally, we discussed AI's drawbacks and its potential use in research on oral cancer. There are methods for reducing risk factors, such as reducing the use of tobacco and alcohol, as well as immunization against HPV infection to avoid oral cancer, or to lessen the burden of the disease. Additionally, officious methods for preventing oral diseases include training programs for doctors and patients as well as facilitating early diagnosis via screening high-risk populations for the disease.

Risk factors for relapse of middle-stage squamous cell carcinoma of the submandibular region and floor of mouth: the importance of en bloc resection

Our aim was to investigate retrospectively the rate of recurrence in the intervening region for middle-stage squamous cell carcinoma (SCC) of the tongue and identify the factors that predict relapse and prognosis. A total of 204 patients were included, 96 in the en bloc group and 108 in the control group. The groups were comparable. Two patients in the en bloc group (2%) and 12 in the control group (11%) developed recurrences in the intervening region. Kaplan-Meier analysis showed a reduction in the 5-year disease-specific survival once a recurrence had developed after the primary operation (77% compared with 14%, p<0.001). The en bloc group developed significantly fewer recurrences (2%) than the control group (11%) during the five years; p=0.037), and also had better 5-year disease-specific survival (80% compared with 66%, p=0.04). Cox's multivariate regression indicated that the pathological nodal status (p=0.016) and surgical technique (p=0.037) were independent predictive factors for the 5-year recurrence rate, as well as of 5-year disease-specific survival (p=0.001 and p=0.050, respectively). Recurrence in the intervening region is a negative prognostic factor for these patients, and we recommend en bloc resection as the management of choice for middle-stage SCC of the tongue.

Magnetic resonance imaging predicts survival and occult metastasis in oral cancer: a dual-centre, retrospective study

The purpose of this study was to investigate the effectiveness of tumour variables measured on magnetic resonance imaging (MRI) to predict 2-year disease-related survival and occult cervical lymph node metastasis in oral carcinoma. In this retrospective, dual-centre study the volume and thickness of tumours were measured using archived MRI staging scans of 199 patients who had curative primary resection for histologically confirmed oral carcinoma. Tumour volume predicted survival when grouped using the median (3.0 cm(3), HR 3.41, p 0.005) and first and third quartiles (0.5 cm(3), HR 8.22, p 0.04; 8.0 cm(3), HR 18.6, p 0.005). Tumour thickness predicted survival using a median of 11.0 mm (HR 2.65, p 0.02). Volume predicted occult cervical lymph node metastasis using a median of 3.0 cm(3) (HR 5.02, p<0.001) and quartiles of 0.5 cm(3) (HR 6.92, p=0.01) and 8.0 cm(3) (HR 11.3, p 0.005); thickness predicted it using a median of 11.0 mm (HR 4.39, p 0.002) and quartiles of 4.0 mm (HR 4.33, p 0.06) and 16 mm (HR 11.9, p 0.003). The thickness and volume of tumour measured on MRI may predict 2-year disease-related survival and occult cervical lymph node metastasis in oral cancer.

[Preoperative radiochemotherapy for advanced oral cavity tumours : the Kiel DOSAK experience regarding curability and quality of life]

BACKGROUND

According the guidelines of the German-Austrian-Swiss Council for maxillary and facial tumours (DOSAK), patients with advanced oral cavity tumours underwent preoperative radiochemotherapy followed by radical surgery. The results were to be evaluated with regard to curability and quality of life and compared with the current literature.

PATIENTS AND METHODS

Between 1993 and 1998, 52 patients were treated. Radiotherapy up to a total dose of 36 Gy was combined with one cycle of cisplatin (12.5 mg/m2, days 1-5) chemotherapy. Besides clinical data concerning radiogenic toxicity and surgical complications, quality of life after therapy was of special interest.

RESULTS

Three years after therapy 33 of 52 patients (63.5%) were alive, and after 5 years 19 of 33 patients (57.6%) were still alive. Seven patients (14.6%) had a local recurrence. Side effects of radiotherapy according RTOG scoring were minor; only one patient (1.9%) had grade 3 toxicity. Of 48 patients, 9 (18.7%) had no surgical complications. Quality of life was good in only 14 patients (29.2%); all the other patients (70.8%) suffered from impaired quality of life.

CONCLUSIONS

Preoperative radiochemotherapy in advanced oralcavity carcinomas with subsequent radical surgery is an effective treatment regarding long-term survival. The treatment is burdened by lasting impaired quality of life. High scientific priority should hence be directed to a steady improvement of quality of life in these patients.

Current management of tonsillar cancer

Traditionally, risk factors for the development of tonsil cancer include the use of alcohol and/or tobacco, however a significant proportion of new cases develop in young patients without these risk factors. Recent investigation suggests that human papilloma virus (HPV) may serve as an etiology in such cases and represent a unique risk factor in a sub-set of patients. Irrespective of the etiology, in the majority of cases early carcinoma of the tonsil can effectively be treated using single modality therapy. While local-regional control and survival are similar following surgery or radiotherapy, primary surgery can be accomplished with minimal functional morbidity while reserving radiation for recurrent disease. In contrast, surgical salvage following external beam radiotherapy can be technically challenging and is often associated with a significant increase in surgical complications and functional morbidity. In contrast to early tonsillar disease, advanced tonsil cancer represents a clinical challenge that requires multimodality therapy. While advanced lesions are often treated with a combination of radiation, chemotherapy, and surgical ablation, management of the neck and distant metastases continues to present a therapeutic dilemma.

Importance of tumour thickness measurement in prognosis of tongue cancer

Eighty-one patients who underwent surgery for cancer of the tongue were retrospectively studied to evaluate the influence on survival of some clinical and pathologic parameters. These parameters and data on the patient's current status were gathered by the study of tissue sections, using haematoxylin-eosin staining, and from medical records. The 5-year survival rate was 68.5%. Univariate analysis showed that the parameters influencing survival were: T (P<0.01), pathologic T (P<0.01), N (P<0.05), pathologic N (P<0.05), extracapsular nodal spread (P<0.05), locoregional recurrence (P<0.01), and tumour thickness (P<0.05). Multivariate analysis showed that tumour thickness had the greatest influence on survival. Patients with tumour thickness of < or = 3 mm had a 5-year survival of 85.7%, significantly greater (P<0.05) than the rates of 58.3 and 57% for patients with tumour thickness of 4-7 mm and >7 mm, respectively. Wider studies are required to unify criteria for the measurement of this important prognostic parameter.

Metastatic cancer to the floor of mouth: the lingual lymph nodes

BACKGROUND

The upper level of a cervical lymphadenectomy is anatomically defined at its anterior extent by the lower border of the mandible and, in surgical practice, by the lingual nerve. A neck dissection completed below this level is generally considered adequate for removal of lymph nodes at risk for metastases from oral cavity cancer. Traditional discontinuous neck dissections do not provide for removal of floor of mouth tissue along with the primary and neck specimens.

METHODS

A case report presenting biopsies from a T2N2bM0 squamous cell carcinoma of the mobile tongue and adjacent floor of the mouth in a 73-year-old man.

RESULTS

Deep biopsy of a ventral tongue and floor of mouth squamous cell carcinoma revealed occult metastatic cancer to lymph nodes located in the superficial floor of mouth associated with the sublingual gland above the lingual nerve. This report identifies floor of mouth lymph nodes that can be involved with cancer and missed through the standard practice of discontinuous neck dissection.Conclusions. This finding offers evidence that, in certain cases, a traditional discontinuous neck dissection may not address all lymph nodes at risk in the treatment of oral cavity cancer. Further investigation into lymph node distribution within the oral cavity is warranted to reappraise the upper limits of cervical lymphadenectomy.

Squamous cell carcinoma of the oral cavity. A review of 176 cases with application of malignancy grading and DNA measurements

This retrospective study comprised 176 patients with squamous cell carcinoma of the oral cavity treated at The Linköping University Hospital over a 19-year period. Clinical parameters, microscopic malignancy grading (according to Jakobsson et al. and Glanz and Eichhorn), DNA cytofluorometry, analysis of therapeutic modalities and statistics regarding survival and prognosis are reported. The mean age was 70 years with a male: female ratio of 1.3:1 One hundred and four patients had T1 or T2 tumours and 109 an N0 neck. Cervical lymph node metastases were more frequent in patients with larger tumours (T3 + T4) than in those with smaller (T1 + T2) (P less than 0.01), in tumours with a high malignancy grading compared to those with a low (P less than 0.05) and in DNA non-diploid tumours compared to diploid ones (P less than 0.001). The aneuploid tumours responded better to preoperative radiotherapy than did diploid (P less than 0.01) or polyploid (P less than 0.05) tumours. Eighty-nine per cent of the recurrences occurred within 1 year of initial therapy. Secondary treatment was successful in 15 of 37 (41%) patients in whom the tumour recurred either at the primary site or in regional lymph nodes, but only in 1 of 8 (12%) with recurrences in both locations. Surgery alone or combined with radiotherapy resulted in equivalent survival rates for tumours in stages I and II. In advanced stages combined radiotherapy and surgery gave better survival figures than either modality alone (P less than 0.01; Kaplan-Meier). The presence of lymph node metastases (P less than 0.001), tumour size (P less than 0.01) and tumour ploidy (P less than 0.005) were the only clinical and histological parameters that significantly influenced survival (Cox regression analysis). Twenty-four patients developed a secondary primary malignancy; 21 of these were located in the aerodigestive tract.

Squamous cell carcinoma antigen in the diagnosis and treatment follow-up of oral and facial squamous cell carcinoma

The squamous cell carcinoma (SCC) antigen was determined by radioimmunoassay in the serum of 40 untreated patients with SCC of the oromaxillofacial region. The mean (+/- SEM) serum concentration for these patients (3.8 +/- 0.8 ng/ml) was significantly higher than that of 52 disease-free patients coming to routine postoperative care (1.2 +/- 0.1 ng/ml) and of 74 healthy controls (1.1 +/- 0.07 ng/ml). Using a arbitrary limit of 2.2 ng/ml, pathologic serum levels of SCC were observed in 15 (38%) of 40 untreated patients, whereas only four (7.7%) of 52 tumor-free patients revealed an elevated serum SCC. Serial measurements of SCC were pretherapeutically available in 28 patients as well as during individual therapy and further follow-up. All but one of these patients had a normal serum SCC postoperatively. The authors' results demonstrate that the clinical value of SCC lies mainly in monitoring the course of the disease. Careful follow-up studies should be undertaken to determine whether serial determination of SCC is promising in early prediction of tumor reoccurrence.

Oncologic and functional considerations of total glossectomy

The efficacy of total glossectomy for advanced carcinoma of the tongue remains controversial. A retrospective chart review was undertaken to evaluate the oncologic and functional results in 17 consecutive patients who underwent this procedure. There were two patients with stage III disease, eight with stage IV disease, and seven with recurrent disease. The larynx was preserved in seven patients. One patient required a secondary laryngectomy. All patients were reconstructed immediately, 11 with a pectoralis major myocutaneous flap and 6 with free-tissue transfer. The operative mortality was 6 percent; the morbidity was 59 percent. At last follow-up, 53 percent of the patients were alive without disease, with a mean disease-free survival period of 36 months. Ninety-three percent of the patients regained swallowing and independent oral alimentation; 80 percent of those with laryngeal preservation regained intelligible speech. We have concluded that total glossectomy should be considered as a primary modality for advanced carcinoma of the tongue and not solely reserved for salvage in hopeless situations. With or without laryngectomy, excellent survival and functional results can be obtained.

Carcinoma of the tonsillar region: surgical complications relative to the type of reconstruction

The local and general complications in a series of 122 patients treated surgically for carcinoma of the tonsillar region are reported. Eighty-five of these patients were submitted to reconstruction with local or distant flaps, and in the remaining 37 patients primary closure was achieved. 28.2% of the flaps underwent marginal necrosis, and 11.8% total necrosis. Infection and the proportion of general complications were significantly higher in those patients submitted to reconstruction with flaps, whereas fistulae, necrosis of the cervical skin, rupture of the carotid artery and common general complications were not. Significant differences were not observed with respect to viability nor to complications between the different types of flaps, so that the choice of flaps should be based exclusively on other properties inherent in each flap.

Functional restoration after subtotal glossectomy and laryngectomy

Extensive resection of carcinoma that involves the tongue base and supraglottic larynx is accompanied by significant potential morbidity and mortality. This is often indicated by poor rates of cure and the limited palliation afforded by radiotherapy alone. Removal of a significant portion of the posterior tongue frequently results in intractable aspiration. Techniques in reconstruction of the oropharyngeal defect and tongue base have included primary closure, random flaps, and myocutaneous flaps. Each of these techniques has been successful, to some degree, in resurfacing pharyngeal defects. However, the functional results in regard to deglutition are less than satisfactory as a result of aspiration. Frequently, simultaneous or delayed total laryngectomy is performed to deal with the pulmonary complications. Various types of laryngoplasty do not uniformly correct the problems of aspiration and deglutition associated with subtotal glossectomy. Our experience includes eight patients who had advanced squamous cell carcinoma of the tongue base, vallecula, and the supraglottic larynx. All patients underwent partial or subtotal glossectomy and laryngectomy. The mucosal defect was reconstructed with pectoralis myocutaneous flap. In order to reestablish voice, a primary tracheopharyngeal shunt was created with the use of a portion of cricoid and upper trachea. The majority of these patients have had successful rehabilitation of deglutition, mastication, and speech.

DNA content, malignancy grading and prognosis in T1 and T2 oral cavity carcinomas

Microscopic malignancy grading using the 8-factor system proposed by Jakobsson et al. (1973), the 4-factor system set up by Glanz and Eichhorn (1985), and DNA cytofluorometry were applied to thirteen T1 and thirty-seven T2 squamous cell carcinomas of the oral cavity, 9 with and 41 without metastases. There was a significant correlation between the presence of lymph node metastases (N1) and the malignancy scores (P less than 0.05) and tumour DNA ploidy (P less than 0.01, chi-square). The total number of patients with initial and late lymph node metastases correlated significantly with polyploid nuclei (P less than 0.05) and with malignancy scores (P less than 0.001), which also correlated with regional recurrences (P less than 0.01, chi-square). No remaining tumour after preoperative radiotherapy indicated less risk for local recurrence than if tumour persisted (P less than 0.01, chi-square). The cumulative survival (Kaplan-Meier) was worse for patients with nodal involvement (N1) than for those without (N0) (P less than 0.01), and for patients with poorly differentiated tumours compared with moderately well differentiated (P less than 0.05) and to well differentiated (P less than 0.001). The prognosis was worse for patients with high malignancy scores than those with low (P less than 0.001). DNA diploid tumours had a better prognosis than DNA non-diploid, but the difference was not significant.

Total glossectomy

Total glossectomy is a procedure based on sound oncologic principles, and its usefulness may not be fully appreciated. Given the dimensions of the tongue and the need to obtain a wide margin of resection, this procedure may be indicated in selected T3 lesions and recurrences after irradiation. The procedure offers excellent palliation of pain, and form and function may be preserved by rim mandibulectomy when indicated. New reconstructive techniques allow for speedier recovery. Aspiration need not be a complication of total glossectomy if care is taken to preserve the superior laryngeal nerve. Speech rehabilitation plays an important role in returning these patients to their normal environment. Overall 1 and 3 year disease-free survival rates have been encouraging.

Adjuvant chemotherapy for advanced head and neck squamous carcinoma. Final report of the Head and Neck Contracts Program

To determine the efficacy of adjuvant chemotherapy in patients with advanced head and neck squamous carcinoma, the National Cancer Institute initiated a multi-institutional, prospective randomized trial termed the Head and Neck Contracts Program. Between 1978 and 1982, 462 patients with resectable Stage III or IV cancers of the oral cavity, larynx, or hypopharynx were randomly assigned to receive one of three treatment options: induction chemotherapy consisting of a single course of cisplatin and bleomycin followed by standard therapy (surgery and postoperative radiotherapy); induction chemotherapy and standard therapy followed by maintenance chemotherapy which consisted of six cycles of monthly cisplatin; or standard therapy alone. Toxicity from the chemotherapy regimens was minimal. Induction therapy resulted in an overall complete response of 3% and a partial response in 34% of patients. With a median follow-up of 61 months, overall survival and disease-free survival were not markedly different among the three groups (P = 0.86 and P = 0.16, respectively). The incidence of distant relapse was reduced in the maintenance group compared to standard or induction groups (P = 0.025 and P = 0.021, respectively) and time to first distant relapse was prolonged (P = 0.032 and P = 0.022, respectively). The results confirm the feasibility of administering chemotherapy prior to surgery or radiation in patients with head and neck cancer but fail to demonstrate a significant impact of one cycle of induction chemotherapy on clinical outcome. The suggestion that distant relapse rates may be reduced with the addition of maintenance chemotherapy supports the need to test traditional adjuvant approaches in patients with advanced head and neck cancer.

Surgical treatment of oral cavity carcinoma

Ninety-four squamous cell carcinomas of the oral cavity, treated on the author's service between 1969 and 1981, were evaluated. The series included squamous cell carcinomas of various intraoral sites excluding the lips and hard palate. Survival of 60 mo was 70% for stage I, 65% for stage II, 45% for stage III, and 27% for stage IV carcinoma. Twenty-four of 34 patients with "early" cancer (stages I and II) were treated by operation alone. Too few patients with "early" cancer were treated by combined irradiation and surgery to draw conclusions regarding relative efficacy of combination therapy. Sixty patients had "advanced" cancer (stages III and IV). Five-year survival was 37% for patients treated by operation alone, 18% after salvage surgery after failed irradiation, and 60% for patients treated by operation combined with planned perioperative irradiation. Combination therapy appeared to improve control of locoregional disease as well as survival in patients with "advanced" cancer.

Clinical uses of prosthetic devices in brachiotherapy for oral cavity tumors

Three different acrylic resin intraoral stents used for radiotherapy are described. They serve multiple functions in the treatment of tumors of the oral cavity. They are prepared individually and are necessary for accurate treatment planning and in order to minimize the exposure of hospital personnel to radiation.

Carcinoma of the tonsil

One hundred and twenty-two cases with squamous cell carcinoma of the tonsil have been reviewed, 101 of which were treated with radiotherapy; the five-year survival rate in these cases was significantly better in early-stage tumours. Surgical treatment in this series was too small to draw any firm conclusion but, from reports in a large series, surgical treatment has been highly recommended in selected cases of advanced tumour, this result could also be improved with a pre-operative course of radiotherapy.

Reconstruction after total or subtotal glossectomy

Total or subtotal resection of the tongue for malignant lesions creates difficult reconstructive problems. Though the introduction of myocutaneous flaps revolutionized the reconstruction of the oral cavity, most patients with total and subtotal (more than 75 percent) glossectomy require laryngectomy as a concommittant or subsequent procedure to prevent persistant aspiration. Two groups of patients have been compared in this study. Group I consisted of 10 patients in whom an attempt was made to preserve voice with a total (4 patients) or subtotal (6 patients) glossectomy without laryngectomy. To decrease the chance of aspiration, the tip of the epiglottis was sutured to the posterior pharyngeal wall (epiglottopexy). This additional surgical step allowed swallowing without aspiration by blocking the glottic entrance. Group II consisted of six patients who underwent total glossectomy and laryngectomy. They had reconstruction with a pectoralis myocutaneous flap in one stage. These patients were rehabilitated without any major morbidity and they resumed an oral diet within 3 weeks after surgery. The muscle bulk of the flap and the additional protection of the airway by epiglottopexy in Group I were the keys to successful reconstruction.

The facial nerve in parotid malignancy

A retrospective study of patients with parotid malignancies who received their primary definitive treatment at the Mayo Clinic was carried out with respect to the effect of sparing the facial nerve. On the basis of this study, it appears that sparing the facial nerve in malignant tumors is reasonable when the tumors are less than 3 cm in size, the exception being when the nerve penetrates the tumor. A more radical approach is necessary for larger tumors. The place of adjunctive radiation therapy is unclear at the present time.

Prognostic factors in oral squamous carcinoma and their relation to clinical staging

One hundred and three patients with an oral squamous carcinoma were studied in an attempt to determine the clinical factors which affect survival. The 5 yr actuarial survival of the whole group of patients was 55%. Although survival depended on clinical staging, in those patients with no palpable nodes on presentation the tumour size did not affect survival. The most significant factor determining survival was the presence of palpable lymph nodes on presentation. Palpable nodes were more likely in patients with large tumours than those with small tumours. On the basis of these findings a modification of the TNM classification is suggested giving more weight to the presence of cervical nodes than in the present staging system.

The prognostic relevance of various factors at the time of the first admission of the patient. Retrospective DOSAK study on carcinoma of the oral cavity

In a retrospective study, on a sample of 1021 patients with carcinoma of the lips, oral cavity and oropharynx, the clinically available factors at the time of the patient's first admission are analysed with reference to their prognostic relevance. Prognostically relevant factors are determined by both univariate and multivariate analyses. Of the 18 factors analysed, the following seven finally proved to be prognostically relevant: tumour size, degree of infiltration, degree of histological differentiation and site by organ of the primary tumour, the combination of evidence + clinical appearance + degree of fixation of the regional lymph nodes, age of the patient, and evidence of distant metastases. On the basis of these results it will be possible to create a prognostic index. This prognostic index should be eligible for use in clinical practice, as opposed to usual classification models.

Preoperative reductive chemotherapy for locally advanced carcinoma of the oral cavity, oropharynx, and hypopharynx

Recent reports have documented that five year survivals have not really improved as a result of combined therapy programs utilizing surgery and radiation therapy. The pattern of treatment failure seems to have changed in that such combined programs offer improved local and regional control but only to have patients develop distant metastases. The need for some form of systemic treatment was obvious. In 1977, a pilot study was initiated at the Ohio State University to evaluate a particular four drug combination and its effectiveness against squamous cell carcinoma of the head and neck. The initial results revealed an acceptable risk-benefit ratio to evaluate this regimen in a group of patients who had previously received no treatment. This report details the final results of the pilot study designed to evaluate response rates in previously untreated locally advanced squamous cell carcinoma of the oral cavity, oropharynx, and hypopharynx. During the 15 month duration of this study there were 58 patients who were evaluable. The overall response to a combination of cis-platinum, vincrinstine, methotrexate, and bleomycin was 66%. All toxicities occurred in less than 10% of the patients except for nausea and vomiting, which occurred to a mild to moderate degree in three quarters of the patient population. There was no increase in surgical or radiotherapeutic complications as a result of utilizing initial chemotherapy. This four-drug combination is now being evaluated to test its impact on survival as a Southwest Oncology Group study.

Randomized study of control of the primary tumor and survival using preoperative radiation, radiation alone, or surgery alone in head and neck carcinomas

Fifty-five selected patients with previously untreated squamous cell carcinoma of the head and neck regions were studied in a randomized, prospective manner. The three treatment categories were primary radiation (Gp R), primary surgery (Gp S), and preoperative radiation of 4000 rads in four weeks (Gp R/S). The local control rates for the 44 evaluable patients with a two-year minimum followup were 24%, 39%, and 43% respectively. Further treatment attempts in patients failing initial therapy yielded local control rates of 35%, 39%, and 43% for Gp R, Gp S, and Gp R/S, respectively. None of the local control rates nor the corresponding survival curves were significantly different at P less than 0.10. However, the group sizes were sufficiently small that true differences might not have been detected. Postoperative complications were higher in the primary radiation failures subsequently operated upon compared to the primary surgery group (P = 0.07).

The importance of tumor attachment to the carotid artery

The records of 508 patients who had undergone radical neck dissection were reviewed. Twenty-eight of these patients (5.5%) were found to have tumor attached to the carotide arterial system. Twenty-four patients (86%) died with tumor, the mean survival time being 16.9 months. Local recurrence of tumor in the neck occurred in 46% of the patients and distant metastases in 67%. Eighteen percent of those who developed local recurrence did so in the absence of distant metastases and might have benefited from a more aggressive approach toward the tumor.

Dinitrochlorobenzene skin sensitization and peripheral lymphocyte count: predictors of survival in head and neck cancer

Dinitrochlorobenzene (DNCB) is a simple chemical useful to evaluate both afferent (sensitizing) and efferent (reacting) limbs of the delayed, cell-mediated immune system. This system invokes the small lymphocyte (T cell) and is apparently part of the host defense against cancer. Severnty-two patients with new primary squamous cell carcinomas of the larynx, hypopharynx and oropharynx were sensitized to DNCB by contact application, and delayed cutaneous hypersensitivity tested. The T cells were also assessed in this study by lymphocyte count. All patients were treated for cure. Ninety-one percent of DNCB reactors were alive and tumor-free at two years. Forty-five percent of negative reactors had recurrent tumor and died of carcinoma. Cases grouped by site among glottic, supraglottic and inferior hypopharynx showed identical results. Lymphocyte counts showed a trend in the same direction. On statistical analysis, all differrences were significant. Eighty-five percent of recurrent tumors occurred in patients who were nonresponders. The present data suggest DNCB reactivity is helpful in predicting outcome after surgery, or combined radiation and surgery, for mucosal squamous carcinoma of the head and neck.

Carcinoma of the lip

A retrospective analysis of 206 patients with lip cancer is presented. Poorly differentiated primary lesions have a high rate of metastases. The metastatic potential of well differentiated lesions, when classified by size in the TNM staging system, is the same as that of intraoral carcinoma. A therapeutic approach is proposed.

Carcinoma of the oral cavity. An analysis of 478 cases

Evaluation and analysis of 478 cases of carcinoma of the oral cavity treated from 1947 through 1970 shows a significant improvement in radiotherapy in the supervoltage (Co60) era. Survival in the early stages of disease (I and II) improved in the supervoltage era but not in the later stages of disease (III and IV). Results with combined therapy for advanced disease showed no significant difference from that of single mode therapy, whether with radiotherapy or with surgery in the supervoltage era.

[Surgery of the tongue and floor of the mouth (author's transl)]

Most carcinomas of the oral tongue and floor of the mouth are presently treated surgically, often combined with pre- or postopervative irradiation. The treatment plan is mainly determined by the primary site and the local and regional extension, desirable are general rules on the basis of the TNM classification. The indications and principles of the most important operative procedures are discussed: Local excision, partial glossectomy, excision of the floor of the mouth with marginal mandibulectomy, composite resection. Operations for removal of the primary and radical neck dissection with preservation of the mandible (e.g. the pull-through procedure) are rarely advised. A radical neck dissection is indicated in each carcinoma of the oral tongue or floor of the mouth with palpable lymph nodes. If no nodes are palpable, an elective neck dissection is advised in view of the high frequency of clinically occult lymph node metastases (between 23 and 43%). Reconstructive measures following radical tongue and floor of the mouth operations are required for regaining a motility of the remaining tongue, for reconstruction of the floor of the mouth and for replacement of the mandible.