Cancer of the gums (gingivae)

CANCER OF THE GUMS (GINGIVAE) *

HAYES MARTIN, M.D.

Attending Surgeon, Memorial Hospital

NEW YORK, NEW YORK

C ANCER of the gums as a distinct anatomic form of intra-oraI

cancer has received Iess attention in the medica Iiterature than its reIative frequency merits. Its importance has been

overshadowed by the greater emphasis placed upon such better known entities as cancer of the Iip and of the tongue, and its identity has been further obscured by a Iack of cIear definition and its inclusion with a group of tumors of adjacent bony and soft parts under the vague term, “cancer of the jaw.”

The present report is based upon an unselected and consecutive group of I 13 cases of cancer of the gums, incIuding aII-comers in a11 stages of the disease who applied to the Memorial HospitaI between the years rgzg and 1933, incIusive.

Definition. t The term, “cancer of the gums” (gingivae) should be used to designate a11 maIignant tumors arising in the soft tissues

* From the Head and Neck Service, MemoriaI HospitaI, New York City. t In the medical literature, gingiva1 cancer is described under a variety of titIes,

such as cancer of the ja, the alveolus, the alveolar border, the alveolar ridge, the alveolar process, the maxilla or the mandible. Cancer of the upper gum is often discussed with cancer of the antrum and/or palate, with no distinction between those growths which arise in the epithelium of the gums and perforate into the antrum, and those which arise in the antrum, erode the alveoIar process and perforate onto the gum surface. Reports on cancer of the Iower gum often include tumors of bone and of the dental organ. As in a11 varieties of intra-oral cancer, the greatest confusion results when more than one anatomic group is reported (under such titles as cancer of the “lip and jaw,” “tongue and jaw,” etc.) without separation of the data.

Much of the confusion in terminology results from the use of the vague term, “jaw,” when referring to the gums, or from misdirected attempts to cIarify the probIem by the substitution of “alveolus,” “aIveolar border,” “alveolar process,” etc., rather than the correct term, “gum,” which is apparentIy considered inelegant and unscientihc. Accord- ing to Webster, the term jaw or jaws incIudes the bone-maxilla and/or mandible- the teeth and the soft structures covering them. This term is, therefore, too inclusive. In anatomica texts there is onIy one term which defines the soft tissues covering the alveolar processes of the maxiIIae and mandibles, namely, the gums. The term, alveolus, refers only to a tooth socket, the terms, alveolar process and alveolar border, refer only to parts of the bone of the maxillae and mandible.

The confusion in terminology is obvious even in foreign Iiterature. Certain French authors speak of cancer of the “machoire” (jaw) and “mandibule” instead of “gencive” (gum). German authors commonly designate cancer of the gum as “Kiefercarzinom”

11Il

770 MARTIN-CANCER OF THE GUMS

overlying the aIveoIar processes of the upper and Iower jaws. Tumors of the gums shouId be distinguished from those which arise in the bone structure of the maxi1Iae and mandibles and in tooth structures.

The term “ epulis” originally referred to all swellings and tumors in this area, particuIarIy to “gumboils” but also to tumors of the bony aIveoIar processes which surround the aIveoIi (tooth sockets). At the present time the word bears a more restricted meaning, and in genera1 is used to designate benign tumors of the gums (giant ceI1 epuIis, granulation tissue epulis, fibrous epulis, etc.) EtymoIogicaIIy there is no objection to the term, “epuIis cancer.”

ANATOMY OF THE GUMS

The gums are composed of a thin Iayer of soft tissue (I to 2 mm. in thickness) covering the aIveoIar processes of the maxiIIae and mandible. The borders of the gums are not sharpIy defined, but approximateIy they are delimited (a) on their outer surfaces by the refIection of the mucous membrane onto the cheeks and Iips in the depths of the gingivo-buccal gutters and (b) on their inner surfaces by the reflection of the mucous membrane onto the hard palate and onto the floor of the mouth from the upper and Iower gums, respectiveIy.

In structure the gums consist of dense, fibrous tissue united internaIIy with the periosteum and covered externaIIy by mucous membrane. They are richIy suppIied with blood vessels but sparseIy with nerves and are covered by stratified squamous epithehum con- taining numerous papiIIae, especialIy in the margins where the gums join the teeth. Around the neck of each tooth the gum forms a free, overIapping collar which is continuous with the aIveolar periosteum (peridenta1 membrane) or root membrane of the teeth.

ANATOMY OF THE LYMPHATICS OF THE GUMS

The Iymphatic drainage differs in the upper and Iower gums and aIso on their outer and inner surfaces. (Fig. I.) Anatomists26*27,2” differ somewhat in regard to the more intimate details of this net-

(jaw carcinoma), atthough in German dictionaries there is a word “Zahnffeisch” to designate the gums. Kaufmann (SpezielIe Pathologische Anatomie. VoI. I, p. $33. BerIin, 1931. Walter de Gruyter & Co.) speaks of “Krebs des ZahnIIeisches” and aIso refers to “epulis carcinomatosa.” In recent Italian literature there is reference to “epiteliomi gengivali,” which appears to have the same significance as “gingival cancer.”

!lzI!

MARTIN-CANCER OF THE GUMS 771

work, but from the practical standpoint these details are of onIy minor importance.

I. The Upper Gum. (a) Externcd or vestibdar surface: (Fig. IA).

The Iymphatics of the externa1 surface of the upper gum are continuous with those of the mucosa of the cheek and anastomose across the midIine anteriorIy. On either side the finer network and coIIecting tubuIes unite to form a plexus which runs backward and IateraIIy aIong the gingivo-buccaI gutter to enter the cheek. The vesseIs of this pIexus then pierce the buccinator muscle aIong its superior attachment and reach the anterior facial vein, which they accompany to the submaxiIIary region, where they enter into the various nodes of the submaxiIIary group. The Iymph vesseIs from the anterior portion of the upper gum occasionaIIy run to the pregIanduIar Iymph-node, but the main Iymphatic drainage from the entire structure goes to the prevascuIar and retrovascuIar nodes. In the present series, metastases from the upper gum appeared first in the prevascuIar submaxiIIary node in 39 per cent of the cases with metastasis. (b) Internal or lingual surface: (Fig. IB). The Iymphatics of the inner surface of the upper gum are continuous with those of the hard and soft palates. The main drainage passes backward beneath the mucosa of the retromoIar triangIe and posterior part of the cheek to the anterior border of the ascending ramus of the mandibIe. The Iym- phatic trunks then incIine backward and downward, passing to the inner side of the submaxiIIary salivary gIand, and terminate in the subdigastric nodes of the interna juguIar chain.

According to Rouviere, 26 there are two other inconstant routes: first, the anterior pathway by which a few Iymphatic vesseIs from the upper gum, after Ieaving the retromoIar triangIe, pierce the buccinator muscIe and go to the pre- and retrovascuIar nodes and, second, the posterior pathway where a few Iymphatics from the upper gum pass posteriorIy to the retropharyngea1 nodes. In our cIinic we have never been abIe to demonstrate cIinicaIIy the presence of metastases in the retropharyngea1 Iymph-nodes from any part of the ora cavity or pharynx, aIthough one must concede that enIarge- ment of the retropharyngea1 nodes wouId in most cases be difl?cuIt to distinguish from a generaIized sweIIing or edema of the posterior pharyngea1 waI1 so commonly found associated with cancer in this region.

2. The Lower Gum. (a) E t x ernul or vestibulur surface: (Fig. rc). The Iower externa1 gingiva1 Iymphatic network, Iike that of the

u311


upper, forms a pIexus in the Iower gingivo-buccal gutter which anastomoses across the midline anteriorly. In the gingivo-buccal gutter on each side the vesseIs pass IateraIIy into the cheek, join the

nodes

Uppar Cum (Outer Surface1 Upper Cum (Inner Surfecej

Lo&- Cum (Inner Surface)

FIG. I. A, B, c and D, lymphtic system of the gums. The Iymphatics of the gums drain to the submaxiIIary and upper deep cervica1 nodes. The pre- and retrovascular nodes and the subdigastric nodes receive drainage from all of the gum surfaces. The preglandular submaxillary node receives drainage from a11 except the inner surface of the upper gum. The submenta1 node receives drainage onIy from the anterior inner surface of the Iower gum. The retropharyngeal node receives drainage only from the upper gum.

Iymphatics of the cheek, and pierce the buccinator muscle to drain into the prevascuIar node and, in most cases, into the pregIanduIar and retrovascuIar nodes as weI1. (b) Internal or lingual surface: (Fig. ID). The internal vesseIs make up part of the Iymphatic network of the floor of the mouth and undersurface of the tongue; the

u41


Iarger vesseIs pierce the myeIohyoid and drain mainIy into the pregIanduIar node of the submaxiIIary group. ConsiderabIe drainage from this area, especiaIIy from the posterior portion, passes directIy to the subdigastric nodes of the interna juguIar chain. A smaI1 part of the Iymph from the anterior inner surface of the Iower gums passes into the submenta1 nodes with the drainage from the adjoining Aoor of the mouth.

ETIOLOGY

General Incidence. According to the admission records of the MemoriaI HospitaI, cancer of the gums makes up about IO per cent of a11 maIignant tumors of the mouth, 7 per cent of a11 those of the upper respiratory and aIimentary tract, and 2.5 per cent of a11 human cancer. Its incidence is about the same as cancer of the cheek. Kirkham, of Texas,14 states that gingiva1 cancer is more common in the negro than in the white race, aIthough he gives no figures to prove his cIaim. In animals, gingiva1 cancer makes up aImost 30 per cent of a11 maIignant tumors of the ora cavity,” about three times the proportion in human beings.

Age and Sex. The average age of the I 13 patients in the present series was sixty-one years, which is sIightIy oIder than that of other forms of intra-ora cancer (lip fifty-six, tongue fifty-eight, cheek sixty). The youngest patient was twenty-two and the oIdest sixty- six. The disease is definiteIy more common in the older age groups; aImost 70 per cent of the tumors occurred after the age of sixty and onIy about 2 per cent under the age of forty. About 82 per cent of the patients were maIes, and 18 per cent femaIes, a reIative incidence identica1 with that reported by EdIing5 in forty cases.

Position of the Growth. In the present series the Iower gum was affected in 54 per cent of the cases, the upper in 46 per cent. Gainis has recentIy reported a series of iifty-three cases in which 68 per cent of the tumors occurred on the Iower jaw. The region of the third moIar was the most common site of origin (about 60 per cent) in the present series with the region of the bicuspids and canine teeth next in order. ReIativeIy few Iesions (5 per cent) arose near the midIine anteriorIy. Forty-two per cent of the growths were Iocated on the right side and 58 per cent on the Ieft. Janeway, in rgr8,12 reported seventeen cases of cancer of the “superior maxiIIa” from the MemoriaI HospitaI, of which twice as many occurred on the right as on the left.


Since most growths are fairIy we11 advanced on admission, it is sometimes difficult to determine the exact point of origin; but from the position of the smaIIer Iesions and from the direction of the greatest extension in the Iarger ones, it appears that the apex of the gum is most often the primary site, and that if the Iesion arises defIniteIy on one or the other side, the outer surface is the point of origin about twice as frequentIy as the inner. In 90 per cent of a11 cases extension had taken pIace to neighboring structures on admission, which is to be expected since the gums are reIativeIy narrow (2 to 2.5 cm.) and the average diameter of the primary Iesions was 3.3 cm.

Causative Factors. An anaIysis of the causative factors in the present series faiIs to revea1 any marked variation between cancer of the gums and of other parts of the ora cavity except that the percentage of syphiIis is not so high. The cumulative effect of severa forms of chronic irritation is obviousIy of more importance than the action of any one irritant. The older mean age in the present series may be simpIy fortuitous, or it may indicate that gingiva1 cancer deveIops onIy after Iong continued chronic irritation. Neither syphiIis nor tobacco appears to be an important factor in the present series. In animaIs the high reIative incidence of cancer of the gums as compared to cancer of other parts of the ora cavity might provide the basis for an interesting investigation-or at least specuIation-on the effect of differences in dietary habits in animaIs and in man. This question, however, is beyond the scope of the present report.

Tobacco. As with a11 forms of intra-ora cancer which have been anaIyzed at the MemoriaI HospitaI, about 70 per cent of the patients with gingiva1 cancer give a history of using tobacco. This figure approximates the incidence of the habit in the genera1 maIe popuIa- tion, and therefore is of IittIe etioIogic significance. EdIing,” of Lund, Sweden, reported a Iarge proportion of tobacco-chewing farmers among his cases of gingiva1 cancer, but the chewing habit does not appear to be common in New York City or the eastern United States, since at the MemoriaI HospitaI the coincidence of tobacco chewing and intra-ora cancer is rare.

Syphilis. In ninety cases of the present series in which Wasser- mann tests were made as part of the routine examination, positive reactions were obtained in onIy 3 per cent, a figure which is below that for syphiIis in the average maIe popuIation of the corresponding age group (6 per cent). 3o The fact that it is beIow the average is

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probabIy onIy accidenta1, but at any rate the Iow figure undoubtedIy indicates that syphiIis is not a factor in the causation of gingiva1 cancer.

Dental Derangements. A causa1 reIationship between denta derangements and cancer of the gums is undoubtedly more apparent than rea1. In the first place, if teeth were not present at the site of the growth, there would necessariIy be a history of denta defects which Ied to extraction. Second, if teeth were present when the growth appeared, the patient wouId naturally beIieve that the troubIe was of denta origin. Third, if the patient wore any form of denture, it wouId necessariIy become iII-fitting in the presence of an underIying gingiva1 tumor, and in such cases a direct causa1 reIationship, even though erroneous, wouId aIways be assumed. For these reasons, a history of past or present denta compIications can be obtained in most cases, but in the majority their significance is doubtfu1. In the present series about 25 per cent of the patients first consuIted a dentist, and 15 per cent had had teeth extracted during the three months before admission to our clinic. An additiona IO per cent had attributed the deveIopment of the growth to iII-fitting dentures. Kirkham14 reports that in practicalIy a11 of his cases an erroneous diagnosis of denta abscess had been made before admission, and Gernezg states that aImost a11 patients with gingiva1 cancer Hurst consuIt a dentist.

In pyorrhea aIveoIaris, primariIy a disease of the peridenta1 membrane in the tooth sockets, there is aIways an associated inflamma- tion of the gums themserves. On the other hand, there are other forms of gingivitis, notably that associated with avitaminoses, which can occur independentIy of pyorrhea aIveoIaris. Any of these forms of chronic inffammation of the gums couId conceivabIy be an important factor in the etioIogy of gingiva1 cancer. However, some degree of gingivitis, probabIy from a combination of these causes, as evidenced by bIeeding of the gums on brushing of the teeth, is aImost universa1. The manufacturers of tooth paste capitaIize upon this fact in their advertisements. The gums and the denta apparatus are among the first structures to deteriorate with the natura1 aging process in both man and animaIs, and for this reason such changes cannot be considered as abnorma1.

Acute abnormaIities of the denta apparatus are seIf-Iimited in duration, since they are usuahy foIIowed by earIy Ioss of the teeth and heaIing of the gums. From the mechanica standpoint, the gums

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are not often affected by sharp or broken teeth which are Iikely to traumatize the border of the tongue or the mucosa of the cheeks. In the final anaIysis, one must con&de that aIthough diseases and defects of the dental apparatus may possibIy pIay a part in the origin of cancer of the gums, their significance is not great; and it is probable that the same extraneous irritants operate here to cause cancer as in other parts of the ora cavity.

SYMPTOMS, MORBID ANATOMY AND CLINICAL COURSE

The most common first symptom noted by the patients in the present series was the Iesion itseIf (70 per cent), with IocaI “ soreness ” occurring first in onIy about 20 per cent. Since the gums themselves are poorIy suppIied with nerves, pain or discomfort seIdom occurs unti1 the growth has extended to neighboring structures. In a few instances, the primary Iesion produced no noticeabIe symptoms whatever, and the patients first consuIted a physician because of enIarged cervica1 nodes (4 per cent).

A patient with cancer of the gum rareIy seeks medica advice in the earIy stages of the disease. In the present series the average size of the growth was 3.3 cm. on admission. (Fig. 2.) In over one-third of the cases the primary Iesion was over 4 cm. in diameter, and in only IO per cent was it less than 2 cm. The average duration of symptoms before admission was 6.2 months.

The Iesion begins as a smaI1 papiIIary uIcer, usuaIIy on the apex or margin of the gum (sometimes on the bucca1 surface separate from

the margin, Iess often on the inner surface), which produces neither pain nor other discomfort. When first discovered by the patient, it is

IikeIy to be considered a denta abscess. If a tooth is extracted, the growth may progress by way of the tooth socket to invade bone. In

other cases, as the tumor enlarges it may interfere with the fit of a denta plate or removabIe bridge, and the patient, mistaking

the effect for the cause, believes that the denture has provoked the Iesion. UnIess the growth invades the underIying bone through the

tooth sockets foIIowing extraction, the periosteum proves resistant for some time, and the tumor spreads peripheraIIy into the cheek,

hard paIate, or floor of the mouth to form a broad, flat, superficia1 uIcer severa centimeters in diameter. In other cases, especiaIIy in

tumors of Iower grade, the periosteum resists invasion and the growth fungates into the mouth.


After a period of severa months the periosteum is finaIIy perforated, and then bone is rapidIy invaded and eroded. With deep invasion of the mandibIe, pathologic fracture may result. A growth

FIG. 2. W. S., age sixty-one, admitted to the Memorial Hospital in 1935. A, the primary Iesion, about 3.5 cm. in diameter, involved practicaIIy the entire right gum. Diagrammatic insert shows extent of Iesion. Biopsy showed squamous carcinoma grade I. ES, treatment was by peroral x-radiation. The patient has survived five years free of disease.

in the Iower gum may extend through the bone to the skin over the outer surface of the mandibIe or the submaxiIIary region. Such deep invasion of bone is usuaIIy associated with sepsis, both IocaIIy and in the submaxiIIary nodes, so that there is a combination of inffamma- tory hyperpIasia, IocaI ceIIuIitis and metastatic invasion of the submaxiIIary and upper deep cervical nodes. A combination of these various disease processes makes it diff%uIt to determine the extent of the cancer.

Extension of the Growth. In the present series the disease had extended beyond the gum into the neighboring structures on admission in 90 per cent of the cases. The mucosa and deep tissues of the cheek (Fig. 3) were the most frequentIy invaded, with the hard and soft paIates, the floor of the mouth and one anterior tonsiIIar piIIar next in order. In most instances, more than one of these structures were invoIved. In 35 per cent of the present cases bone erosion was demonstrabIe both cIinicaIIy and roentgenographicaIIy on admission. When the growth has once invaded the meduIIa of the mandibIe,

U9B

MARTIN-CANCER OF THE GUMS

it may then progress for several cm. before again appearing on the surface.*

In the upper gum erosion of the maxilla eventuaIIy resuIts in

FIG. 3. A. K., age sixty-seven, admitted to the Memorial Hospital in 1934. A, the primary lesion of the right lower gum had deeply invaded the gingivo- bucca1 gutter and perforated onto the skin surface. Diagrammatic insert shows extent of lesion. Biopsy showed squamous carcinoma grade 1. B,

treatment was by a combination of x-radiation and radon seeds with com- plete regression. The patient later deveIoped two separate primary cancers of the mucosa of the cheek and of the hard palate, which were excised by cautery.

extension of the disease into the maxiIIary antrum or nasa1 cavity. Invasion of the antrum, aIthough aImost aIways associated with purulent infection, seldom Ieads to marked swelling of the cheek and edema of the periorbita1 tissues, because the antraI wall has been eroded and neither tumor nor pus can produce marked pressure within the cavity. From the anatomic standpoint this observation may be of some vaIue in the differentia1 diagnosis of doubtfu1 cases. After posteriorIy situated Iesions of the upper gum have invaded the soft paIate and cheek, there is sepsis in the region of the pterygoid and temporal tendons, and Iate in the course of the disease there may be sweIIing of the entire cheek and tempora1 region.

* In a recent case I have observed epidermoid carcinoma of the gum which invaded through the socket of an extracted left lower bicuspid tooth and progressed through the medulla of the mandibIe toward the right, crossed the midline, and then perforated the cortex to appear on the outer surface of the right Iower gum opposite the right first moIar. This continuous direct extension through the medullary cavity for a distance of about 6 cm. was proved both by roentgenographic examination and by gross and microscopic examination of the surgical specimen of the excised mandible.

64


Metastasis. In general, the behavior of metastasis in cancer of the gums follows that of other intra-oral cancers. About 35 per cent of the patients in the present series had cervical metastases on admission, which is about the same as the figure reported by Jane- way12 over twenty years ago. An additional 20 per cent developed metastases subsequently, so that 55 per cent had metastatic involvement at some time during the course of the disease, a figure which is only slightly lower than in cancer of the tongue and of the floor of the mouth. In the upper gum, metastases on admission (28 per cent) were less frequent than in the lower (39 per cent), aIthough eventually 6 I per cent of the growths of the upper gum metastasized as compared to 51 per cent of the lower. These ligures are based upon too small a series to be absolutely concIusive, but in any case they do not con- firm the statements of MacFee15 and Schleyzs that metastasis to the cervical lymph-nodes from cancer of the upper jaw is infrequent.

The pathway of lymphatic drainage and the position of the nodes first invoIved vary considerably in cancer of the upper and lower gums, respectively. The difference may be adequately explained by the anatomy of the lymphatics, which has already been described. In the upper gum the lymphatic drainage is chiefly to the subdigastric nodes of the interna jugular chain which were involved first in the present series in over half of the cases with metastasis from this area. In a lesser number (39 per cent) metastases from the upper gum appeared first in the pre- and retrovascular nodes of the submaxillary group.

From the lower gum the main drainage is into the submaxillary

group (preglandular, pre- and retrovascuIar) where nodes were involved first in about 65 per cent of the cases with metastasis from this area, with only about 30 per cent occurring first in the subdigastric region. The pre- and retrovascular lymph-nodes lie very close to the primary lesion in cancer of the posterior lower gum, and in advanced cases the two foci of the growth tend to coalesce and invade jointly the adjacent tissues. After involvement of the first “echelon,” the disease disseminates to the middle and Iower nodes of the jugular chain and to the viscera. Bilateral metastases occurred in only about 4 per cent of the entire series. Johnson,13 reporting upon 122 cases from the Memorial Hospital clinic in 1925, recorded only one instance of bilateral involvement.

Systemic Metastases. In the autopsy records at the Memorial Hospital there are reports of 284 patients dead of cancer of the upper

Urrll


respiratory and alimentary tracts. Among these are fourteen cases of gingival cancer, in five of which (34.7 per cent) there was visceral invoIvement. From these records it appears that viscera1 dissemination occurs more frequently from cancer of the gum than from cancer of any other part of the oraI cavity except the mucosa of the cheek (36.3 per cent).

Double Primaries. As in other anatomic forms of intra-oral cancer, the coincidence of a second primary cancer in another site is not unusua1. MuItipIe cancers occurred in eight of the present series, in one of which there was a separate growth of the gum on the opposite side. In the others the second cancers occurred, respectiveIy, in the skin of the face, tongue, prostate, soft paIate, pancreas, breast and sigmoid.

Cause of Death. The termina1 symptoms in cancer of the upper gum are about the same as in cancer of the antrum. In cancer of the Iower gum, the floor of the mouth and the tongue are invaded, with metastasis or sepsis in the submaxiIIary Iymph-nodes, terminating in ceIIuIitis of the whoIe submaxiIIary region. Death ensues from a combination of causes-exhaustion from pain, sepsis, mahrutrition, and hemorrhage from the eroded externa1 maxiIIary and/or man- dibuIar arteries. It is probable that systemic metastasis is-more often a factor in causing death than is commonIy reaIized.

Melanoma. Melanoma occurs more often in the gums than in any other part of the ora cavity. In the present series there were four cases, two on the upper gum and two on the lower. One occurred in a maIe and three in femaIes. The average age was forty-five years, about seventeen years younger than the average for carcinomas (sixty-two years). The average duration of symptoms in these cases was eIeven months, five months Ionger than in the carcinomas.

The clinica appearance of mucous membrane melanoma is fairIy characteristic. AI1 of the four tumors were deepIy pigmented, smoothIy granular and ovoid, tending to fungate from the surface rather than to infiItrate deepIy. Except for the pigmentation, they resembIed the benign giant ceI1 epulis in appearance. AI1 of the growths metastasized first to the submaxiIIary Iymph-nodes, then wideIy throughout the neck and eventually systemicahy. In one case which occurred in a femaIe of forty years, the patient survived without recurrence for four years, when she deveIoped metastases in the Iungs and pIeura, as shown both by her symptoms and roentgen examination of the chest. She survived the pulmonary metastases for

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about fifteen months, during which time she coughed up from the bronchi a mass of granular tissue which was examined histoIogicaIIy and found to be meIanoma. AI1 of the cases terminated fatally despite treatment, with an average surviva1 of aImost five years, two patients Iiving more than five years.

HISTOPATHOLOGY

Epidermoid carcinomas made up aImost go per cent of the cases of gingiva1 cancer in the present series, as shown in TabIe I, with squamous carcinomas, grade II, predominating (62 per cent). As in the Iip and cheek, squamous carcinomas, grades III and IV, were rare. Adenocarcinomas arising in minor saIivary glands made up about

TABLE I HISTOPATHOLOGY ,N I13 CASES OF CANCER OF THE GUM AT THE MEMORIAL HOSPITAL

Squamous carcinoma grade 1. ................................... 29 Squamous carcinoma grade II., ................................. 66 Squamous carcinoma grade III .................................. I MeIanoma .................................................... 4 Lymphoepithelioma ............................................ I SpindIe cell carcinoma. ........................................ I Adenocarcinoma .............................................. 5 Lymphosarcoma ............................................... I No disease at primary site on admission .......................... 5

Total...................................................... 113

3 per cent of the cases, with IymphoepitheIiomas occurring onIy occasionally. There were four cases of melanoma in the present series. As already stated, this tumor occurs more commonly in the gum than in any other part of the mouth.

DIAGNOSIS

A biopsy is an essentia1 part of the management of intra-ora cancer, and a specimen shouId be taken in al1 cases from any suspi- cious ulcerated Iesion in the mouth at the time of the first examination. Such confirmation of the diagnosis should be mandatory before the patient is subjected to the necessariIy aggressive treatment for cancer, either radioIogic or surgica1, and no cIaim shouId be made for cure in cases which are not histoIogicaJIy proved.

Benign tumors which may be confused with cancer, or vice versa, are common in the gums. Their comparative incidence is shown in Table II. In generaI, their clinica appearance should immediateIy

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suggest their benign nature, but since errors are so frequentIy made, they wiI1 be discussed in detai1 under separate headings.

TABLE II COMPARATIVE INCIDENCE OF BENIGN AND MALIGNANT TUMORS OF

AT THE MEMORIAL HOSPITAL

Ipg to 1935, IncIusive MaIignanttumors.........................................

Carcinoma............................................. MeIanoma.............................................. Lymphosarcoma.........................................

Benigntumors............................. . . GiantceIIepuIis............................ Grandation tissue epulis.. Fibrousepulis........................................... MiscelIaneous (papilloma, myxofibroma, angioma).

THE GUM

108

‘03 4

67 29 23 12

3

Delay in Diagnosis. At Ieast one-fourth of the patients with gingiva1 cancer first consuIt a dentist under the impression that the Iesion is a dental abscess, commonly known as a “gum boil.” In most instances the dentist extracts one or more teeth, whether or not he recognizes the true nature of the condition. Such errors obviousIy shouId occur only in the smaI1 or moderate-sized Iesions, for the maIignant nature of the ulcerated and fungating tumors can hardly be missed. Twenty-three patients in the present series (20 per cent) stated definiteIy that they had first consuIted a dentist. In seven of these the dentist suspected that the Iesion was a malignant growth and recommended medical consultation. In sixteen of the cases it is obvious that the dentist missed the diagnosis because teeth were extracted or mouth washes prescribed, and in these cases there was an average deIay of 6.4 months before a correct diagnosis was made. Fifty-three patients (about 50 per cent) stated that they had con&ted a physician first. In thirty-six of these a tentative diagnosis was made and the proper treatment advised. In seventeen it is apparent that the physician did not suspect cancer because the patients were treated with topica appIications and mouth washes for varying periods. No average period of deIay can be caIcuIated because the patients’ statements concerning the time interva1 were too indefinite.

Dental Abscess or “Gum Boil.” This Iesion is apparently common in denta practice and is the most frequently confused with cancer when the patient consuIts a dentist. A denta abscess is aIways a mound-Iike, painfu1 swehing of the gums opposite a tooth. Fluctuation and acute tenderness are characteristic, and there is no


ulceration unless the abscess has ruptured or the gum has been incised. By contrast, cancer of the gum is always uIcerated from the beginning and is never painfuI or tender unti1 the Iater stages.

Giant Cell Epulis. The most common benign tumor of the gums is giant ceII epulis, an infectious granuloma of Iong duration in which inAammatory giant ceIIs have formed. Giant ceJI epuIis usuaIIy occurs as a deep bluish-red, ovoid, partIy pedunculated tumor, usuaIIy on the outer surface of the gingiva1 margin in cIose associa- tion with a tooth or sometimes in an edentuIous gum. The surface may be covered with thin mucous membrane or it may be partIy uIcerated, but there is never erosion. The history is usuaIly of severa months’ duration with no symptom except the presence of the tumor. As Iong as the growth is not mcerated, there appears to be consider- able growth restraint; but folIowing incompIete removal, there is rapid recurrence from the base. The treatment is Iocal remova with curette and thorough cauterization of the base. It is usuaIIy necessary to extract one or more adjacent teeth in order to obtain com- plete destruction of the base of the tumor.

Granulation Tissue Epulis and “Pregnancy Tumor” of the Gums. GranuIation tissue epulidi may appear in either sex and are usualIy associated with peridental sepsis. They aImost aIways arise on the outer surface of the margin of the gum at its junction with a tooth and may be distinguished from cancer by the history and the characteristic deep-red, granuIar, peduncmated, non-infiltrating appearance. This Iesion is fairIy common during pregnancy when it is known as a “pregnancy tumor” of the gum. Exuberant granulomas of the gum are occasionaIIy a feature of the gingivitis which accompanies avitaminosis B. The treatment is the same as for giant ceII epulis. Most cases are benefited by the administration of vitamin B.

Fibrous Epulis. This tumor, usuahy associated with a tooth, appears as a firm peduncmated mass, 3 to IO mm. in diameter, at the gum margin. The surface is covered by mucous membrane of normaI coIor, and the growth apparently represents a granuIation tissue epulis which has become organized. The tumor occurs more com- monIy in females than in males and is usuaIly situated anteriorly on the outer surface of either the upper or Iower gum. The treatment is IocaI surgical removal with moderate cauterization of the base. There is no marked tendency toward recurrence.

Leukemia. The gums are occasionahy the site of the first objec- tive lesion in Iymphatic or aleukemic Ieukemia, aIthough the patients

[ISI


compIain mainIy of Ioss of strength. in these cases the gums are swohen, bIuish-red in coIor, and present granmomas of varying size at the margin. Biopsies from these areas may give a picture of Iymphosarcoma, but the true character of the disease is shown by a bIood count which will revea1 the Iymphocytosis. SeveraI such cases have been observed at the MemoriaI HospitaI.

Syphilis. Th e onIy syphiIitic Iesion which might simuIate cancer in appearance is gumma. AIthough this Iesion can theoreticaIIy appear in the gum, there is no case on record at the MemoriaI Hospi- ta1. It cannot be differentiated cIinicaIIy from cancer, but it is so rare as to be of no diagnostic significance and shouId not be incIuded in any theoretical considerations, provided that a biopsy is part of every routine examination.

MisceZZuneous Benign Tumors. PapiIIoma, a benign warty epitheIia1 tumor, may occur in any part of the oraI mucous membrane. The treatment depends on the individua1 characteristics of each case and may be either by narrow surgica1 excision or by super- ficia1 cautery. Myxofibroma, hemangiomas and Iymphangiomas may occur in the gums but offer no particmar probIem in diagnosis.

TREATMENT OF THE PRIMARY LESION IN CANCER OF THE GUM

The effectiveness of any form of treatment of cancer of the gum (surgery, cautery or radiation) is dependent upon certain anatomic features which are unique in the gums and hard paIate. Growths in these areas arise in a thin layer (I to 2 mm.) of soft tissue overIying bone. Whether or not the periosteum has been invaded, adequate surgica1 treatment requires the remova of at Ieast a thin she11 of the underIying bone; otherwise there is no assurance that the base of the growth has been removed. In the upper gum, the remova of overIying bone usuaIIy means opening into the antrum and sometimes the nasal cavity. This portion of the bone, so near the surface, aIso limits the possibilities of radiation therapy. In many cases the thinness of the growth over bone makes the retention of interstitial impIants impossibIe or at Ieast uncertain, and therefore the depend- ence must be pIaced chiefIy upon external radiation. The administration of cancer letha radiation doses in gingiva1 cancer wiI1 at Ieast partiahy devitaIize the underIying bone, subjecting considerabIe areas to the danger of subsequent radio-osteomyeIitis. If the periosteum and bone have been invaded, sterilization of the growth will


inevitabIy Ieave the bone exposed, radio-osteomyehtis foIIows, and sequestration of the bone must take pIace before heaIing.

The treatment method in the individua1 case of gingival cancer should be selected after a full consideration of these limitations and complications. In carcinoma, which makes up over 95 per cent of the maIignant tumors of the gum, no singIe method is suitable in all cases. Radiation, surgery and combinations of the two a11 have a definite place in the treatment of this disease. In two of the rare histologic types, the indications in the seIection of the treatment method are more definite; that is, melanoma shouId be treated onIy

by surgical excision and Iymphosarcoma only by radiation. In the Iiterature most of the references to gingival cancer are

found in articIes on cancer of the upper and lower “jaw,” and they frequentIy incIude antra1 or bone tumors in the same group. As has aIready been mentioned, so-caIled “carcinomas of the jaws” are often grouped with growths of the ffoor of the mouth, cheek or tongue, and the data are therefore confusing. When the pertinent opinions regarding treatment of gingival cancer are sifted out, they are found to be about equahy divided between local excision of the

tumor by actual cautery (CriIe,4 BIoodgood,3 0chsner22) or endo- thermy (Gernez,g Ohngren, 23 FischeI’j), radiation methods (Johnson,13 Quick,25 Ashbury, 2 Janeway12), radical resection of the maxiIIa (MacFee,‘> Meyer,21 Woodman, SchIey,zX Frenckner,’ HarmerlO) and combinations of surgical excision and radiation (EdIing,6 Maure120). Many of the tota resections of the upper jaw have probably been done for reasons similar to those for amputation of the extremities at so-caIIed “sites of election.” Such a principle is not we11 conceived when apphed to the maxiIIa, for a line of resection passing through the nasa1 cavity and the orbit can hardIy be considered a “site of eIection.” A s f ar as the comparative merits of any singIe one of these methods is concerned, one can lind no proof in the literature, since none of these authors has given five-year end resuIts on a series of histoIogicaIIy proved cases.

General Hygienic Measures. As in a11 forms of intra-ora cancer, hygienic care of the ora cavity both before and during treatment is an important factor in a successful resuIt. In the uncomplicated case, IocaI sepsis is superficial and can be controhed by mouth irrigations (q. 2 to 3 hr.) with Ik I a a ine-saIine solutions (sodium bicarbonate and sodium chIoride aa 3i to I quart of warm water) and cIeansing by power sprays (2 to 3 times a day),

ur7ll


The presence of teeth d irectIy at the site of the primary growth or in the immediate vicinity aIways constitutes an obstacIe not onIy to the administration of treatment but aIso to proper hygienic care. The soIution of this probIem must be individuaIized in each case. WhoIesaIe extraction of teeth is objectionabIe for several reasons. First, Iaceration of the gum opens the tooth sockets to invasion by the growth or by infection foIIowing radiation. Moreover, if there is an eventua1 Ioss of bone in either the upper or Iower jaws, the retention of some sound teeth is invaIuable if restorations by mechanica prosthetic appIiances are to be used. A few teeth may have to be extracted so as to permit the introduction of the proper sized cylinder for perora1 x-radiation. Other teeth may be so Ioose and so involved by denta sepsis that extraction is necessary even though objection- abIe from some standpoints. In other instances, sound teeth are best amputated at the gum margin, the nerve extracted and the root canals fiIIed, Ieaving the tooth sockets pIugged to guard against invasion by growth or infection.

As with many forms of intra-oral cancer, dietary deficiencies, especiaIIy avitaminosis B, accompanied by Iow grade stomatitis may pIay an important rbIe in the etiology and treatment of cancer of the gum. The maInutrition associated with this condition can be greatIy improved by the administration of Iarge doses of the vitamin B

compIex as, for instance, dried granuIar yeast in doses of three tabIespoonsfu1 (so Gm.) daiIy.

Treatment of the Primary Lesion by Radiation. AIthough there may be definite advantages in surgica1 remova of the smaIIer Iesions, the fact remains that radiation therapy is the most usefu1 and suitable method of treatment, since in the average case the growth in the gum is situated posteriorIy, is over 3 cm. in diameter and invoIves at Ieast one neighboring reIativeIy inoperabre structure. In super- ficia1 growths arising in the thin layers of soft tissue overIying bone, externa1 rather than interstitia1 radiation must be the main form of treatment. Quick25 has caIIed attention to the mechanical impossibil- ity of deep impIantation of interstitia1 sources and the inadequacy of contact appIication of radium in cancer of the gum.

At the MemoriaI HospitaI the radiation technic for cancer of the gum consists of (I) perora1 x-radiation given through the open mouth by the use of meta cyIinders, thus avoiding irradiation of the over- Iying skin, cheeks and lips; (2) supplementary x-radiation through accurateIy centered portaIs on the skin of the cheek, the tongue and

64


the opposite side of the mouth being at Ieast partIy protected by Iead shieIds pIaced on the lingua1 surface of the affected gum; (3) suppIe- mentary impIantation of smaI1 doses of radon seeds in residual disease

FIG. 4. A, a patient is shown in position for peroral x-radiation to a cancer of the lower anterior gum. The surgeon checks the accuracy of the set-up by an eIectricaIly lighted periscope, following which the periscope is removed and the treatment administered. B, peroral x-radiation for a growth of the upper gum.

in the cheeks or ffoor of the mouth or, rareIy, in the gums themselves. The use of suppIementary contact appIications of radon in dental compound molds is usefu1 onIy in rare instances.

After the preIiminary extraction or amputation of such teeth as constitute a definite obstacIe, peroral x-radiation is given through a meta cylinder of the correct size (2.~ to 3 cm. in diameter) to incIude the primary Iesion ampIy with a margin of at Ieast I cm. of surrounding normaI tissue if possible. (Fig. 4.) A detaiIed description of the apparatus and of the advantages of this technic has aheady been

UI9ll


pubIished. l’j Accurate direction of the beam and centering of the peroral porta is favored by the use of an eIectricaIly lighted periscope. (Fig. 4.) For the peroraI x-radiation of intra-ora cancer we have used both high voltage x-ray (200 to 250 kv., fiIter 0.5 to 1.5 mm. Cu) and Iow voItage x-ray (IOO to 120 kv., no filter except the tube waI1, T mm. AI eq.) at the shortest target skin distance (15 to 35 cm.) which can be obtained within the mechanica Iimitations of the apparatus. The treatments are given daiIy or at least three times a week, The individua1 dose in roentgens depends upon the correIation of such physica factors as the voItage, the size of the porta and the frequency of the treatments. On an average the tota dose in about twenty to twenty-five days with high voItage radiation (200 to 250 kv.) is from 5,000 to 7,000 r; with low voltage radiation ( IOO to 120 kv.) the tota dose over the same period is 10,000 to

15,000 r. In most cases perora1 x-radiation to the gum as described above

is combined with externa1 radiation given through the skin of the cheek, the exact center of the portal being carefuIIy determined and marked on the skin by a smaI1 tattoo mark.* Treatments are given to the two ports on aIternate days, the daiIy dose depending on the size of each porta1. The externa1 porta shouId be kept to a minimum size (3.5 to 5 cm. in diameter), just Iarge enough to cover the primary Iesion with a margin of about I cm. A tota dose of 4,000 to 5,000 r is given to this portal over a period of three weeks. At the compIetion of this x-radiation, subsequent treatment depends upon the amount of reaction in the normal tissues and the regression of the tumor. In some instances further externa1 radiation may be given. If only a smaI1 noduIe of residua1 disease can be paIpated in the margin, it is often best to impIant a few radon seeds (2 to 5 of I mc. each). In rare instances contact appIication of radon in denta moIds might be used after x-radiation.

Treatment of the Primary Lesion by Surgery. As has been mentioned previousIy, it is best to restrict purely surgica1 remova to smaI1 superIicia1 tumors which have not extended into neighboring structures. The technic for the combined use of cautery and bone chise1 in these Iesions is described in Figures 5 and 6 with their

* The skin is cIeansed with aIcoho1 and a smal1 drop of India ink is pIaced at the selected point. With a steriIe, sharp-pointed surgica1 needIe, severa punctures are made through the India ink into the skin. Such a mark remains permanently, but its size can be so smaI1 as to be unobjectionable.

Dolt

MARTIN-CANCER OF

beensectioned irt this Cm,“+

THE GUMS 789

FIG. 5. A, IS, c, D and E, resection of tbe mandible tbrougb tbe moutb. A, the mandibIe is usuaIIy sectioned near the symphysis, preferably with a Gigli saw inserted through stab wounds from the floor of the mouth out through the skin of the submenta1 region. The skin is advantageously protected by a speciahy devised guard. B, after the mandible is sectioned, the mucous membrane surrounding the Iesion in the gum is cut through by an actual cautery, Ieaving a safeIy wide margin of normal tissue. c, the bone is grasped by a bone-hoIding forceps and freed by sharp and blunt dissection. D, the attachment of the tempora1 muscIe to the choronoid process is severed and the temporomandibuIar joint disarticuIated by torsion. E, hemorrhage is controIIed mainly by packing and the wound is Ieft open.


mandible with

‘A nah,I,aP,3 fr,

B C

FIG. 6. A, B, c and D, resection of the mandible tbrougb an external incision. A,

after exposure of the outer surface of the mandibIe through an externa1 incision (A and B), the bone is sectioned by a motor saw (C). B, after section of the bone, the ora cavity is entered by an incision placed suffIcientIy wide of the tumor, as inspected through the open mouth. c, after incision through the soft tissues safeIy wide of the Iesion, the bone is again sectioned near the angle by a motor saw and the bone fragment removed with the contents of the submaxiIlary triangle (submaxiIIary salivary gIand and Iymph- nodes). The ascending ramus of the mandibIe may also be sectioned by disarticurating at the temporomandibuIar joint. D, the operative wound is cIosed in Iayers, the mucous membrane by an inversion stitch (F and C) reinforced by a layer of muscIe sutures (H and I), and finalIy the skin is closed with provision for subcutaneous drainage (J).

ibn


accompanying Iegends. These more extensive operations should be preceded by Iigation of at Ieast one externa1 carotid artery.

In the upper gum this technic may be used to excise the Iarger

Closure afsecond Iayer by ca+qu+ sutures

Ends OF bone haqments buried by approxlmaton

of s&t tissues

D

For descriptive legend see opposite page.

portion of the maxiha including the floor of the antrum. As far as cancer of the gums is concerned, such an operation is just as effective as tota resection of the maxiIIa with the additiona advantage that neither the uninvoIved floor of the orbit nor the IateraI waI1 of the nasa1 cavity is disturbed.

In the Iower gum the possibiIities of 1ocaI surgica1 remova are somewhat Iess than in the upper gum, for unIess the voIume of resected bone is smaI1, it is impossibIe to maintain the continuity of the mandibuIar arch. When a portion of this bone is removed, the deformity is extensive and the function of mastication is perma- nentIy Iost. PartiaI or hemiresection of the mandibIe is sometimes indicated for persistent or recurrent cancer or for radio-osteomyeIitis. If a posterior portion of the horizontal ramus is to be excised, a better cosmetic resuIt is obtained by incIuding the ascending ramus in the resection, disarticuIating it at the temporomandibuIar joint (Fig. 6~); otherwise, the fragment of the ascending ramus tends to be drawn forward and upward into the oraI cavity and, after heaIing,


constitutes a minor nuisance. When the mandibIe is resected for cancer, the line of incision passing through soft tissues must be determined by the probable extent of the growth. In these cases it is usua1Iy advisabIe to make an external incision through the skin. When the mandible is resected for radio-osteomyelitis alone, the dissection is subperiostea1 through the open mouth. When resection of one mandible is contemplated and teeth are present in the unin- volved side of the mouth, arrangements should be made to wire the jaws together at the time of the operation so as to avoid distortion during the healing process. Such a precaution makes it much easier to construct prosthetic appliances.

MeIanomas of the gums shouId always be treated surgicaIIy since this tumor is as radioresistant as norma tissue. In spite of its malig- nancy, meIanoma does not tend to recur IocaIly after removal with an average margin of normal tissue, so that an extremely radica1 excision gives no greater assurance of cure. The choice between IocaI remova and more extensive excision of the maxilIa or mandibIe

shouId be based upon the size and extent of the Iocal tumor. Combinations of Surgery and Radiation. In seIected instances,

bulky infected tumors in the upper and Iower gums not suitabIe to either radiation or surgery alone may be treated by a combination of the two, first appIying radiation (x-ray pIus interstitia1 radon) in what is believed to be a cancer lethal dose, followed immediateIy by a debridement of the heavily irradiated and condemned tissue which would otherwise undergo massive radionecrosis. The dosage technic under such a plan is extremely variabIe and must be individualized.

In the present series the method of treatment giving the highest percentage of success was a combination of perora1 x-radiation supplemented by impIantation of radon seeds, aIthough in onIy a slightly lesser number x-radiation aIone, peroraIIy and externally, was successfu1. Cautery methods used either alone or in conjunction with radiation were successfu1 in seIected instances.

TREATMENT OF METASTASES IN CANCER OF THE GUM

Prophylactic Treatment. One of the most controversia1 aspects in the treatment of cervica1 metastases from any form of intra-oral cancer is the management of those cases in which metastases are not cIinica1Iy demonstrabIe in the cervica1 lymph-nodes. There are three prevailing opinions : (I) The older surgica1 concept is that metastases

I[241


are present in the majority even though they cannot be paIpated, and therefore block dissection shouId be performed in a11 cases. Some surgeons aIso advise the administration of postoperative radiation. (2) The more recent radioIogic concept hoIds that only prophylactic radiation shouId be given in these cases. The dosage which has been advised varies from I to 2 skin erythema doses upward, aIthough few advise the administration of dosages which have been proved letha for demonstrabIe cancer. (3) The watchfuI- waiting pohcy is based upon the theory of treating cancer onIy where it is demonstrabIy present. In the Iatter case the surgeon assumes fuII responsibility for systematic fohow-up with the intention of giving aggressive treatment (surgical, radiologic or combinations of the two) onIy when there is actual clinica evidence of metastases. A fuIJ discussion of the comparative merits of these three pIans is beyond the scope of the present paper and has aIready been pubIished in previous reports.24

The poIicy in the Head and Neck Clinic of the MemoriaI HospitaI may be summarized brieff y as foIIows: (I) Prophylactic neck dissection (an operation performed in the absence of cIinicaIIy demon- strabIe metastases) is a tedious procedure attended by a morbidity of two to three weeks and a definite though smaI1 mortahty even in experienced hands. Statistics wiII prove that this operation, when performed in the absence of cIinicaIIy invoIved nodes, wiII be of actua1 vaIue in too smaI1 a number of cases to be justified. If it is conceded that its benefit is Iimited to the cases of those patients who are first seen without cervica1 metastases in whom the primary Iesion is permanentIy controhed and who Iater deveIop metastases, it wouId be usefu1 in only one in thirty-five cases of cancer of the Iip, one in eight cases of cancer of the tongue, and one in four cases of cancer of the gum. In some of these forms of cancer the operative mortaIity far exceeds the possible saIvage. AIthough there is a comparativeIy greater risk of deveIoping cervical metastases in cancer of the gum than in these other forms, prophyIactic neck dissection is neverthe- Iess stiI1 objectionable since it is attended by a greater risk of exposing the irradiated or surgicahy scarred areas within the mouth to such compIications as osteomyehtis or a break-through with infection. (2) The case for prophyIactic radiation is even Iess tenabIe. The critica observer realizes that the compIete eradication of cancer by radiation depends upon giving a letha dose and that no permanent benefit is to be derived from Iess than a IethaI dose of radiation.

u25ll


The IethaI dose for epidermoid carcinoma has been proved to be at Ieast 5 to 6 skin erythema doses. r* Such a dose of radiation to the entire area of the neck in which metastases might occur is attended by marked disability and is often fatal. None of the proponents of prophylactic radiation to the neck advises giving cancer IethaI doses to the entire neck. The administration of I to 2 skin erythema doses, a dose which has no visibIe effect upon the average epidermoid carcinoma, can hardly be caIIed IogicaI. (3) In view of the foregoing, the watchfuI-waiting policy seems the most reasonabIe from the theoretica standpoint. In brief this policy is as foIIows: If no metastases are cIinicaIIy demonstrabIe at the time of admission, no treatment is given to the neck. The patient is examined at reguIar intervals (at Ieast once a month for the first year). If cIinica1 evidence of metastasis appears, aggressive treatment-either surgical or radiologic-is given, the choice depending upon the individua1 case. The actua1 merit of any plan of treatment depends upon the end resuIts to be obtained both in the five-year end results in unseIected groups and in the number and cures of proved metastases, as wiI1 be discussed further under subsequent headings.

Treatment of Clinically Demonstrable Metastases. The treatment of metastasis from the upper gum is essentiaIIy the same as in intra-ora cancer in generaI, since the nodes first invoIved are usuaIIy in the upper or subdigastric group of the interna jugular chain. In cancer of the Iower gum, the mode of metastasis resembIes that in cancer of the mucosa of the cheek, that is, the first invoIve-

ment usuaIIy occurs to the pre- and retrovascuIar submaxihary nodes. In cancer of the posterior cheek or posterior Iower gum, a

rather unique situation occurs, that is, the first metastasis (pre- or retrovascuIar submaxihary node) is almost in direct contact with the primary Iesion.

The treatment for metastasis from cancer of the upper gum depends mainIy upon the time of the appearance of the metastases. If nodes are invoIved on admission, radiation is undoubtedIy the most usefu1 form of treatment. The technic for the radiation treatment of cervica1 metastatic cancer has been described in detail in previous reports from our cIinic, lg the most important factors being the administration of fractionated x-radiation through smaI1 portaIs (3 to 5 cm. in diameter) Iimited to the region of the node itseIf, giving a tota of 5,000 to 8,000 r over a period of about three weeks (200 to 250 kv., 35 to 50 cm. T.S.D., 0.5-1.5 mm. Cu. fiber), supple-

Ml


mented by the implantation of radon gold seeds either in a single dose or in fractions. In the present series, six patients with proved metastases, who were treated by radiation aIone, have survived for

more than Iive years. In metastases from cancer of the Iower gum the probIem is

infIuenced by the juxtaposition of the primary Iesion and the pre- and retrovascular Iymph-nodes. In peroral x-radiation of the primary, the beam can often be tiIted so as to incIude both the metastases (in the pre- and retrovascuIar nodes) and the primary Iesion. The x-radiation is suppIemented by the impIantation of radon seeds mainly in the Iymph-node, thereby Iessening to some extent the risk of radionecrosis and radio-osteomyelitis which are more IikeIy to resuIt if the seeds are impIanted within the mouth. In posteriorIy pIaced Iesions of the Iower gum with metastases to the submaxillary nodes, IocaIized radio-osteomyelitis often occurs, but if the growth has been destroyed this compIication can be treated conservativeIy unti1 the bone sequestrates spontaneously.

For metastases which appear after heahng of the primary Iesion in the Iower gum, the selection of treatment must be individualized, depending upon the amount of radiation scarring. Either surgery or radiation might be preferabIe in the individua1 case in an effort to favor prompt heaIing of the tissues. In certain compIicated cases in which a metastatic node becomes attached to or invades the mandibIe, submaxiIIary dissection may be combined with resection of a portion of the mandibIe. In such cases the skin incision may be closed at the completion of the operation or, if Iarge areas of skin must be removed, the wound may be Ieft open for Iater plastic closure.

The present series of I 13 cases is not Iarge enough to permit any fina concIusions in regard to the reIative merits of radiation and surgery in the treatment of cervical metastases in cancer of the gum. Of the sixty-two patients with metastases, seven were seIected as being suitabIe for neck dissection on the basis of apparent contro1 of the primary Iesion and the presence of earIy and operabIe metastases in the neck. AI1 seven survived the operation but subsequentIy succumbed to recurrences in the neck (four cases), at the site of the primary Iesion (two cases), or to systemic dissemination (one case). In the fifty-five remaining cases with Iymph-node invoIvement, the metastases were considered inoperabIe or at Ieast unsuitabIe for neck dissection, and treatment was by radiation aIone. Six of these


patients with histoIogicaIIy proved metastases (aspiration biopsy) have survived for Iive years or more, as we11 as an additiona three in whom the nodes were cIinicaIIy positive aIthough aspiration biopsies were omitted. The survival of at Ieast six (about I I per cent) for live years in comparison to no survivaIs by surgery is a strong indication that radiation is a more usefu1 method than surgery in metastases from cancer of the gum. In any event, neck dissection, if used in gingiva1 cancer, shouId be Iimited to those cases in which the primary Iesion is under apparent contro1 and the nodes occur Iate in the course of the disease. When nodes are present in the beginning, neck dissection can hardIy be combined safely with the necessariIy aggressive treatment (by either surgery or radiation) to the primary lesion.

In meIanoma of the oraI mucous membrane an exception might be made to the ruIe against prophylactic neck dissection, aIthough it is doubtfu1 whether the end resuIts wouId be greatIy influenced. As far as the MemoriaI HospitaI cases are concerned, intra-ora meIanoma invariabIy metastasizes so that it might be argued reasonabIy that a neck dissection is in order. On the other hand most of such metastases are bilatera1 and the systemic metastases which have also occurred in a11 of our cases indicate that dissemination

takes pIace by way of the bIood stream as we11 as by the Iymph stream; therefore, neck dissection wouId be useIess.

PROSTHETIC REPAIR OF DEFECTS OF THE MAXILLA, PALATE AND

MANDIBLE

Adequate treatment of a11 forms of intra-ora cancer frequently necessitates a Ioss of the soft parts or bone and the production of both cosmetic and functiona deformities. Defects of soft parts may often be repaired satisfactoriIy by plastic surgery; but if there has been a Ioss of bone of the jaws or paIate, surgical repair or bone grafting is seIdom practicabIe, and some mechanica contrivance is not onIy more effective but easier to appIy. Dr. Andrew Acker- man, denta surgeon of the MemoriaI HospitaI, has reported in considerabIe detai1 the forms and methods of construction of various mechanical devices for the repair of defects in the jaws and palate foIlowing treatment of cancer in the m0uth.l In cancer of the gums, the deformities resuIting from treatment are due aImost entireIy to Ioss of bone.


In the upper gum the defect, usuaIIy opening into the antrum and sometimes into the nasal cavity, produces a doubIe disability. With Iarge defects in this area speech is UninteIIigibIe since articu- lation is impaired and resonance altered. Furthermore, eating and drinking are diffrcuIt since part of the ingesta tends to enter the nasa1 cavity, to be expeIIed through the nose on swaIIowing. WhiIe surgica1 repair of these upper jaw and paIata1 defects is impractica1, they may usuaIIy be almost perfectIy remedied by prosthetic apph- antes so that normal function in both speech and swaIIowing is restored. Such devices consist mainIy of a modified upper denta pIate so shaped and fitted as to cIose tightIy the opening in the

paIate and floor of the antrum. Firm retention is attained by a combination of severa expedients, such as the usual suction cup, cIasps on remaining teeth, and undercutting of the edges which fit into the defect. In the smaIIer defects, such prostheses can be made satisfactoriIy by the average dentist. When there is extensive Ioss of bone and soft tissue past the posterior border of the hard palate, the defects may be such as to require the services of a dentist with special training and experience in the construction of such appIiances.

In the Iower jaw any loss of substance invoIving a break in the continuity of the mandibuIar arch aIso produces both a cosmetic and functional deformity. FolIowing the Ioss of the whoIe or of a portion of one horizonta1 ramus, the opposite mandibIe shifts toward the defective side, drawing the remaining teeth out of proper occIu- sion. Depending upon the amount of bone lost, and especiaIIy on

whether the defect is situated anteriorly, the shape of the Iower part of the face is distorted to a variable degree. When the anterior por- tions of both horizontal rami are Iost, the normal contour of the chin is markedly aItered, and the tongue, deprived of its anterior support, recedes backward and downward into the pharynx for a short distance. In addition to this cosmetic deformity the power of mastication is compIeteIy lost since the grinding of food by the moIars is produced by a complicated vertical, horizonta1, and IateraI motion of the mandibIe by the combined action of two sets of temporal and pterygoid muscles. Even the simple biting action is impossible since the teeth can no Ionger be brought to proper occIusion. Despite these cosmetic and functiona abnormaIities, the Ioss of a portion of the mandibIe is compatibIe with perfect heaIth, aIthough the nature of the food must be aItered.


In the repair of bone defects of the Iower jaw, the interposition of a bone or cartiIage graft from a rib or other bone is sometimes advised. AIthough such an operation is technicaIIy feasibIe if done immediateIy foIIowing partia1 resection of the mandibIe, it can seIdom if ever be appIied in cancer of the gums. Such bone or carti- Iage grafts, to be successfu1, must be embedded in heaIthy vascuIar soft parts in a steriIe fieId. In surgical resection of the average gum cancer, the intra-oraI wound cannot be sutured, and in any case wouId be grossly contaminated by infection. FoIIowing radiation the decreased vascuIarity of the tissues in the heaIed state wouId make the success of the bone grafting doubtfu1. Furthermore, in most cases after the treatment of cancer, the possibility of recurrence wouId make it prudent to wait for a year or two before any grafting were attempted, and by that time the scarring and con- tracture are so firm as to make restoration of the normal contour impossibIe, even if a sufficient thickness of soft tissue were present in which bone grafts might be embedded.

In the most marked deformities foIIowing partia1 Ioss of the mandible, there is no method of compIete restoration. In certain instances, however, in which there is minima1 scarring and not too great a Ioss of bone and soft tissue, Ackerman has succeeded in markedIy improving both the appearance and the function by

ingenious hinged devices attached to an upper denture. AIthough the abiIity to masticate has seIdom been restored, such devices contribute a great dea1 to the patient’s comfort and appearance.

COMPLICATIONS

Radionecrosis and Osteomyelitis. As has been previousIy mentioned, the gum consists of a thin Iayer of soft tissue about 2 to 3 mm. in thickness overIying bone. The bIood suppIy of the gum is entireIy periphera1, coming from the adjacent cheek, paIate or floor of the mouth. The thinness of the gum and the Iack of a bIood supply from its base make this structure particuIarly susceptible to IocaI radionecrosis following cancer IethaI radiation. Radiation in such dosage, which aIso reaches the underlying bone, is sufficient to destroy the finer osseous circulation, so that when bone is exposed by radionecrosis of the ovedying gum, radio-osteomyelitis is aImost inevitabIe. It is onIy by appreciation of these facts and by meticuIous attention to the detaiIs of radiation technic that such compIications can be avoided or their severit,y diminished. The most important


precaution is the Iimitation of the porta or externa1 radiation to the smaIIest efficient diameter and the accurate centering of the radi-

ation beam. In the present series there was radionecrosis of soft tissue in

about 50 per cent of the cases, and at Ieast haIf of these subsequentIy deveIoped radio-osteomyelitis with some Ioss of bone. When super- ficia1 radionecrosis occurs with exposure of the underIying bone, the best treatment is conservative, combatting the sepsis with frequent irrigations and appIying oxygenic preparations (zinc peroxide) over a period of weeks or even months unti1 the bone finaIIy sequestrates. The exposed fragment of bone may be manipulated gently from time to time in an attempt to hasten its separation. If IocaI sepsis and pain attendant upon the osteomyelitis are particuIarIy severe, partia1 resection of the bone in either the upper or Iower jaws may be indicated. In such cases the Iine of resection shouId be through viabIe bone, which is possibIe onIy if the beam of externa1 radiation has been Iimited in extent. When wide beams of 8 to IO cm. in diameter are used, the radio-OsteomyeIitis usuaIIy progresses through the entire mandibIe or maxiIla. The morbidity is Iong, and the compIications often fata1.

Dental Complications. The extent to which the presence of teeth in either the upper or Iower jaws is an obstacle to the administration of both surgica1 and radiologic treatment has aIready been mentioned. The compIications which are IikeIy to foIIow the extraction of teeth have aIso been described. When sound teeth are per- mitted to remain within the fieId of cancer IethaI radiation, denta compIications are inevitabIe. When the teeth and adjacent aIveoIar processes are irradiated in cancer IethaI doses, the gums retract and the teeth are devitaIized, probabIy as the resuIt of a devitaIization of the peridenta1 membrane and the destruction of the apica circu- Iation. Over a period of severa months to a year, such teeth Iose their; norma gIoss and assume a chaIky appearance. Numerous cavities deveIop, not onIy on the occIusa1 surface but near the gum

margins. The tooth structure crumbIes away, and in some cases the entire exposed portion of the tooth disappears down to the gum margin, Ieaving a’decaIcified exposed root.

When teeth are extracted before treatment is begun, the granu- Iation tissue in the tooth sockets tends to disappear under heavy irradiation, Ieaving avascuIar bone exposed. When teeth are extracted at an interva1 after heavy irradiation, the tooth sockets

1311)


may bIeed very Iittle, and granmation tissue may faiI to deveIop. Osteomyelitis then occurs, beginning in the exposed bone. There is no way of eIiminating these denta compIications, but their extent and severity can be markedIy reduced by meticuIous attention to the detaiIs of radiation therapy and hygienic care.

Pain. As has been mentioned previousIy, pain is not a promi- nent earIy symptom in cancer of the gums, due mainIy to the fact that these tissues are poorIy suppIied with nerves. Pain seIdom becomes a marked symptom in cancer of the gums except after invasion and sepsis of the bone or of the soft tissues of the cheek, the ffoor of the mouth or the paIate.

With osteomyehtis of the maxiIla or mandibIe, it is mainIy the superior and inferior denta nerves which are affected, and in these cases neuroIysis of the second and third divisions of the fifth crania1

nerves by alcohol may effect compIete reIief from pain provided that compIications do not extend into the areas supplied by other

nerves, such as the ninth or the upper cervica1 branches. Hemorrhage. F II o owing erosion by disease or radionecrosis,

hemorrhage occurred as a compIication in over 20 per cent of the present series and was the cause of death in six cases. It occurred

most frequentIy in growths of the upper gum. The bIood suppIy to the upper jaw is mainIy from the interna maxiIlary artery, the Iarger

branches of which Iie rather deepIy in the pterygotempora1 fossa so that serious hemorrhage rareIy occurs except when there is deep

erosion foIIowing radionecrosis in this area. The bIood suppIy of the Iower jaw and adjacent soft parts is from the inferior denta1, the

externa1 maxiIIary and the lingua1 branches of the externa1 carotid arteries. Serious hemorrhage does not occur from the inferior denta

artery which is reIativeIy smaI1 in size. Deep erosion or sIough in the floor of the mouth or in the gingivobucca1 gutter may erode

either the externa1 maxiIIary or the IinguaI artery or both, and hemorrhage may be severe enough to be fata immediateIy.

When bIeeding occurs from any one of these vessels, the imme-

diate treatment is by IocaI tamponage with gauze packing and digital pressure, foIIowed as soon as possibIe by Iigation of the externa1

carotid artery. Since in most cases the heaIing of the wound in the mouth may not take pIace for severa months, the occlusion of the

artery shouId be permanent, either by section of the vesse1 by double ligatures or, preferabIy, by the use of a meta ligature. When

f321


bIeeding occurs from the Iower jaw, the Iigature on the externa1 carotid must be placed below the origin of the lingua1 artery.

PROGNOSIS

In the medica Iiterature where specific reference is made to the subject, cancer of the gum is usuaIIy reported to have a bad prog-

nosis .11,14 At the Memorial HospitaI the chance of cure in this group of tumors is sIightly better than that in cancer of the tongue, ffoor of the mouth, or tonsi1, and about the same as in cancer of the cheek. The factors influencing the chance of cure are given in TabIe III,

the most important of which wiI1 be discussed separateIy. Age. AIthough in most forms of intra-oraI cancer the chance

of cure is better in the younger age groups, an anaIysis of the present series gives Iittle evidence in this regard. AIthough two of four patients (50%) under the age of forty were cured, but the number is too smaII to permit of any definite concIusions.

Sex. As in al1 forms of intra-ora cancer which we have studied in our cIinic, an analysis of the present series indicates that the chance of cure of cancer of the gums is better in females (50 per cent) than in maIes (23 per cent). It is probabIe that this difference is due mainIy to the fact that a11 anatomic and histologic forms of cancer are more radiosensitive in the femaIe than are their counter-

parts in the maIe. Position of the Growth. AIthough one might expect a difference

in the cure rate between cancers of the upper and Iower gum and between Iesions near the symphysis and those situated posteriorIy near the soft paIate, there appears to be no significant variation in this regard.

Size of the Primary Growth. As might be expected, the size of

the primary Iesion on admission is one of the most important factors in the prognosis. When the growths were Iess than 2 cm. in diameter, the cure rate was 50 per cent, as compared to 13 per cent in those over 4 cm. The average size of the growths in a11 cases was 3.3 cm., in the fata cases 3.5 cm., and in the cured cases 2.9 cm.

Metastases. In gingiva1 growths, as in al1 forms of cancer, the occurrence of metastases is the most important factor in prognosis. Among patients with no metastases at any time, the five-year cure rate was aImost 50 per cent, as compared to I I per cent when metastases were present some time during the course of the disease. There were no survivals among the thirty-eight patients with metastases on

a331


TABLE III FACTORS INFLUENCING THE PROGNOSIS IN 105 DETERMINATE CASES OF CANCER OF TIIE GUM


Age Under40 ................................. 40to49 .................................. 50to59 ................................... 60 and over ................................ Not stated .................................

Sex MaIe ...................................... FemaIe ....................................

Position of the growth Right ..................................... Left ...................................... Both ..................................... MidIine .................................... Upper ..................................... Lower ..................................... Both ......................................

Size of Iesion oto r.gcm.. ............................... 2 to 2.9 cm ................................. 3to3.9cm.. ............................... 4 cm. or over ............................... Size not stated or scar present. ...............

Metastases On admission. .............................. None on admission .......................... CervicaI invoIvement later. .................. Distant metastases later ..................... Metastases sometime during course. .......... No metastases at any time ...................

Histopathology Squamous carcinoma grade 1. ................ Squamous carcinoma grade 11. ................ Squamous carcinoma grade III ................ Adenocarcinoma. ........................... Spindle ceII carcinoma ...................... Lymphoepithetioma. ....................... Lymphosarcoma. .................. ...... MeIanoma ................................ No disease at primary site on admission. .....

- Tot a1 Cases

4 10

21

67 3

85 20

44 56

2

3 47 57

I

8

25 IG

35 21

38 67 17

6:

43

26

62 I 5 I I I 4 4

+e-year Cures

- 1

( ;ive-year :ure Rate

2

2

7 I5 I

50 20

30 22

19 22

8 40

14 32 12 21

0 0

I 33 12 25 ‘5 26 0 0

38 28

31 ‘7 29

0

27 6

: 21

0

40 35

0

IO

49

I2 46 II 18

I 10” 2 40 0 0

I IO0

0 0

0 0

0 0

u34n

MARTIN--CANCER OF THE GUMS 803

admission. These figures might suggest that cancer of the gum is unusuaIIy malignant once it has metastasized, but when compared with other forms of intra-oraI cancer (TabIe IV), it wiI1 be seen that the cure rates in cancer of the tongue, the tonsil, and the cheek with metastases are at about the same IeveI, whiIe in cancer of the floor of the mouth, the lip, and the nasopharynx with metastases, the cure rates are somewhat higher.

Histopathology. The cure rate in cases of squamous carcinoma grade I was 48 per cent in the present series, aImost twice the average and about two and one-haIf times that of the most frequent tumor, squamous carcinoma grade II (18 per cent). The totat number of adenocarcinomas is too smaI1 to be of significance, but two of the five survived. MeIanoma of the ora mucous membranes is aIways serious and is seldom cured. Al1 four patients of the present series succumbed to wideIy disseminated disease.

END RESULTS

We have been unabIe to find any specific figures for five-year end resuIts in cancer of the gums which are weII-attested, that is, the few pubIished reports are not based upon consecutive, unseIected cases, a11 histoIogicaIIy proved, and in most instances too Iarge a percentage of the patients are untraced. In some reports the data are inconcIusive because of the incIusion of gingiva1 tumors with other forms of cancer, chiefly of the antrum. The cIosest approxi- mation to accurate end resuIt figures is found in the reports of EdIing5 and Gaini, * both of whom used radiation as the main form of treatment. In EdIing’s series the diagnosis was not verified histoIogicaIIy in one-third of the cases. He reports three of twenty- six patients (I I per cent) aIive and weI1, but admits that in one of these the presence of cancer was not confirmed by biopsy. Gain? attempts to give five-year end resuIts in a series of fifty-three cases. His figures are rather confusing, but the Iack of adequate foIIow-up is apparent since in a11 his caIcuIations at various periods, about one-third of the patients are untraced. He reports that at the end of five years, six patients were aIive and we11 (I 2 per cent). The five-year cure rates in both of these series wouId probably be higher if there had been accurate foIIow-up and a correction for those

patients who died of other causes without recurrence of cancer. The net end resuIts in the present series of cases, a11 histoIogicaIIy

proved, are given in TabIe v. As has been mentioned, this series is

a351


TABLE IV CURE RATES IN METASTASES FROM INTRA-ORAL AND PHARYNGEAL CANCER


Per Cent

Gum .._.. ._.. ._.. .._. ._.__._... ._ II TonsiI........................................................ IO Cheek.....................................,,,..,,.,.......... II Tongue...................................,,.,....,,.......... 12 Nasopharynx.................................................. zo FIoorofmouth................................................. 22 Lip........................................................... 27

made up of al1 patients with gingiva1 cancer who appIied at the MemoriaI HospitaI during the years 1929 to 1935, incIusive, and were able (ambmatory) and wiIIing to return for treatment or pahiation. None was excIuded because of an advanced stage of the disease. Before caIcuIating net end resuIts, those patients were excIuded who died of other causes or who were Iost track of after a year’s freedom from disease. In the entire group the cure rate is

TABLE v

MEMORlAL HOSPITAL FIVE-YEAR END RESULTS IN CANCER OF THE GUMS

1929 to 1935, IncIusive This series consists of all patients with histoIogicaIIy proved cancer of the gums,

both earIy and advanced, admitted during the specified period. OnIy those patients are excIuded who, for any reason, were unable to return for treatment, paIIiation and observation in the out-patient department or who were Iost track of within the first month after no more than one or two visits (clinic shoppers).

Totalnumberofcases............................................. 113

Indeterminate group: Dead as a result of other causes and without recurrence. ............. 6 Lost track of without recurrence. ................................. 2

TotaI number of indeterminate results., ......................... 8

Determinate group: TotaI number minus those of indeterminate group.. 105

FaiIures: DeadasaresuItofcancer ...................................... 72

Lost track of with disease (probably dead). ......................... 5 Living with recurrence., ......................................... I

TotaI number of failures in treatment., .......................... 78

Successful results: Free from disease after five years or more.. 27

Five-year end resuIts: Successful results divided by determinate group (2Jius). 25.7%


25.7 per cent. Among the cases of carcinoma aIone, excIuding meIa-

noma, the cure rate is 27 per cent.

SUMMARY

A series of I 13 consecutive cases of cancer of the gums (gingivae)

is analyzed from the standpoint of etioIogy, clinica course, treat-

ment and end resuIts. Treatment methods by radiation, surgery,

and combinations of the two, with their attendant compIications,

are described in detai1.

The net cure rate in the series, caIcuIated in 103 determinate

cases, is 25.7 per cent.

REFERENCES

1. ACKERMAN, A. J. The dentat care before, during and after treatment for intraoral cancer. Arch. Chn. Oral Path., 3: 141, 1939.

2. ASHBURY, H. H. The treatment of carcinoma of the upper alveolar ridge. Radial. Rev. Ed Mississippi Valley M. J., 59: 65, 1937.

3. BLOODGOOD, J. C. Oral cancer. J. Am. Dent. A., 20: 1790, 1933. 4. CRILE, G. W. Carcinoma of the jaws, tongue, cheek and lips. Surg., Gynec. ti Obst.,

36: 159. 1923. 5. EDLING, L. Bisherige Resultate van Teleradiumbestrahtung beim BuccaI- und

Kieferkarzinom an der RadioIogischen KIinik in Lund. Acta Radiol., 18: 97, 1937. 6. FISCHEL, E. The use of radium in carcinoma of the face, jaws and ora cavity. J.

Missouri M. A., 17: 267, 1920. 7. FRENCKNER, P. and SUNDBERG, S. Einige FLIIe van Plastik- und Prothesen-behand-

Iung nach Oberkieferresektion wegen Ca. maxiIIae. Acta oto-laryng., 27: 147, 1939. 8. GAINI, G. La curieterapia degli epitheliomi gengivaIi. Radial. med., 26: 32, 1939. 9. GERNEZ, L., MOULONGUET, P. and MALLET, L. Traitement des cancers epitheliaux

de Ia mandibuIe par I’eIectro-coaguIation suivie de curietherapie. J. de Cbir., 45:

22, 1935. IO. HARMER, W. D. Treatment of maIignant disease in the upper jaw. Lancet, I: 129,

1935. 1 I. HUBBARD, J. E. Cancer of bucca1 mucous membrane and jaw. West Virginia M. J.,

29: 527. 1933. 12. JANEWAY, H. H. The treatment of tumors of the superior maxiIIa. Ann. Surg., 68:

353, 1918. 13. JOHNSON, F. M. Certain difficult problems in the treatment of carcinoma of the

lower jaw. Radiology, 5: 280, 1925. 14. KIRKHAM, H. L. D. Tumors of the aIveoIar border of the jaws. Texas State J. Med.,

17: 351. 1921. 15. MACFEE, W. F. Resection of the upper jaw for cancer. Am. J. Surg., 30: 21, 1935. 16. MARTIN, H. E. PeroraI x-radiation in the treatment of intra-oral cancer. Radiolog.y,

28: 527, 1937. 17. MARTIN, H. E. and HOLLAND, B. F. The zoologic distribution of intraoral cancer.

Scien. Monthly, 49: 262, 1939.

18. MARTIN, H. E., QUIMBY, E. V. and PACK, G. T. Calculations of tissue dosage in radiation therapy. Am. J. Roentgenol., 25: 490, 1931.

19. MARTIN, H. E. and BLADY, J. V. Cancer of the Iip. Ann. Surg., in press. MARTIN, H. E. The treatment of cervica1 metastatic cancer. Ann. Surg., in press.

!I371

MARTIN--CANCER OF THE GUMS

20. MAUREL, G. and WEILL, R. Les indications respectives du traitement chirurgical et du traitement radiumtherapique dans les tumeurs malignes du mavilIaire inferieur. Presse mhd., 42: 896, 1934.

21. MEYER, H. W. Epithelioma of the right superior maxilla. Am. J. Surg., 6: 378, 1929. 22. OCHSNER, A. J. The treatment of cancer of the jaws. Ann. Surg., 76: 328, 1922. 23. OHNGREN, G. MaIignant disease of the upper jaw. J. Laryngol. TV Otol., 52: 18, 1937. 24. PACK, G. T. and LIVINGSTON, E. M. Treatment of Cancer and Allied Diseases.

Vol. I. New York, 1940. Paul B. Hoeber, Inc. 25. QUICK, D. Carcinoma of the lower jaw. Am. J. Surg., I : 360, 1926. 26. ROUVI$RE, H. Anatomie of the Human Lymphatic System. Ann Arbor, 1938.

Edwards Brothers, Inc. 27. SASSIER, P. Lymphatiques des gencives. Ann. d’anat. patbo/. d’anat. norm. mtd.-

cbir., 4: 212, 1927. 28. SCHLEY, W. S. Cancer of the upper jaw, its surgica1 treatment. Surg., Gynec. ti

Obst., 37: 683, 1923. 29. SCHWEITZER, G. Ueber die Lymphgefaesse des Zahnffeisches und der Zaehne beim

Menschen und bei Saeugetieren. I. Die Lymphgefaesse des ZahnfIeisches beim Menschen. II. Lymphgefaesse der Zaehne. Arch. J. mikrosk. Anat. IL. Entwick Lungsgescbicbte, 69: 807, 1907. III. Topographie. IV. Feinerer Bau bei Saeugetieren nebst Beitraegen zur Kenntniss der feineren Blutgefaessverteilung in der Zahn- puIpa und Zahnwurzehaut. Ibid., 74: 927, Igog.

30. USILTON, L. J. Persona1 communication. 3I. WOODMAN, E. M. Mabgnant disease of the upper jaw, with special referance to

operative technique. &it. J. Surg., I I : 153, 1923.

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Cancer of the gums (gingivae)

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