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Institut Bergonie, Regional Cancer Center, Bordeaux Cedex, France; 2Department of Maxillofacial and
Plastic Surgery, Centre Hospitalier Universitaire, Bordeaux Cedex, France
SUMMARY. Background: Squamous cell carcinomas of the gingiva are relatively rare tumours. Standard
treatment is based on surgery and radiotherapy. The extent of bone involvement affects mandibulectary indications.
Purpose: A retrospective review of squamous cell carcinomas of the gingiva was performed to evaluate the
incidence of mandibular or maxillary bone involvement. Indications for marginal and segmental bone resections are
specified. Material: From 1985 to 1996, 83 patients with squamous cell carcinoma of the gingiva were treated at the
Department of Surgery (Institut Bergonie, Bordeaux, France) and at the Department of Maxillofacial and Plastic
Surgery (Centre Hospitalier Universitaire, Bordeaux, France). Forty-three underwent surgery plus postoperative
radiotherapy. Twenty-two had flap reconstructions. Clinical evaluation and panorex rntgenography were the
means used to evaluate bony invasion and to decide on the extent of bone resection. Methods: A retrospective
review of 83 consecutive patients was performed. This series is unusual in its homogeneity: surgery was performed
by only two individuals and the radiotherapy was the responsibility of just two physicians. Outcome was calculated
using the Kaplan-Meier method. Results: Primary local control was achieved in 72 patients (87%). Overall survival
and rate of recurrence were comparable to those of other squamous cell carcinomas of the oral cavity and
oropharynx. Conclusion: Surgical resection continues to be the mainstay of treatment and this study tends to
confirm the validity of modified neck dissection and marginal bone resection in suitably selected patients. # 2000
European Association for Cranio-Maxillofacial Surgery
INTRODUCTION
Squamous cell carcinoma of the gingiva is relatively
rare and represents less than 10% of squamous cell
carcinomas of the oral cavity (Cady & Catlin, 1969;
Byers et al., 1981; Soo et al., 1988; Eicher et al., 1996).
The initial symptoms are similar to those of other
primary sites in the oral cavity (Cady & Catlin, 1969;
Byers et al., 1981). Standard treatment is based on
surgery and radiation therapy (Fletcher & Jessee,
1977; Vikram et al., 1980; Byers et al., 1981; Soo
et al., 1988). We performed a retrospective review of
83 consecutive, previously untreated patients with
carcinoma of the gingiva to assess outcome and to
evaluate the incidence of mandibular or maxillary
bone involvement, since this affected the extent of
bone resection (Byers et al., 1981; Totsuka et al.,
1990; Loree & Strong, 1990; Totsuka et al., 1991;
Overholt et al., 1996).
PATIENTS AND METHODS
The medical records of 96 patients with previously
untreated squamous cell carcinoma of the gingiva,
seen between 1 January 1985 and 31 December 1996
at either the Department of Surgery (Institut Bergonie, Bordeaux, France) or at the Department of
Maxillofacial and Plastic Surgery (Centre Hospitalier
331
RESULTS
There were 52 men (63%) and 31 women (37%) who
ranged in age from 4090 years (mean age 68 years).
Mean follow-up was 61 months. Accurate evaluation
of tobacco and alcohol consumption was available in
50 patients. Tobacco was used regularly by 31
patients. Twenty-five patients consumed alcohol
daily. Irritation from ill-fitting dentures was present
in 20 patients. The prevailing initial symptom was an
intraoral mass or swelling in 31 patients (37%).
Ulceration was noted in 27 patients (33%), whereas
pain was reported by only 5 (6%). Mobility of teeth
was seen in two patients (2.5%), there being no link
between the extraction of teeth and carcinoma of the
gingiva. The pre-treatment evaluation usually included clinical history, physical examination, biopsy,
chest rntgenography, endoscopy and a full blood
count. Panorex rntgenography was used in all
patients. Facial bone scans were performed in only
15 patients.
Primary tumour site was the lower alveolar ridge in
53 patients (64%) and the upper in 30 patients (36%).
Forty lesions were located on the left side (48%), 28
on the right side (34%) and 15 were midline (18%).
Tumours were staged according to the 1987 recommendations of the Union Internationale Contre le
Cancer (U.I.C.C.; Table 1) and the American Joint
Committee on Cancer (1988). Tumours of patients
admitted before 1987 were reclassified. Among the 58
patients with tumours classified as T4, 48 had clinical
or radiological evidence of bone invasion. No patient
was found to have a distant metastasis at the first
consultation. The tumours were categorized as well
differentiated in 67 (81%) and moderately differentiated in 14 patients (17%). The tumour grade was
not classified in two patients (2%).
Among the 69 patients treated surgically, there was
one postoperative death due to general complications
Table 1 Tumour and node staging for the complete series of
gingival carcinomas (UICC, 1987)
N0
N1
N2a
N2b
N2c
N3
Total
T1
T2
T3
T4
TX
Total
6
1
10
1
39
12
2
60
14
2
1
2
4
83
72
17
2.5
1
2.5
5
100
1
7
11
2
3
58
1
2
Total
Fistula
Wound infection
Wound haematoma
Partial flap necrosis
Total flap necrosis
Systemic complications
Total
4
3
1
3
1
3
15
27
20
6.5
20
6.5
20
100
influence survival amongst T stage, N stage, histologically proven bone involvement, surgical margins
and lymph node involvement: in this series T stage
(p 0.05), N stage (p50.001) and surgical margins
(p 0.016) emerged as significant predictors of
survival.
Among the 72 patients with primary disease
control, recurrences occurred in 29 patients
(40.3%): there were 13 local recurrences, four local
with cervical recurrences, one local recurrence plus
distant metastasis, seven lymph node recurrences in
the neck, one local plus lymph node in the neck plus
distant metastasis, and three distant metastases.
T stage (T1, T2 and T3 vs. T4: p 0.05), surgical
margins (p 0.006), and lymph node invasion
(p 0.005) predicted a statistically significant risk of
recurrence. One- and 5-year survival rates following
detection of recurrence were 47.3% and 18.8%,
respectively. On multivariate analysis, only lymph
node involvement emerged as a significant predictor
of recurrence (p 0.016).
DISCUSSION
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