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MALIGNANT EPITHELIAL TUMORS OF THE NECK

CARCINOMA OF BRANCHIOQENIC ORIGIN ROBERT LEE OLIVER, M.D.

(From the Surgical Pathological Laboratory of the dohns Hopkins University and the Surgical Service of the Xt. Agnes Hospitul, Baltimore, Maryland)

INTRODUCTION Deep-seated epithelial tumors of the neck without obvious connection

with the epidermis are fairly rare in the literature. Prior to the year 1913 Lorenz (1) was able to collect only 64 cases, including those in his own experience. Since his classical review the number of cases reported has increased, but still is not large. From a study of our own material, which includes 80 cases, we have been led to conclude that these lesions are more common than is ordinarily recognized, and it is the purpose of the present paper to call attention to the pathologic and clinical features of these tumors based upon the study of this larger material.

All the lesions in this study have been deep-seated, in the soft parts of the neck. Where superficial lesions occurred, they were Becondary to deep-seated tumors, having invaded the skin by direct extension, in fungoid fashion, or were secondary to surgical intervention, namely drainage or incomplete removal. Cases in which there was any question of origin in the superficial epidermis have been ruled out.

In an attempt to explain the localization of these cancers in a region where sarcoma rather than carcinoma would ordinarily be expected, the question of metastases from primary lesions of the oral cavity and associated carcinomas immediately arises. In none of the cases of this series, however, was any primary lesion demonstrable at the time of examination or later in the course of the disease. There is a possibility that a small percentage of the cases may have been metastatic from an unrevealed source in the nasopharynx or some unrecognized lesion of the fauces, bronchi, or esophagus. Careful examinations, however, revealed no such primary focus. The lesions were also studied carefully in order to rule out a possible origin from the thyroid, parathyroid, submaxillary, lingual, o r smaller secretory glands of the oral cavity. No such origin could be demonstrated.

Since Volkmann’s (2) original description, in 1882, of the deep- seated carcinomas of the neck, and his explanation of their genesis in persistent branchial remnants, the origin of these tumors has been subjected to extensive study, and the name branchiogenic carcinoma has been universally adopted. Frazer (3) , however, has advocated

16

MALIGNANT EPITHELIAL TUMOR6 OF THE NECK 17

abandoning the term “branchial” because of the lack of correspondence of these arches in man and the lower animals.

The study of the cysts and fistulae of the neck, which has opened much discussion, has a direct bearing on the origin of these new growths. His came to the conclusion that the medial fistulae were developed from a defective thyroglossal duct. Wenglowski (4) stated that the lateral fistulae are derived from the deranged development and embryonic remains of the thymopharyngeal duct. The derivation of carcinomas is analogous to that of the benign cysts and fistulae, and the same principles of origin apply. Voelcker has termed these carcinomas thymopharyngeal, but Lorenz believed that the lateral fistulae arose not from the thymopharyngeal duct alone, but in some instances directly from the gill clefts corresponding in location to the tumor site.

Lorenz enters into a full discussion of the origin of the anomalies of the branchial clefts which are apparently implicated in the development of these neoplasms. Briefly the theories prevalent are as fol- lows: (1) The opening or rest may persist from any of the four clefts (von Hausinger, Bland Sutton, His, etc.). (2) Only the second cleft is at fault (Rabl, etc.). (3) The cervical sinus is responsible f o r the external opening or the rest (Kostaniecki, Mielecki, His, etc.). (4) The thymic stalk is also responsible (Wenglowski).

For the carcinomas, however, with their varied distribution and extent of growth, such fine differentiation in site of origin can hardly be proved. The infiltrating growths obscure the anatomical relations and permit no definite conclusions in a strictly embryonic sense. Since the gill system is a forerunner of the development of the thymus, thyroid, etc., and is responsible for yestigial elements through defective closure or incomplete obliteration of the precervical sinus, it seems wise to designate those growths as branchiogenic in origin. The main point is that the carcinomas are primarily derived from the embryonic cell rests resulting from defective obliteration of parts of the gill system.

EMBRYOLOGY OF THE BRANCHIAL APPARATUS I n the early weeks of intra-uterine life, four arches are prominent

externally in the region of the neck, though six make their appearance internally. Between each pair of these six arches, interiorly in the lateral wall of the anterior part of the foregut, is a depression known as the pharyngeal pouch. Opposite these externally are indentations of the ectoderm forming the branchial grooves or clefts. Between the endoderm, internally, lining the pharyngeal pouches, and the ectoderm, externally, forming the branchial clefts, is the mesodermal layer, which between the internal and external grooves is absent or nearly so (Fig. 1). It is here then that these two layers fuse to form a thin membrane between the gut and the exterior. I n gill-bearing animals, these mem- branes rupture and thus form real clefts-the gill slits. In mammals,

1 The authors named are c i ted by Loreiiz (1).

18 ROBERT LEE OLIVER

however, this does not occur. Later the mesodermal layer penetrates between the inner and outer layers, causing a thickening in the clefts. In each arch between the clefts a cartilaginous bar develops, consisting of right and left halves.

The first or mandibular arch is larger and grows more rapidly than the others. It divides early, the dorsal end forming the maxillary process from which the cheeks and the lateral parts of the upper lip are developed, while from the lower portion the lower lip, the mandible, the muscles of mastication and the anterior part of the tongue are developed. Its cartilaginous bar is known as Meckel’s cartilage. This extends from the capsule of the ear to the symphysis menti and enters into the formation of that part of the mandible which contains the

Ext. ear{::--- / \

\

rreoid

fueoid

__.,...” ..

-Tomil--- - * - - .Thyreoid cartiluge

FIG. 1. BCHEMATIC DRAW IN^ SHOWINQ THE BRANCHIAL POUCHES, THE BRANCHIAL CLEFTS AND BARS, AXD THE THYROGLOSSAL DUCT, AND SOME OR THEIR DERIVATIVES FOUND IN

POST-NATAL LIFE

(After Cunningham’s Anatomy.)

incisor teeth. The dorsal end enters into the formation of the malleus of the ear. The intervening cartilage disappears except for a portion adjacent to the malleus, which remains as the spheno-mandibular liga- ment.

The second or hyoid arch, together with the third, assists in the formation of the lateral and ventral portions of the neck, forming the styloid process and the body and horns of the hyoid bone, and the posterior part of the tongue. The cartilages of the fourth and fifth arches unite to form the thyroid cartilage. The sixth cartilage of either side unites with that of the other side to form the cricoid and arytenoid and the cartilages of the trachea.

Corresponding to the six branchial arches, six vascular arches ap- pear on either side, taking their origin from the ventral aortic trunk

MALIGNANT EPITHELIAL TUMORS O F THE NECK 19

and coursing through the arches to meet posteriorly the dorsal aortic trunk. The first two aortic arches soon drop out, but the ventral aortae persist as the external carotids. The third arches with the dorsal aortae become the internal carotids. The fourth arch on the right and part of the dorsal aorta become the right subclavian, while on the left the fourth arch persists as the arch of the aorta. The fifth and sixth arches are ultimately lost. It is important to note here that a remnant of a branchial cleft higher than the third arch would course superior to the internal carotid and one below would be inferior to the junction of the internal and external carotids.

The pharyngeal pouches which lie between the arches are formed earlier than the corresponding external branchial clefts. They grow

FIG. 2. SCHEMATIC DRAWING SHOWING THE FORMATION OF THE PRECERVICAL SINUS, TEE BRANCHIAL CLEFT DUCTS, AND THE PRECICRVICAL S m c u s

(After Cuiiiiingham 's Anatomy.)

out from the anterolateral part of the embryonic pharynx laterally and dorsally, being separated from the corresponding growths on the opposite side by a groove-the ventral pharyngeal groove. Between the pouches the branchial arches develop as elevations projecting into the pharynx. The ventral parts of the pouches deepen to form ventral prolongations which are more distinct in the second and third. Pro- longations in excess may rupture the closing membrane and result in a fistula, which may persist.

The mandibular and hyoid arches grow more rapidly than the others, with the result that the latter are covered over by the former and a deep depression, the precervical sinus, is formed on either side of the neck (Fig. 2) . This is thought to account for many of the lateral dermoids found in the neck. The percervical sinus is at first open laterally, but the hyoid arches grow down over the mouth of the sinus. The opening remains for some time and is known as the cervical duct. The duct finally closes, leaving a sac which lies lateral to the third pouch and is connected to the second and fourth pouches of the external clefts, which have been drawn out into long canals. Neither persists for long. The lumina disappear and the.epiblastic cells forming the


sac disintegrate and vanish, the walls uniting by fusion. It is easily seen that any failure in retrogression leaves epithelial cells buried in the neck, which provides all that is necessary for the production of a tumor.

The first branchial groove or external cleft is concerned with the acoustic apparatus, while the internal cleft or pharyngeal pouch is prolonged dorsally to form the eustachian tube and the tympanic cavity, The closing membrane is invaded by mesoderm and forms the tympanic membrane. No traces of the second, third, and fourth branchial grooves persist.

The inner part of the second pharyngeal pouch is called the sinus tonsillaris and in it the tonsil is developed, above which a trace of the sinus persists as the supratonsillar fossa. The fossa of Rosenmuller is regarded by some as a persistent remnant of the second pharyngeal pouch.

From the third pouch the thymus arises as an endodermal diverticulum on each side, and from the fourth pouch a small diverticulum projects which becomes incorporated with the thymus. The last named may or may not form thymic tissue. The parathyroid also arises from diverticula of the third and fourth pouches. From the fifth pouch the ultimo-branchial bodies originate and are enveloped by the lateral prolongations of the medial thyroid rudiment. They do not form true thyroid tissue.

The persistence of any portion of the external o r internal clefts of the branchial apparatus which normally disappears will give rise to epithelial remnants which may develop as cysts or be the origin of deep-seated malignant epidermoid tumors of the neck.

CLINICAL FEATURES Not only do the malignant epithelial tumors of the neck have a

common and unique relationship to the embryonic development of cervical structures, but clinically, also, they present a well defined entity.

Sell;, Race, a d Age Ilzcideizce: Of the 80 cases of carcinoma of the neck of deep origin constituting this series, 72 were in males and 8 in females, the ratio being nine to one. Seventy-five instances of the disease were found in white persons. No conclusions can be drawn from this, however, as the majority of the patients were from the clinic of Dr. Joseph Colt Bloodgood, who operates in a hospital where there are no colored patients. Among 30 patients from the service of the Johns Hopkins Hospital or referred from other clinics, 5 were colored. Of the colored patients, 4 were males and one was female. This agaiii shows a preponderance of male cases and is in accord with similar studies reported in the literature, except that of Hertzler ( 5 ) , who reports a predominance of females, without enumerating the number of cases studied.

Figure 3 shows the prevalence of the disease during the fifth, sixth, and seventh decades (forty to seventy-nine years). Sixty-five of the

MALIGNANT EPITHELIAL TUMORS OF THE NECK 21

80 cases, approximately 80 per cent, occurred during this period of life. The curve sweeps upward abruptly after the age of forty. The maxi- mum is reached with the sixth decade, in which 20 of the cases occurred. There were only 3 persons affected below the age of thirty, and none of these was younger than twenty-three years. This characteristic age distribution is in keeping with the observations of McKenty (6), who found the peak of incidence between the ages of forty-four and seventy-three, and Schreiner ( 7 ) , whose patients were above fifty in 14 of 16 cases.

FIQ. 3. CHART SHOWINCI THE AGE INCIDENCE OF EIQHTY CASES OF CARCINOMA ARISINQ IN TEE DEEP TISSUES OF THE NECK

Duratioa of Symptoms: In 76 cases the average duration of symptoms at the time of coming under observation was between six and seven months, and in 21 of these cases, treatment was instituted within six months or less. I n the four remaining cases, which are not included with the others, there was an exceptionally long duration. One of these occurred congenitally in a woman fifty-four years old, who lived three years and seven months after operation and was lost track of after that time. Another patient had had the tumor sixteen years before seeing his physician, and died shortly after treatment. I n a third the tumor had been present thirty-four years, and in a fourth nineteen years before operation. This third patient lived seven and one-half years after treatment and died of other causes.

Although these tumors apparently have their origin in defects of development dating from birth, this is not often revealed in the history, the onset of the malignant neoplastic process being delayed until late in life.

Symptoms of Orzset: In 64 cases a lump was noticed as the first


symptom. As a rule, this was not associated with other symptoms. In two cases the lump appeared following extraction of teeth; in three cases it was associated with abscessed teeth, and in one case, described as rheumatic, it followed an acute attack of pain. Pain as one of the initial symptoms, however, was infrequently noted, being recorded in only 13 of the 80 cases. There was a history of trauma in 9 cases, or 11 per cent of the total number. This was associated with swelling immediately or shortly afterwards. Among other symptoms noted were stiffness of the neck, headache, hoarseness, sore throat, general node enlargement, questionable ulcer in throat, and a superficial blister (Fig. 4).

TABLE I: Position of Tumor

Right Left Not Stated

- 1 Upper neck, siiterior to sternomastoid ......................... 1 Submaxillary region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 5 Angle of jaw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 16 1 Mid sternomastoid ............................................ 2 1 5 Beneath sternomastoid a t angle of jaw .......................... - 2 1 Low in neck, opposite pharynx and above clavicle . . . . . . . . . . . . . . . . 6 Anterior and mid jaw - 6 - Posterior triangle ............................................ 1 2

-

- 4 .........................................

-

TOTAL ............................................... 39 37 4 = 80

Positiorz of Tumor: The position of the tumor is shown in Table I. In 39 of the 80 cases, it was found on the right side and in 37 on the left side. In 4 cases the side was not designated. The most usual site was at the angle of the jaw in the subparotid region, 42 of the tumors occurring here, 25 on the right and 16 on the left side.

Hudson (8) claims an occupational incidence of branchiogenic carcinomas in grooms and miners, the tumor occurring at the site of the jugulo-digastric gland, just below the angle of the jaw. McWhorter (9) and McKenty (6) have observed the tumor behind and below the angle of the jaw. Barthelemy and Fairise (10) report a squamous-cell carcinoma in the submaxillary gland and comment on the varied distribution of tumors of this type. Fredet and Chevassu (11) report a case of carcinoma, epidermoid in character, embedded in the parotid gland.

It is worthy of note that all of these tumors were situated laterally in the neck, occurring usually in the upper anterior triangle behind and below the angle of the jaw. This coincides accurately with the region of migration of the structures developed from the first and second branchial arches, and it is significant that the derivatives of the first branchial arch which traverse this region migrate further in development than the derivatives of the other arches.

Composite Cliizical Picture: The typical o r composite case at the time of clinical observation has the following outstanding features. The patient is an adult with a rapidly increasing swelling in the upper anterior cervical triangle. The tumor in its early stages has been


neglected under the supposition that it was an enlarged cervical node associated with some transient infection in the throat. Upon palpation the tumor is firm and infiltrating, being adherent to the neighboring structures in the neck. The accompanying symptoms are meager; there may be tenderness only, hoarseness, earache, or stiffness of the neck. The swelling may show a point or area which gives the feeling of fluctuation to the examining finger, and in the older cases such an area is not infrequently lanced as an abscess. However, instead of

FIG. 4. PATIENT WITH BRANCHIAL CARCINOMA BENEATH AND BEHIND THE ANQLE OF THE JAW. P. N. 26773

The character and position of the swelliiig are typical. The patient was a white male, He died of generalized metastases

Histologically aged twenty-seven, with symptoms of two months duration. four and one-half years after radical excision followed by deep x-ray therapy. the tumor was of the squamous-cell type.

pus, blood or turbid granular tumor tissue is encountered. The point of incision provides a sinus through which the tumor fungates readily. From such a stage the tumor passes rapidly to an enlarged and often inoperable swelling. Pressure symptoms develop, and the surrounding lymph nodes become secondarily involved ; the supraclavicular lymph nodes and axillary nodes are occasionally involved in extreme cases. Examination of the mouth, throat, and esophagus is strikingly negative in these cases. The salivary glands, thyroid, and parathyroids show no primary focus of disease.

OPERATIVE ATTACK The infiltrative character of the malignant epithelial tumors of the

neck and their vital location call f o r heroic measures. Jawdynski (12),

FIG. 5 . INOPERABLE RECURRENCE FIVE MONTHS AFTER LOCAL REMOVAL OF A BBANCHIOQENIC CARCINOMA. P. N. 10422

The patieiit died two years after the operation from a neoplasm of the basal-cell, diffuse type.

RQ. 6. POSTOPERATIVE RESULT AFTER COMPLETE EXCISION OF CANCER OF THE BRANCHIAL CLEFT WITH A PORTION OF THE INTERNAL JUQULAR VEIN. P. N. 22460

The gross specimen is shown in Fig, 7. The pcttieiit died five and one half months later.

24


in 1888, was the first to advocate a method of resection involving the carotid artery and internal jugular vein. Hertzler and Crile (13, 14, 15) both advocate radical dissection. Crile (14) described block dissection with the inclusion of the collar of lymphatics. The entire primary focus is to be eradicated, and although the internal and common carotid arteries are to be spared because of the danger of hemi- plegia, the entire superficial muscular layer as well as the internal jugular vein, and the vagus nerve as well as the phrenic and hypo- glossal, may be sacrificed on the affected side. Roeder reports a case with five-year survival after complete removal of all the structures of the right side of the neck, including a portion of the transverse proc- esses of the vertebrae. Microscopically, this was a typical alveolar, ouboidal-cell type of cancer (Fig. 10). McWhorter advocates radium treatment in advanced cases, or surgery where feasible. Hudson, how-

FIG. 7. GROSS SPECIMEN FROM THE CASE SHOWN IN FIG. 6

The tumor is of the cystio type with central areaa of iiecrosis enclosed by fibroid tumor substance.

ever, prefers radium to surgery. A combination of surgery and irradiation, it would seem, offers the greatest possibility of a cure, although there are no data in the records of the present series to indicate that irradiation of any type has been curative. However, some of these tumors are of the histologic type that should prove radio- sensitive.

In over 50 per cent of the present series, when the patient presented himself at the clinic there had been either an incomplete or partial operation, followed by recurrence, or the lesion had already reached the point of inoperability (Figs. 5 and 6). In other words, over half of the cases were not favorable for primary adequate surgical treatment. In the remainder of the cases the operation was either very extensive or complete. In 9 of the cases the glands and muscles were included without the large vessels. In 24 cases the larger vessels of the neck (external carotid, internal jugular) were included in the dissection,


and in one even the common carotid was excised. Despite this radical surgery, the results following the more complete operations have proved equally as poor as those of excision with or without a preceding incomplete operation. The outlook with even the most radical type of pro- cedure is thus exceedingly poor. This is so because of the exceedingly invasive character of the tumor rather than its tendency to metastasize. This is shown by the fact that in 8 of the cases the tumor was found at operation to have invaded the bones of the skull, as well as infiltrating the surrounding soft structures.

P ATUOLOGY

Gross Pathology: Various terms have been used to describe the gross pathology of these tumors. The leading characteristics which im- pressed the operator or the pathologist are shown in the accompanying table and are there correlated with the microscopic findings. The two predominant types of gross pathology encountered can be classed as cystic and solid. In the present series the solid type predominated, 42 cases being so described, while 16 were classed as cystic (Fig. 7 ) . Ewing (16), however, has emphasized the cystic character of this tumor as its most common feature, though he admits the possibility of the solid type, particularly when squamous-cell carcinoma is present.

TABLE 11: Gross Pathology

Cubocell Basocell Adeno- _-__I-_

Squamous Diffuse Alveolar Diffuse Alveolar carcinoma Total

. . . . . . . . . . . . . . . . 42

Invading . . . . . . . . . . . . . 3 5 3 13 2 Necrotic . . . . . . . . . . . . . 4 4 3 1 1 1 14 Fibrous . . . . . . . . . . . . . . 4 1 2 2 - 9

7 Priable . . . . . . . . . . . . . . 3 4 . . . . . . . . . . . . . . . . 1 - 5 1 Hard 3 -

. . . . . . . . . . . . . . 1 1 1 - 5 Lobular 2 - Granular . . . . . . . . . . . . . 1 1 2 1 - 5

- 3 Degenerated - 1 - 2 White . . . . . . . . . . . . . . . 2 1 2 1 - 6

2 Hemorrhagic - 2 - 1 Opaque - - - 1 -

. . . . . . . . . . . . . . 1 - 1 Comedo - - - - 2 . . . . . . . . . . . . . . . . 1 1 Firm -

. . . . . . . . . . . . . . . . . 1 1 - 3 Soft 1 - -

Solid 11 14 10 2 4 (19) Cystic . . . . . . . . . . . . . . . 5 4 2 2 2 1 16

- -

- - - - - -

- . . . . . . . . . . -

- - - - - . . . . . . . . . .

. . . . . . . . . . . . . . - - -

The solid type of branchiogenic cancer is a firm, infiltrating growth of white fibrous-like tumor tissue. Occasionally a lobular character predominates. In this solid form adherence to the neighboring structures is particularly marked and the borders of the tumor are indefinite and definable only with the microscope. The cystic type of tumor shows a friable, degenerated center in which necrotic material has been partially resorbed with definite cavity formation. The tumor tissue lining the cystic region is friable and necrotic. The borders of the gross

F I G . 8. LOW-POWER A N D HIQH-POWER PITOTOMICROGRAPHS OF THE SQTJAMOTJS-CELL TYPE OF BRANCHIAL CARCINOMA. P. N. 36592

This is the most highly differentiated form of these neoplasms, indicated by keratillization and formation of pearly bodies.

27

2$ ROBERT LEE OLIVER

specimen are more easily defined than in the solid variety, but there is a definite overlap in the characteristics of the two groups. The solid variety may present cystic areas, and the cystic type may show solid infiltrating portions.

Microscopic Pathology : Sixty-six cases were accompanied by sections which were available for study. In the majority of the remaining cases, although sections were not available, an adequate microscopic report was at hand. The variety of microscopic pictures represented in this group of tumors is shown in Table 111. Fifteen of the cases were of the squamous-cell type, with a tendency to keratinization or pearly body formation (Fig. 8). Thirty-six were classed as transitional or cubocell in type (Fig. l o ) , and 13 were of the basal-cell variety (Fig'. 11). Cases in which no sections were available were not classified, although in many instances they corresponded closely in description to the findings reported here.

The cases grouped under the heading of squamous-cell carcinoma represent the more uniform group. These cases all show the typical islands of squamous cells with a tendency towards keratinization and pearly body formation, and on the basis of microscopic study are considered the most highly differentiated or least malignant of this highly malignant series.

TABLE I11 : M h w s c o p i c Pathology with Node Involvement

Mirroscopic Diagnosis Number of Cases Nodes Involved

Squamous . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Cubocell diffuse ........................ 23 Cubocell alveolar ....................... 13 Basocell diffuse ........................ 5 Basocell alveolar ....................... 8 Adenocarcinoma ........................ 2

66 -

9 14

6 5 3 1

38 -

The majority of the cases studied were transitional or cuboidal-cell in type. These cases were divided into two groups, the diffuse and alveolar. The diffuse type consists of a sheet-like arrangement of cells in which numerous epithelial strands and small nests of cells are infiltrating into fibrous tissue or the neighboring structures (Fig. 9). This group corresponds closely to the gross picture of the solid type of tumor and resembles the grade IV squamous-cell epithelioma of Brod- ers. The cells of this diffuse group are not so uniform in type as in the alveolar group, which contains growths of larger nests of cells and even sheets of cells in which there are small areas of necrosis. In some of the larger sheets, however, there are greater cystic cavities of necrosis, which leads one to suspect that some of the cystic areas in these cases are secondary to necrosis rather than primary in origin. I n the alveolar type the cells are large and very clearly defined. The nuclei stand out well, and the cytoplasm stains faintly (Fig. 10).

In a smaller group of cases the histological picture resembled that

FIG

con

, 9. LOW-POWER AND HIGH-POWER PHOTOMICROGRAPHS OF THE CUBOCELL DIFFUSE TYPE

This relatively undifferentiated type of neoplasm shows a diffuse infiltrative arrangeme

BRANCHIOGENIC CARCINOMA. P. N. 26092

iposed of sheets of cells of varying shape with the cuboidal cell predominating.

O F

nt,

29


of the rodent ulcer or basal-cell type of cancer of the superficial epidermis, and to this group likewise the terms diffuse and alveolar were applied. These types correspond very closely to the cubocell in manner of growth, and except for the type of cell the two could readily be confused. In many cases there was some degree of overlapping between these two types (Fig. 11).

Histologically it appears here that there is a gradual transition from the basocell type to the cubocell to the squamous-cell, with little to choose from as far as prognosis is concerned. Apparently the cell of origin is one of the basal type included in a remnant of the branchial apparatus, and the degree of differentiation determines whether the resulting neoplasm will be predominantly of the basal, cuboidal, or squamous-cell type. This interpretation implies that all of these tumors are variations of a single pathologic entity, and this is borne out by the clinical individuality of the series taken as a whole.

From the microscopic picture it is t o be expected that the basocell group would be the more malignant, but from this series no definite conclusion could be drawn because of the small number of cases in this group in comparison with the number of cases of cubocell type. It is significant, however, that no cures were obtained in the basocell group.

Of the 66 cases in which sections were available there was involvement of the lymph nodes in 38, presumably in the majority of cases from metastases. I n one case it could easily be seen that a lymph node was being invaded by direct extension.

Two cases were found in which there was a report of adenocarcinoma, but the possibility of a metastatic gastro-intestinal tumor could readily be ruled out because of lack of symptoms or findings referable to the viscera and because the histological picture could be traced to a variation of the cubocell group.

CLINICAL DIAGNOSIS The differential diagnosis in branchiogenic carcinoma of the neck

is difficult in the early stages, when the tumor or discomfort is usually confused with lymphadenitis associated with some transient infection of the throat. When the tumor fails to recede despite negative findings in the throat, the possibility of abscess formation is often considered. The absence of fever, leukocytosis, or marked tenderness to palpation, as well as the age of the patient and the negative findings in the throat and oral cavities, should aid the clinician in ruling out lymphadenitis with abscess formation. The fluctuation which is characteristic of abscess is rarely present.

Tuberculous adenitis was the initial impression in four of the cases in this series, but the age of the patient, the fact that but one side of the neck was involved, and the distinct localization of the swelling are against such a diagnosis.

I n four cases of the series a diagnosis of benign branchial cyst was considered. The solid and infiltrative character of the swelling, its

FIG. 10. LOW-POWER AND HIGH-POWER PHOTOMICROGRAPHS OF THE ALVEOLAR CUBOIDAL-CELL

In this relatively undiff ereiitiated type the cuboidal cells are distinctly outlined, and The cells lie in islands embedded in a connective-tissue

TYPE OF BRANCHIOQENIC CARCINOMA. P. N. 10271

numerous mitotic figures are present. stroma.

31


rapid increase in size, and the age of the patient are against this benignform of tumor. The usual branchial cyst is present from birth, thepatient is not elderly, and can remember the persistence of the swellingfor many years.

In the majority of the cases (69), carcinoma or malignancy of sometype was suspected. Lymphosarcoma or Hodgkin's disease may beruled out first by the unilateral and localized character of the tumor;second, by the absence of mediastinal shadow in the x-ray film of thechest, and finally, by a trial course of deep x-ray therapy. The malignant lymphomas should rapidly decrease in size after a course ofdeep x-ray therapy, while the branchiogenic carcinomas are more resistant to such treatment.

Metastatic carcinoma is a much more common condition in the regionof the neck than is a prim,ary cancer of the branchial remnants. Sincea primary focus i§'llot readily found, metastasis or extension from thethyroid, larynx, sinuses, or some other hidden source in the region ofthe head or neck is often suspected. In such instances, biopsy shouldbe performed. If a ll!lcroscopic picture is found characteristic of anyof the various forms of'branchiogenic cancer described here, the patientshould be given the -benefit of a primary radical excision if the tumorhas not progressed to the point of inoperability. The microscopicdiagnosis at biopsy readily rules out a mixed tumor of the parotid,with which these neoplasms are sometimes confused clinically.

ULTIMATE RESULTS

The total duration of the disease from the time symptoms wereobserved until death occurred, excluding postoperative deaths and thosepatients who have remained well five years or over, is slightly overfourteen months. The average duration of the symptoms in this samegroup of cases is a little over eight months. The prognosis for lifeafter treatment, then, in this type of case, is only about six months,when the patients living over five years are excluded. Although mostof the patients have died early after operation, a few have lived longer,some almost five years. There were only 4 postoperative deaths inthis series, which, considering the extensiveness of the operations, isremarkable.

The results in the various histologic types are of interest.(a) Squamous-Cell Forms. In this group there were 15 cases. Fol

lowing operation the duration of life averaged almost six and a halfmonths if two patients are excluded. Of these two, one lived nineyears and died of other causes. This patient had involvement of thenodes and the lesion had been lanced three months prior to excision.The other patient lived four and a half years following operation anddied of carcinoma. The tumor in this instance was recurrent twomonths after the first operation, and complete excision followed afterfourteen months. X-ray treatment was given preceding the secondoperation. Two patients in this group died postoperatively.

F I G . 11. LOW-POWER AND HIQH-POWICE PHOTOMICROGRAPHS SHOWINQ TYPICAL BASAL-CELL BRANCHIAL CARCINOMA OF THE ALVEOLAR TYPE. P. N. 24124

This is the most undifferentiated aiid most malignant form among this group of tumors.

33


( b ) Cubocell Diffuse Forms: There were 23 cases classed under this heading. Three are excluded in computing the average duration of life postoperatively. The first of these three patients lived twenty- seven months, the preoperative duration of symptoms was two months, and the complete operation was performed with excision of the external carotid and the internal jugular. The second patient had symptoms six months, with node involvement. Complete excision was performed, following which the patient remained well seven years and three months, and died of other causes. In the third case death occurred postoperatively. For the other cases the average duration of the disease was almost thirteen and a half months ; the postoperative life was eight months.

(c ) Cubocell Alveolar Forms: Thirteen cases constitute this group. One postoperative death occurred. This patient and one who is living over five years are excluded in computing the averages. The latter case was clinically a cyst, but had carcinoma growing out into the wall and papillary projections into the cavity. The cyst was ruptured before it was completely removed. The average postoperative length of life for the group was six and a half months. The total duration of the disease was over fifteen months.

( d ) Basocell Diffuse Forms: There were only 5 patients in this group, one of whom lived two years. Among the others the duration of life after operation averaged twelve months, and the total duration of the disease twenty months. In one instance the tumor was said to have existed for nineteen years.

( e ) Basocell Alveolar Forms: There were 8 cases of the basocell alveolar type. The total duration of the disease averaged slightly over fourteen months, and the average length of life after operation was less than five and a half months. None of this group survived operation more than two years.

( f ) Adeuzocarciuzoma Forms: Two cases of the adenocarcinoma form were found. One of these patients could not be traced and the other lived eight months after operation. The patient who could not be traced lived three years and seven months before he was lost. In this instance the growth was said to be congenital, with increase in size for four years. It was clinically a branchial cleft cyst. Simple excision was done.

Despite the extreme malignancy of these growths and the rarity of permanent cures (three), the prognosis varies to some extent with the microscopic pathology. As previously pointed out, the outlook becomes progressively worse as we pass from the squamous to the cuboidal to the basal-cell forms. From the standpoint of prognosis, there- fore, the basal-cell form must be considered as a highly malignant and undifferentiated form of the squamous-cell type, rather than a separate and more benign group, such as might be expected from its resemblance to the basal cancers or rodent ulcers of the skin.

While some authors (Schreiner) believe cures in this type of tumor to be beyond the bounds of expectation, and recommend palliative ir-


radiation only, the present study emphasizes the importance of an early clinical recognition, and complete and radical surgery. There is no contraindication to combining irradiation with surgery, although there are no conclusive data in this study to support the recommenda- tion.

SUMMARY A study of 80 cases of carcinoma arising in the deep tissues of tht?

neck without relation to the epidermis or glandular organs has been presented. The relationship of these tumors to the development of the branchial clefts has been discussed, and the embryology of these structures, which form the basis f o r the origin of the tumors, has been outlined.

Among the 80 cases, males predominated in the ratio of nine to one, and the peak of age incidence was in the sixth decade. The average duration of symptoms was between six and seven months. The usual symptom of onset was the appearance of a tumor in the neck without relationship to clinical findings in the throat or in other organs in the cervical region. Stiffness of the neck, headache, hoarseness, pain, and general cervical node enlargement were among the other clinical findings. In about 10 per cent of the cases trauma marked the onset of the cliniial history. The position of the tumor was usually in the upper anterior cervical triangle, behind and below the angle of the jaw.

Radical surgery only sufficed as an attack upon these rapidly growing and infiltrating tumors. The usual operation advocated involves the block dissection of the glands of the neck with resection of the larger vessels of the neck, including in some instances the internal and common carotid artery.

Pathologically the tumors were grossly either solid or cystic; under the microscope they could be divided into squamous, cuboidal, and basal-cell forms. The cuboidal and basal-cell forms were subdivided into two groups: diffuse and alveolar.

In the differential diagnosis it was found necessary to rule out, cervical lymphadenitis, benign branchial cleft cysts, malignant lymphomas, and metastatic carcinoma from the nasal sinuses or structures of the throat.

A consideration of the ultimate results in relation to the modes of treatment and the types of cellular pathology justifies the conclusion that these tumors, which are usually fatal (77 out of 80 cases), are best treated by radical surgery if seen in the earlier stages. They comprise a single pathological entity grading from the less differentiated basal- cell forms through the cuboidal-cell type to the most highly differentiated sqnamous-cell form. Surgery is slightly more favorable in these last two forms than in the first. Irradiation is probably advisable in conjunction with surgery in all forms, but particularly in the basal-cell type. In advanced and inoperable cases palliative irradiation may be helpful.


CASE HISTORIES

Path. No. 1461 : A white male seventy-three years of age complained of stiffness in the left side of the neck for nine months and pain behind the ear f o r five months. There was a hard, firm, tender diffuse tumor, present for one month, in the upper neck, extending downward and backward below the ear. An exploratory operation was performed and the tumor found to be inoperable. The ultimate result is unknown.

Path. No. 141-193: A white male forty-three years of age complained of pain and difficulty in moving the jaw five weeks after trauma, There was a tumor of three months’ duration, resembling a myoma, with metastases to the submaxillary region. A complete excision of the left lower jaw with the submaxillary and lymph glands was performecl. The microscopic section showed diffuse cuboidal cells. There was a recurrence involving the axillary nodes, and death ensued seven months after operation.

Path. No. 479: A white female fifty-four years of age complained of a freely movable, nodular mass, the size of a pea, which had gradually increased in size for four years. The mass was located in the superior carotid triangle. A diagnosis of benign cyst was made, and excision performed, The pathological report was adenocarcinoma. The patient was reported well three years and seven months after discharge from the hospital.

Path. No. 524: A white male forty-three years of age complained of a tumor the size of a hazelnut, and pain radiating to back of the head, of three and one half months’ duration. A partial excision was performed. The section showed diffuse basal cells. The ultimate result is unknown.

Path. No. 915: A white male sixty years of age complained of difficulty in swallowing and breathing, sore throat, hoarseness, and difficult speech. There was a small tumor i n the middle of the sternocleidomastoid muscle, left, of three and on& half months’ duration. A tracheotomy and incision of the thyroid isthmus were performed for inoperable carcinoma of the neck. The tumor was of the alveolar basal-cell type. The patient died five months after the operation, from hemorrhage.

Path. No. 1221: A white female fifty-one years of age had a tumor of sixteen years’ duration, with gradual growth f o r the past six years. There was a mass the size of a hen’s egg beneath the angle of the right jaw. An operation had been done two years previously, with subsequent recurrence. Death followed shortly af ter discharge from the hospital with inoperable carrinoma of the neck.

Path. No. 5499: A white male fifty-one years of age complained of a tumor of two months’ duration, appearing after trauma and extending from the eye to the angle of the mouth back to the ear and behind the sternocleidomastoid muscle. The patient died a few days after admission to the hospital from inoperable carcinoma of the neck with metastases to the lymph nodes.

Path. No. 1489: A white female twenty-three years of age complained of a slow- growing, painless, freely movable tumor of two years’ duration, located behind the sternomastoid muscle at the angle of the jaw. A n incomplete excision was performed f o r rarci- noma of the neck with metastases to the lymph nodes. The section showed alveolar basal cells.

Path. No. 2295: A white male of sixty-five years had a general enlargement of the right neck, including the lymph nodes, and a single mass of six months’ duration with the appearance of multiple nodes of six weeks’ duration. The swelling followed extraction of a tooth. Excision of the cervical nodes and par t of the sternomastoid muscle was performed. The section showed diffuse cuboidal cells. The patient died one year and seven months af ter the operation from internal metastases.

Path. No. 2609: A colored man forty-six years of age had a tumor in the posterior angle of the right jaw with pain of one year’s duration. The axillary and inguinal nodes were palpable. A node excised for diagnosis showed carcinoma. The result is unknown.

Path. No. 3377: A colored male twenty-three years of age complained of swelling and enlargement of the lymph nodes of both sides of the neck, of thirteen months’ duration. Excision

The tumor was located in the superior carotid triangle, left. The nodes were found to be involved.

The nodes were involved.

Death followed one month after operation.

The tumor was at the angle of the right jaw.

There was a tumor low in the left side of the neck, opposite the pharynx.


of the nodes of the left side of the neck was performed f o r what was believed at first to he a carcinoma of the larynx.

Path. No. 4754: A white male forty-five years of age complained of swelling with sharp and stinging pain. There was a large, fungous mass adherent to the jaw and structures of the neck in the left maxillary region. Excision of the fungating growth ww performed. The patient died five months after the operation.

Path. No. 9079: A white male of fifty-eight years had a rapidly growing, freely movable tumor of three months’ duration. The tumor was the size of a n orange, fluctuant in places and located just below the inferior ramus of the left jaw. A complete removal of tumor, lymph nodes, muscle, and clavicle was performed f o r carcinoma of the branchial cleft.

Path. No. 9226: A white male of fifty years complained of a lump under the left lower jaw, of one year’s duration. There were palpable lumps in the left cervical and submaxillary region. An exploratory operation revealed a carcinoma of left side of the neck, which could not be entirely removed. The patient died one year af ter leaving the hospital.

Path. No. 9243: A white male seventy-one years of age had a tumor of four months’ duration, with severe pain during the last month. The tumor was the size of a n egg and occupied the upper, right side of the neck. Excision of tumor and carotid was performed. The section showed diffuse cuboidal cells. Thc result is unknown.

Path. No. 9442: A white male of forty-two years had a tumor in the right side of the neck, above the middle of the clavicle, of seven months’ duration. There had been previous drainage of the tumor and a diagnosis of cellulitis. A cervical node was excised f o r diagnosis. The section showed alveolar cuhoidal cells. Death followed seven months later.

Path. No. 9683: A white male fifty-five years of age complained of a tumor and red- dening of the skin of ten months’ duration. There was a slightly movable, deeply attached, adherent and ulcerated mass in the right side of the neck, wedged between the jaw and mastoid process. Excision of the mass with the interior jugular vein was performed, and the tumor was found to extend to the skull. Death followed one year later from internal metastases.

Path. No. 20045: A white woman of forty-two years had a tumor of five months’ duration, which was lanced, recurred seven months later, and was again lanced. The second recurrence was of ten days’ duration when seen; it was the size of a peanut and was located in the right side of the neck below the angle of the jaw. A clinical diagnosis of tuberculosis of the nodes of the neck was made. Partial excision was performed and the section showed alveolar basal cells. The patient died nine months later from cancer of the throat.

Path. No. 10271: A white male sixty-three years of age had a rapidly growing tumor of six months’ duration, with pain for eight weeks, the pain radiating to the ear. The tumor was located on the left side of the neck a t the angle of the jaw. Excision of tumor and nodes was performed f o r carcinoma of the branchial cleft. The section showed alveolar cuboidal cells.

Path. No. 10422: A white male forty-five years of age complained of a tumorjap- pearing one day after trauma. It was removed hut recurred five months later, with rapid growth and pain in the nodes. Site of the tumor was the right lower jaw. A diagnosis of recurrent carcinoma of the neck was made, and the cervical nodes were excised, with drainage of the wound.

Path. No. 11359: A white male sixty-eight years of age complained of a tumor the size of a hickory nut, of five months’ duration. There was a hard, non-fluctuant, projecting, nodular mass extending from the hyoid bone to the clavicle, left of the median line to the middle of the right jaw. A clinical diagnosis of carcinoma of the thyroid was made. A t operation, the tumor could not be entirely removed even after resection of the common carotid artery and internal jugular vein. The nodes were involved. The section showed diffuse basal cells. Autopsy revealed tumor extending through the jugular foramen.

Path.. No. 11417: A white male forty-eight years of age had a fluctuant, tender, hard,

One month af ter operation there was a recurrence.

The section showed squamous cells.

The patient died two hours after operation, from shock.

The patient died sixteen months later.

The patient died two years later.

The patient died two months later.


nodular mass the size of a hen’s egg, adherent to the skin near the left submaxillary gland. It had been present f o r one year. Excision of a cyst was followed by complete operation for mixed tumor or cancerous cyst. The patient died three months after operation from a recurrence.

Path. N o . 21469: A white male fifty years of age complained of a gradual swelling of two months’ duration. There was a tumor the size of a fist beneath the ear and mastoid to the left of the mid-jaw. Excision of tumor, internal jugular vein, sternomastoid muscle, and nodes was performed for carcinoma of the branchial cleft. The cells were squamous in character.

Path. N o . 22118: A white male fifty-six years of age had a swelling, the size of a bean, of six months’ duration. There was pain two months after onset, and a yellow exudate. The tumor, located under the lobe of the left ear at the angle of the jaw, was hard, nodular, fluctuant, and adherent to the skin and sternocleidomastoid. Excision of tumor, sternocleidomastoid muscle, and nodes was performed for carcinoma of the neck, some tumor being left at the base of the skull. Death followed nine months af ter operation from recurrence and metastases.

Path. N o . 23035: A white male forty-nine years of age complained of a tumor of thirty-four years’ duration. It had appeared af ter extraction of a tooth and during the past three months had increased in size and become painful. The tumor was the size of a n egg and was adherent to the skin; cervical nodes were palpable. The nodes were removed.

Path. N o . 13221: A white male of sixty-four years complained of a tumor of four months’ duration with sudden increase in size. The tumor was the size of a fist and was fixed to the deeper tissues on the right side of the neck from the clavicle to the axilla. Excision of nodes of the right side of the neck for carcinoma was performed. Death followed one month later.

Path. N o . 13442: A white male twenty-six years of age complained of a small lump of six months’ duration. This lump had been lanced three times and a node had been removed three months after onset. The tumor was the size of the end of the thumb and was ulcerated. It was located in the left side of the neck beneath the mandible. There was also a discharging sinus. Partial excision was performed for malignant cervical adenitis.

Path. No . 23479: A white male sixty-six years of age complained of a lump the size of a pea, of three months’ duration. I t had been lanced two months previously and cheesy material removed. A t examination, the growth was the size of a walnut and was attached to the deeper tissues and adherent to the skin. It was located a t the angle of the jaw beneath the left ear. Excision was performed. The nodes were found to be involved and the microscopic section showed squamous cells. The patient died nine years later of an unknown cause.

Path. No . 15472: A white male fifty-four years of age complained of a tumor and a tingling sensation in the left ear, of four months’ duration. H e had had a cough for twenty years. There was a lump at the level of the pharynx on the left side of the neck, behind the sternocleidomastoid muscle. The clinical diagnosis was carcinoma of the neck. A complete excision of the cervical nodes was performed with resection of the internal jugular vein. The patient died ten months later from metastases to the chest.

Path. No. 26892: A white male of fifty-eight years had a tumor behind the sternocleidomastoid muscle of six months’ duration. It was the size of a walnut, ulcerated, and adherent to the skin. Excision of tumor, nodes, and internal jugular vein was performed for carcinoma of the branchial cleft. The patient died seven months later f rom recurrence.

Path. No. 17301: A white male thirty-four years of age complained of a tumor between the sternomastoid muscle and the clavicle of four and one half months’ duration, appearing after trauma. There were loss of weight, weakness, and difficulty in breathing. Palpable nodes were present in the neck, axilla and groin. A node was excised for diagnosis. I t was involved and the diagnosis of carcinoma of the branchial cleft was made from the section. The patient died three months later from metastases to the axilla and mediastinum.

The patient died four months later.

Death followed one month later.

The nodes were involved. Death followed one year af ter operation.

The microscopic section showed basal cells, diffuse in character.


Path. No. 17394: A white male of forty-seven years complained of swelling of the left side of the neck, with headaches and cough for two months. H e also complained of pain in his chest, bulging of the manubrium, an abdominal mass, and axillary nodes. There was a tumor in the region of the right lobe of the thyroid and edema of the left side. Excision of the right axillary nodes was performed for possible lymphosarcoma. The patient died ten days later.

Path. No. 18396: A white male fifty-eight years of age complained of swelling of his neck for two years, loss of weight, weakness, and a cough and pain of four months’ duration. An exploration was performed for carcinoma of the branchial cleft. The nodes were involved and the section showed cuboidal cells of alveolar type. The patient died one month later from metastases to the lungs.

Path. No. 18538: A white male of fifty-eight years complained of a tumor appearing in association with a n abscessed tooth, of three months’ duration. The tumor was diagnosed as tuberculous and was lanced, after which growth was rapid and the pain increased. The tumor was located in the right subparotid area a t the angle of the jaw. Clinical diagnosis at this time was tuberculosis or carcinoma. Excision was attempted, with resection of the internal jugular vein and the external carotid artery. The tumor, however, extended into the jugular foramen. The section showed diffuse cuboidal cells. Death followed in four and one half months from recurrence and starvation.

Path. No. 19062: A white male of fifty-two years had a tumor below the parotid on the right side, of five months’ duration. Excision was attempted, but the carcinoma extended through the jugular foramen. Resection of the internal jugular vein and the external carotid artery was carried out in the attempted removal of the tumor. The cells were squamous in character. Death followed eighteen months later from a recurrence and generalized metastasis.

Path. No. 19068: A white male thirty-six years of age had a tumor on the right side of the neck, with pain in the head and eyes, of three months’ duration. The tumor extended from the mucous membrane of the pharynx and tonsil to the base of the skull. Excision was complete, with removal of the nodes a t the base of the skull and resection of the internal jugular vein, and was performed in three stages. The nodes were involved and the section showed diffuse cuboidal cells. Death followed three months later from localized recurrence.

Path. No. 19694: A white male sixty-three years of age complained of pain in the side of his head and difficulty in swallowing, of three months’ duration. There was swelling on the right side and a tumor was wedged against the base of the skull and the right side of the pharynx. Excision of the jaw was done f o r inoperable carcinoma of the branchial cleft.

Path. No. 20104: A white female thirty-two years of age had a swelling in her neck of two months’ duration. This was diagnosed as lymphadenitis and an operation performed, followed by a recurrence. The recurrent tumor was the size of a hazelnut and was located in the subparotid region. Incomplete operation f o r removal of the mass was performed. The nodes were involved. Death followed four and one half months later from metastases.

Path. No. 21985: A white male of forty-six years complained of a lump in his neck of seven months’ duration. The growth grew slowly and ulcerated; the patient had fre- quent hemorrhages. A diagnosis was made of inoperable carcinoma of the branchial cleft, and the patient died two months later.

Path. No. 22155: A white male of seventy-three years had a lump in his neck of two months’ duration, appearing after trauma. It was a hard, freely movable mass just beneath the left ear. Excision with the internal jugular vein and external carotid was performed. The cells were squamous in character. The patient died seven months later.

Path. NO. 18083 (S t . A g . ) : A white male of forty-five years complained of a lump of one year’s duration, appearing after rheumatism. The lump was removed but recurred in three weeks. Six months later there was a second recurrence involving the whole side of the left neck, from the jaw to the clavicle. The condition was considered inoperable, and a clinical diagnosis of carcinoma of the branchial cleft was made.

The mass was a t the head of the right clavicle.

The patient died six months later.

The whole neck was involved above the clavicle.

A second operation was performed and x-ray treatment given.

The patient died five months later.


Path. N o . 22460: A white male of fifty-nine years complained of a nodular tumor a t the angle of the right jaw, of ten months’ duration. A freely movable mass the size of an orange extended from the mid-jaw almost to the mastoid. Complete excision with the internal jugular vein was performed for carcinoma of the branchial cleft. The section showed alveolar cuboidal cells.

Path. No. 2422424: A white male of sixty-two years had a small painless lump of five months’ duration in the subparotid area behind the left sternocleidomastoid muscle. The mass became larger and seven weeks after the onset of growth it was soft and tender. The growth was lanced at this time and pus removed. When the growth continued and the opening did not heal, carcinoma was suspected and the tumor was excised with resection of the internal jugular vein.

Path. No. 24738: A white male of forty-four years complained of a recurrent nodule of thirteen months’ duration, the first nodule having been removed twenty-two years before. The mass, located a t the angle of the left jaw, was indurated and fixed. Drainage and biopsy were decided upon, and a small piece was taken a t the time for biopsy. The section was typical carcinoma, and the cells were cuboidal and alveolar in character. Postoperative radium and x-ray therapy were given, but the patient died four months later.

Path. N o . 25057: A white female of forty-six years complained of a fluctuant, movable mass of nine months’ duration following drainage of an abscess eighteen months before. Incision and drainage were performed for possible carcinoma or tuberculosis. The section showed alveolar basal cells.

Path. No. 9395 ( J C B ) : A white male of sixty-five years had a fungating mass, the size of a dollar, in the left subparotid region, below the lower jaw and mastoid. It had been present nine months. The case was considered inoperable carcinoma of the branchial cleft and the patient died four months later.

Path. No. 26093: A white male of thirty-nine years complained of a tumor of seven months’ duration. Following an operation for removal, there was a recurrence with gradual growth and little pain. The tumor was located beneath the sternomastoid muscle, just below the left parotid. Excision with division of the internal jugular was performed. Examination showed diffuse cuboidal cells. The nodes were involved. X-ray treatment was given, but death followed six months later from metastases to the lungs.

Path. N o . 26162: A white male of thirty years complained of a swelling in the submaxillary region of three weeks’ duration. Five months previously the glands on the left side of the neck were removed for carcinoma and subsequent radium treatment was given. The mass was diagnosed as carcinoma of the branchial cleft and was removed. The patient died twelve months later.

Path. No. 26225: A white male of forty-six years complained of a lump posterior to the sternocleidomastoid muscle, of ten months’ duration, appearing after trauma. Nodes had been removed four months before. No further operation was performed, and the patient died six months later from general metastases. X-ray treatments had been given.

Path. No. 26462: A colored man of thirty-eight years complained of a soft lump the size of a marble, of eighteen months’ duration. A hard, firm, movable tumor had been removed six months previously; the growth had recurred and a second operation had been performed two months before. At operation, the tumor was found to be a carcinoma of the branchial cleft. An excision was attempted with resection of the internal jugular vein.

Path. No. 26773: A white male of forty-seven years complained of a small lump on his neck of two months’ duration. A tumor on the right side had been excised fourteen months previously with no subsequent recurrence. The present tumor was the size of an orange, fairly movable, and located between the angle of the left jaw and mastoid. Preoperative x-ray therapy was administered and excision followed. The nodes were involved and the cells were squamous in character. Postoperative x-ray treatment was also given, but the patient died four and one half years later from general metastases.

Path. No. 20282 ( J C B ) : A white male of fifty-eight years had a lump of fourteexi months’ duration. It had been removed five months ago, with postoperative radium treatments. There were swelling and induration of the whole side of the right sub-


The patient died eight months later.

There were discharging sinuses at this time from numerous incisions.

Death followed seven months later.

The lymph nodes were involved. The patient died five months later.


parotid region, and the patient had difficulty in swallowing. The operation consisted in removal of the tumor. The section was diagnosed as adenocarcinoma. Death followed eight months later.

Path. No. 27794: A white man of sixty-five years complained of multiple lumps of fifteen weeks’ duration. There was severe pain for fourteen weeks, swallowing became difficult, and the sinuses drained for eleven weeks. The lump was located in the right mastoid region and extended to the clavicle. Incomplete excision with the internal jugular vein was performed. The nodes were involved, and the section showed cuboidal cells with alveolar arrangement.

Path. No. 28383: A man complained of a lump appearing after trauma, which had increased rapidly in size until he was unable to open his mouth. Four months previously it had been drained, but now involved the whole right side of the neck. An incomplete excision was performed, the nodes being found involved. The cells were squamous in character.

Path. No. 10847 ( J C B ) : A white male forty-nine years of age complained of sore throat for three months, hoarseness for two months, and a mass beneath the lower jaw. The tumor was considered inoperable.

Path. No. 30990: A white male of thirty-eight years complained of a pimple below the ear, of four months’ duration. H e attributed it to irritation from the wearing of gIasses. The tumor gradually increased in size and when seen was fluctuant and freely movable, occupying the angle of the left jaw. An excision was performed f o r mixed tumor of the parotid. The ultimate result is unknown.

Path. No. 32964: A white male of forty-five years had a swelling of eight weeks’ duration in the anterior region of the sternomastoid muscle a t the level of the thyroid cartilage. There was rapid increase in size, the skin was red and thick, and the patient complained of a drawing sensation over the tumor. It was excised with the internal jugular and external carotid. The nodes were involved.

Path. No. 32197: A white male forty-six years of age complained of a stiff neck and pain for two months. The whole left side of the neck was involved, with discoloration and induration of the skin. A piece of tissue removed for diagnosis showed carcinoma of the branchial cleft. The nodes were involved and the condition was considered inoperable. The section showed diffuse cuboidal cells. The patient died one month later.

Path. No. 22936 ( J C B ) : A white male of fifty-nine years complained of hoarseness of two years’ duration and a tumor involving the whole left subparotid region. Local and x-ray treatments had been given. The growth was considered a n inoperable branchial cleft carcinoma.

Path. No. 33446: A white male of fifty-nine years complained of pain and a tumor of four months’ duration, appearing after trauma. The tumor, located at the angle of the right jaw, was adherent to the skin, which was discolored. Tissue removed f o r diagnosis showed carcinoma of the branchial cleft. The nodes were involved and the condition was considered inoperable. Radium treatment was given, but the patient died nine months later.

Path. No. 33458: A white male of fifty-eight years had a tumor at the inner end of the right clavicle, of three months’ duration. The trachea was deflected and the tumor tender, nodular, and firm. The section showed diffuse cuboidal cells.

Path. No. 35021: ‘A colored male of forty-four years complained of a tumor and stiffness of neck of four months’ duration. The tumor had been lanced at various times. It involved the whole left side of the neck. An exploratory operation showed inoperable carcinoma of the neck.

Path. No. 36222: A white male of seventy-six years complained of a movable tumor involving the angle of the left jaw, of five months’ duration. It had increased from the size of a pea to that of a n orange. Complete excision was performed, f o r branchial cyst or carcinoma.

The patient died postoperatively.

Death followed three months after discharge from the hospital.

Death followed one month later.

The cells were alveolar and basal in type.

The cells were diffuse and cuboid. Death ensued two years and three months later.

Poultices and pastes had been used.

The patient died three months later.

The section showed diffuse cuboidal cells.

Partial excision of the tumor was performed. The result is unknown.

The patient died six months later.

The cells were squamous in type. The patient died six months later.


Path. N o . 36562: A white male of fifty-nine years had a tumor of one year’s duration, appearing af ter trauma. A dome-shaped mass, freely movable and encapsulated, involved the angle of the right jaw between the sternomastoid muscle and the thyroid. Complete removal with the internal jugular vein was performed, f o r carcinoma of the branchial cleft. The section showed diffuse cuboidal cells. Death occurred two months after operation.

Path. No. 36592: A white male fifty-three years of age complained of a swelling of five weeks’ duration. There was a hard and painful mass in the angle of the right jaw. The tongue was sore. The tumor was excised and the internal jugular vein was resected. A diagnosis of branchial cleft carcinoma was made. The cells were squamous in character.

Path. No . 36594: A white male of seventy-five years complained of a n ulcer in the throat, of three years’ duration. There was a hard, painful, non-movable mass in the angle of the left jaw. The patient had difficulty in opening his mouth. An exploratory operation showed carcinoma of the branchial cleft. The condition was regarded as inoperable. The patient died seven months later from extension of the disease to the skull.

Path. No. 36801 : A colored female of forty-five years complained of a sense of full- ness and aching in the jaw, of twenty-two months’ duration. There was a lobulated, stony hard mass, adherent to the skin below the angle of the jaw. Excision of the cervical nodes was performed for carcinoma of the eustachian orifice. The section showed diffuse cuboidal cells.

Path. No. 37259: A white male of fifty-eight years had a small, indurated and irregular tumor of five months’ duration, in the anterior region of the right sternomastoid muscle, apparently involving the larynx. A node had been excised four months previously. A tracheotomy was performed f o r carcinoma of the branchial cleft. The nodes were found to be involved. The cells were alveolar and cuboidal in shape. Death followed soon after the operation.

Path. No. 37642: A white male of sixty-five years complained of a lump in the right subparotid region of four months’ duratiod. The tumor was cystic, freely movable, and fluctuant. Cautery excision was performed for carcinoma of the branchial cleft. The cells were squamous in character.

Path. N o . 37725: A white male of fifty-five years complained of a blister which had first appeared nineteen years before, had ulcerated and never healed. Two years ago the mass had become indurated and painful and in the past few months it had grown rapidly. It was fixed and tender and was located at the angle of the right jaw, Excision of the nodes was performed and they were found to be involved. The cells were diffuse and basal in character. The patient w&s not heard from after his discharge.

Path. No . 37743: A white male of forty-two years had a soft, movable mass of three months’ duration in the left submaxillary region. An excision was performed f o r a branchial cyst. The cells were alveolar and cuboid in character. The result is not known.

Path. No. 38290: A white man of sixty-four years had a small lump in the left subparotid region of five months’ duration. It was freely movable, and a clinical diagnosis of carcinoma or lymphosarcoma was made. The tumor was completely excised, but death followed five months later.

Path. No. 38860: A white male of fifty-one years complained of a cough and a lump in the jaw of three months’ duration. The lump appeared three days after a coughing spell and gradually grew in size. It was located between the mental foramen and angle of the left jaw and was adherent to the mandible. A clinical diagnosis of abscess was made, and excision of the nodes was done. The cells were diffuse and cuboidal in character.

Path. No. 39516: A white man of fifty-seven years had a swelling of three months’ duration, which had suddenly increased in size in three days’ time until it was as large as a n orange. There was a hard, firm, movable, nodular mass located posteriorly to the sternocleidomastoid muscle in the left pQ8terior triangle. The tumor-typical carcinoma -could be only partly removed. The patient died two months later.

Path. No. 17411 ( J C B ) : A white male of forty-eight years complained of a tumor a t the angle of the right jaw of four months’ duration. Originally the size of a pea, it

Death followed nine months later.


The patient died eight days following the operation.

Death occurred six and one half months later.

MALIGNANT EPITHELIAL TUMORS O F THE NECK 43

suddenly began to grow rapidly and was treated with poultices, ice, and heat; the tumor was lanced and six x-ray treatments were given. The case was considered inoperable, and the patient died four and one half months later.

Path. No. 39754: A white male of fifty-nine years complained of swelling of the jaw ?or seven months and definite pain for two months. The mass was attached at the angle of the jaw to the right of the mastoid. Excision with the internal jugular and branches of the internal carotid was performed for carcinoma of the branchial cleft. The cells were squamous in character. The patient died two months later from metastas.es to the lungs.

Path. No. 40364: A white male of sixty-seven years complained of a mass of eleven months' duration, in the jaw, the size of a pea at onset. It had increased in size six months ago and lamp treatments (presumably ultraviolet) were given. The patient had difficulty in swallowing. There was a hard, nodular mass occupying the angle of the jaw and the left subparotid region. A diagnosis of carcinoma of the branchial cleft was made at operation. The nodes were involved. On section the cells were found to be squamous in character. Death occurred three months later.

Path. No, 40432: A white male of sixty-three years complained of swelling of the right subparotid region of five months' duration. There was sharp pain a t times and sudden increase in size for the past six weeks. Complete excision with ligation of the internal jugular vein was performed for carcinoma of the branchial cleft. The cells were of alveolar and basal type.

Path. No. 40669: A white female sixty-five years of age had a hard, deeply imbedded and quite firm mass at the bifurcation of the left common carotid. I t was of six months' duration and had increased in size. Excision was performed for carcinoma of the branchial cleft with involved nodes. The patient died eleven months later from recurrence.

Path. No. 40852: A white male of sixty-two years had a painless adherent mass in the subparotid region extending from the mastoid to the right mid-jaw, of three months' duration. A previous operation had been performed followed by x-ray and radium treatments for carcinoma. Incomplete removal with internal jugular vein and external carotid was performed. The tumor extended into the skull. The cells were alveolar and cuboidal in shape. Death occurred four months later.

The mass could be only partially removed.

The patient died seven months later from recurrence.

BIBLIOGRAPHY

1. LORENZ, H. E. : Das branchiogene Carcinom, Beitr. z. klin. Chir. 85 : 599, 1913. 2. VOLKMANN, R.: Das tiefe branchiogene Halskarcinom, Centralbl. f . Chir. 9: 49, 1882. 3. FRAZER, J. E. : The nomenclature of diseased states caused by certain vestigeal struc-

tures of the neck, Brit. J. Surg. 11: 131, 1923. 4. WENGLOWSKI, R. : Pathogenese der lateralen Halsfiqteln. Bemerkungen zur der Ab-

handlung von H. E. Lorenz, ,,Das branchiogene Carcinom," Beitr. z. klin. Chir. 88: 604, 1914.

5. HERTZLER, ARTHUR E.: Treatise on Tumors, Philadelphia, Lea and Febiger, 1912, p. 367.

6. MUKENIT, F. E.: Tumors of the neck, Surg., Gynec., & Obst. 19: 141, 1914. 7. SCHREINER, B. F.: Results of treatment of tumors of branchiogenic origin, Surg.,

Gynec. & Obst. 48: 507, 1929. 8. HUDSON, R. V. : The so-called branchiogenic carcinoma, its occupational incidencs

and origin, Brit. J. Surg. 14: 280, 1926. 9. MOWHORTER, J. E. : Malignant epithelial tumors of the neck of unknown origin, Ann.

Surg. 90: 1, 1929. 10. BARTHELEMY AND FAIRISE, S.: EpithQlioma branchial du cou inclus dans la glande

sous-maxillaire, Rev. de l'est. 45: 501, 1913. 11. FREDE'P, P., AND CHEVASSU, M. : EpithQlioma branchiales du cou, Bull. et mQm. SOC.

anat. de Paris 77: 645, 1902. 12. JAWDYNSKI, F. : Primary cancer of the neck, so-called branchial cancer of Volkmann.

Excision of the tumor with resection of the common carotid artery and internal jugular vein, Gaz. lek. Warszawa 8 (2d s.) : 530, 554, 582, 1888.


13. CRILE, Q. W.: Excision of cancer of the head and neck with special reference to the plan of dissection based on 132 operations, J. A. M. A. 47: 1780, 1906.

14. CRILE, 0. W.: On the surgical treatment o f cancer of the head and neck with the summary of 121 cases of operations performed upon 125 patients, Tr. South. Surg. Qyn. Assoc. 18: 108, 1905-06.

15. CRILE, Q. W.: Further considerations of the treatment of cancer of the neck, Surg., Qynec., & Obst. 5: 91, 1907.

16. EWING, J.: Neoplastic Diseases, W. B. Saunders & Co., Philadelphia, Ed. 2, 1922.

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