CA Oral Cavity

Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme
Oral Cavity carcinoma
Oral Cavity 1 Mar. 2006

Work-up procedure TNM staging Primary treatment Follow-up Treatment of recurrent and/or metastatic disease Appendix: surgical techniques
References
Standard clinical evaluation

l l l l l l l l
Evidence Option Type C Type C Type C Type C Type C Type C Type C Type C Std. Std. Std. Std. Std. Std. Std. Std.
Complete history of the disease Alcohol and tobacco consumption Weight and weight loss Performance status (Karnofsky or WHO scale) Neck examination Evaluation of cranial nerves V2 ,V3, VII, XII Drawing of all lesions on a common template Biopsy under local anesthesia
Advanced clinical evaluation Dental examination by oral surgeon Panendoscopy under general anesthesia Prosthetic rehabilitation (if maxillectomy) Nutritional assessment PEG
Evidence Type C Type C Type C Type C Type C
Option Std. Std. Std. Std. Individ
Laboratory tests
l
Evidence Type C Type C
Option Std. Std.
Hemogram, ionogram, coagulation tests, liver enzymes, Kidney function Thyroid function: TSH (if radiotherapy scheduled)
Local imaging and metastatic work-up

Orthopantomogram (+dental X-rays if
Evidence Option Type C Type C Type C Type C Type C Type 3 Std. Std. Std. Std. Ind. Std. Invest.
needed) MRI CT scan1 (oral cavity and neck) Chest X-ray and thoracic spiral CT Esogastroscopy Additional examination based on previous findings PET scan
1
See guidelines for loco-regional imaging

References
Staging
l l
Evidence Type C Type C
Option Std. Std.
TNM classification (5 th ed., 1997) WHO International Classification of Diseases for Oncology (ICD-O 9 or ICD-O 10)
TNM/AJCC 1997 Staging

Tis: Carcinoma in situ T1: Tumor 2 cm or less in greatest dimension T2: Tumor > 2 cm but 4 cm in greatest dimension T3: Tumor > 4 cm in greatest dimension T4 (lip) Tumor invades adjacent structures (through cortical bone, inferior alveolar nerve, floor of mouth, skin of face) T4 (oral cavity) Tumor invades adjacent structures (through cortical bone, into deep muscle of tongue, maxillary sinus, skin.) (Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify as T4)

N0: no regional node metastasis Nx: regional nodes cannot be assessed N1: single ipsilateral node, 3 cm N2a: single ipsilateral node, > 3 cm and 6 cm N2b: multiple ipsilateral nodes, 6 cm N2c: controlateral or bilateral nodes, 6 cm N3: node > 6 cm

Mx: Distant metastasis cannot be assessed M0: No distant metastasis M1: Distant metastasis

References
Treatment of lip carcinoma

l
Evidence Option Type 3 Type 3 Std. Std.
T1-T2 N0 : Surgery T (only) Brachytherapy (T<3cm, no ulceration, no infiltration, dry vermillion) T3-T4 N0: Surgery T + SOH ND post- operative RxTh1 T1-T4 N1: Surgery T + SOH or radical modified ND post-operative RxTh1 T1-T4 N2a-N3: Surgery T + radical modified ND2 postoperative RxTh1
1 2
Type 3 Type 3
Std. Std.
Type 3
Std.
See guidelines for post-operative radiotherapy Radical or extended neck dissection might be required (e.g. N3)
Treatment of buccal mucosa carcinoma
l
Evidence Option Type 3 Type 3 Type 3 Type 3 Std. Std. Std. Std.
T1N0 : Surgery T (only) Brachytherapy T2N0 : Surgery + SOH ND Brachytherapy (T< 3 cm, no oral commissure extension) + SOH ND T1-T4 N1-N3 : Surgery + SOH or radical modified ND post-operative RxTh2
1 2
Type 3
Std.
Radical or extended neck dissection might be required (e.g. N3) See guidelines for post-operative radiotherapy
Treatment of oral sulcus carcinoma

l
Evidence Type 3 Type 3
Option Std. Std.
T1N0-N1: Surgery T + SOH or radical modified ND1 T1 N2-N3: Surgery T + radical modified ND1, 2 postoperative RxTh3 T2-T4 N0-N1: Surgery T + alveolar resection + reconstruction + SOH ND2 post-operative RxTh3 T2-T4 N2-N3: Surgery T + alveolar resection + reconstruction + radical modified ND1, 2 post-operative RxTh3
1 2
Type 3
Std.
Type 3
Std.
Bilateral neck dissection for midline tumors Radical or extended neck dissection might be required (e.g. N3) 3 See guidelines for post-operative radiotherapy
Treatment of upper alveolar rim carcinoma

l
Evidence Option Type 3 Type 3 Type 3 Std. Std. Std.
T1-T4 N0 : Surgery T (only) T1-T4 N1 : Surgery T + SOH ND post-operative RxTh1 T1-T4 N2-N3 : Surgery T + radical modified ND2 postoperative RxTh1
1 2
Treatment of lower alveolar rim and retromolar trigone carcinoma l T1 N0-N1: Surgery T + SOH ND1 post-operative RxTh2 l T1 N2-N3: Surgery T + radical modified ND1, 3 postoperative RxTh2 l T2-T4 N0-N1: Surgery T + reconstruction + SOH ND1 postoperative RxTh2 l T2-T4 N2-N3: Surgery T + reconstruction + radical modified ND1, 3 post-operative RxTh2
1 2
Evidence Option
Type 3 Type 3
Std. Std.
Type 3
Std.
Type 3
Std.
Bilateral neck dissection for midline tumors See guidelines for post-operative radiotherapy 3 Radical or extended neck dissection might be required (e.g. N3)
Treatment of hard palate carcinoma

l
Evidence Option Type 3 Std.
T1-T3 N0 : Surgery T reconstruction post-operative RxTh1 T1-T3 N1 : Surgery T reconstruction + bilateral SOH ND post-operative RxTh1 T4 N0-N1 : Surgery T + reconstruction + bilateral SOH ND + post-operative RxTh1 T1-T4 N2-N3 : Surgery T reconstruction + bilateral radical modified ND2 post-operative RxTh1
1 2
Type 3
Std.
Type 3
Std.
Type 3
Std.
Treatment of mobile tongue (dorsum, apex, ventral side) carcinoma
l
Evidence Option
T1 N0-N1 : Surgery T + bilateral levels I-IV ND post-operative RxTh1 Brachytherapy + bilateral SOH ND RxTh (T+levels I-III) + brachytherapy T T2 N0-N1 : Surgery T reconstruction + bilateral levels I-IV ND postoperative RxTh1 T1-T2 N2-N3 : Surgery T reconstruction +bilateral radical modified ND2 + post-operative RxTh1 Locally advanced RxTh protocols (T+N)3 ND4 T3-T4 N0-N3 : Locally advanced RxTh protocols (T+N)3 ND4 Surgery T + reconstruction +bilateral ND + post-operative RxTh1
Type 3 Type 3 Type 3 Type 3
Std. Std. Std. Std.
Std. Std. Std. Std.
See guidelines for post-operative radiotherapy Radical or extended neck dissection might be required (e.g. N3) 3 See guidelines for organ preservation protocols
2
See guidelines for post-radiotherapy ND (slide 27)
Treatment of mobile tongue (lateral border) carcinoma
l
Evidence Type 3 Type 3 Type3 Type 3 Type 3 Type 3
Option Std. Std. Std. Std. Std. Std.
T1 N0 : Surgery T + unilateral SOH ND Surgery T Brachytherapy T T1 N1 : Surgery T + unilateral levels I-IV ND post-operative RxTh1 Brachytherapy + unilateral levels I-IV ND or RxTh T2 N0-N1 : Surgery T reconstruction + unilateral levels I-IV ND postoperative RxTh1 T1-T2 N2-N3 : Surgery T reconstruction +unilateral radical modified ND2 + Post-operative RxTh1 Locally advanced RxTh protocols (T+N)3 ND4 T3-T4 N0-N3 : Locally advanced RxTh protocols (T+N)3 ND4 Surgery T + reconstruction +unilateral ND2 + post-operative RxTh1
Std. Std. Std. Std.
See guidelines for post-operative radiotherapy Radical or extended neck dissection might be required (e.g. N3) 3 See guidelines for organ preservation protocols 4 See guidelines for post-radiotherapy ND (slide 27)
2
Treatment of anterior floor of mouth carcinoma l T1 N0 : Surgery T + bilateral SOH ND Brachytherapy + bilateral SOH ND l T2 N0 : Surgery T reconstruction + bilateral SOH ND post-operative RxTh1 l T1-T2 N1 : Surgery T reconstruction + bilateral SOH or radical modified ND post-operative RxTh1 l T1-T2 N2-N3: Surgery T reconstruction + bilateral radical modified ND2 post-operative RxTh1 Locally advanced RxTh protocols (T+N)3 ND4
1
Evidence Type 3 Type 3 Type 3
Option Std. Std. Std.
Type 3
Std.
Type 3 Type 3
Std. Std.
2
Treatment of anterior floor of mouth carcinoma l T3-T4 (no bone invasion), N0-N3 : Locally advanced RxTh protocols (T+N)3 ND4 Surgery T reconstruction + bilateral radical modified ND2 post-operative RxTh1 l T4 (bone invasion), N0-N3 : Surgery T reconstruction + bilateral radical modified ND2 post-operative RxTh1
Option Std. Std.
Type 3
Std.
2
Treatment of posterior floor of mouth carcinoma l T1 N0 : Surgery T + unilateral SOH ND1 l T2 N0 : Surgery T reconstruction + unilateral SOH ND post-operative RxTh2 l T1-T2 N1 : Surgery T reconstruction + unilateral SOH or radical modified ND post-operative RxTh2 l T1-T2 N2-N3: Surgery T reconstruction + unilateral radical modified ND3 post-operative RxTh2 Locally advanced RxTh protocols (T+N)4 ND5
1 2
Option Std. Std.
Type 3
Std.
Type 3 Type 3
Std. Std.
Bilateral neck dissection for midline tumors See guidelines for post-operative radiotherapy 3 Radical or extended neck dissection might be required (e.g. N3) 4 See guidelines for organ preservation protocols 5 See guidelines for post-radiotherapy ND (slide 27)
Treatment of posterior floor of mouth carcinoma l T3-T4 (no bone invasion), N0-N3 : Locally advanced RxTh protocols (T+N)4 ND5 Surgery T reconstruction + unilateral radical modified ND3 post-operative RxTh2 l T4 (bone invasion), N0-N3 : Surgery T reconstruction + unilateral radical modified ND3 post-operative RxTh2
1 2
Option Std. Std.
Type 3
Std.
Bilateral neck dissection for midline tumors See guidelines for post-operative radiotherapy 3 Radical or extended neck dissection might be required (e.g. N3) 4 See guidelines for organ preservation protocols 5 See guidelines for post-radiotherapy ND (slide 27)
Procedures for neck node treatment
Option Invest. Std.
Sentinel node biopsy Comprehensive neck node dissection/irradiation according to the recommendations for each subsites*
*See guidelines for target volumes on slide 27
Primary treatment: RxTh regimen l Target volumes T: CTV = GTV + 1.5-0.5 cm margin depending on anatomical barriers N: see table on node levels according to T site l Technique -conformal radiotherapy -IMRT radiotherapy l Dose / fractionation / treatment time - Early stage:1 -prophylactic dose: 50 Gy, -therapeutic dose: 66-70 Gy, 2 Gy daily -"moderately advanced"2 / "locally advanced"3 stage -on protocol: GORTEC 99-02 / IMCL CP02-9815 -off protocol: moderately accelerated regimen (concomitant boost) - post-operative RxTh -dose: 60-64 Gy, 2 Gy daily4
1 2
Evidence Option
Type 3 Type 3 Type C Type C Type 1
Std. Invest. Std. Std. Invest. Std.
Type 2
Std.
T1 N0-N1 T2 N0-N1 3 any T N2a-N3 4 See guidelines for post-operative radiotherapy
Target Volumes: oral cavity Level of evidence : type 3 / option : standard

Stage N0-N1 N2a-N2b N2c N3 Ipsilateral neck I-II1-III + IV for ant. tongue tumor or oroph. ext. I-II-III-IV-V2 According to N stage on each side of the neck I-II-III-IV-V adjacent structures according to clinical and radiological data Controlateral neck I-II1-III + IV for ant. tongue tumor or oroph. ext. I-II1-III + IV for ant. tongue tumor or oroph. ext. According to N stage on each side of the neck I-II1-III + IV for ant. tongue tumor or oroph. ext.
1level
IIb could be omitted for N0 patients 2Level V could be omitted if only level I-III are involved
Primary treatment: neck dissection following a primary radiotherapy

Planned
Evidence Type 3
Option Std.
ND (SND, RMND, RND or extended ND) 2-3 months after completion of RxTh in patients with a controlled primary site and in case of residual or suspected residual, resectable N disease irrespective of the initial N stage

References
Follow-up
l
Evidence Option Type C Std.
l l l
Clinical examination of head and neck mucosa (including fiberoptic ) and neck palpation / performance status / nutritional assessment every 2 months (first 2 years), every 6 months (years 3-5), once a year (> 5 year) Dental examination and orthopantomogram every 6 months Chest X-ray every year Chest spiral CT every year Laboratory tests: TSH every year (if Radiotherapy delivered) Evolution of late toxicity (EORTC/RTOG) scale
Type C Type C Type C Type C Type C
Std. Std. Invest. Std. Std.

References
Salvage treatment for recurrent disease

l
Evidence Option Type 3 Type 3 Type 3 Type 3 Type 3 Type 3 Std. Std. Std. Indiv. Indiv. Std.
Lip, mobile tongue, floor of mouth: rT1 N0 : Brachytherapy Surgery Any other T, any other N Surgery + radical ND post-operative RxTh1 if not previously delivered RxTh Palliative care Metastasis : Chemotherapy + best supportive care
1
See guidelines for post-operative radiotherapy

References
Appendix: surgical techniques

Labial surgery - vermillionectomy : mucosal advancement flap - full thickness resection : - < 1/3 lip : primary closure, V-Y or W plasty - < 2/3 lip : flaps - total resection : free flaps (composites) - mandibulectomy ...

Mandibulectomy - not if T clinically > 1 cm - interrupting if -T4 - recurrence - previous RT - T clinically < 1 cm with evidence of bony extension - atrophic mandibular height < 1 cm - non interrupting if T clinically < 1 cm and no evidence of bony extension or only evidence for alveolar bone defect of expansive type (and not of erosive type)

Mandibular reconstructions - clean margins are predictible Type 3 - primary : -vascularized bone : 1rst choice Type 3 - fibula - iliac crest - scapula - reconstruction plate + muscular pedicled flap, pectoralis major or latissimus dorsi : 2nd choice

- reconstruction plate :Type 3 - AO : - skin/mucosa perforations 9% - plate fracture 4,5% - screw loosening 32% - THORP - always if mandibular height < 10 mm after marginal resection - secondary - same techniques - Vascularized bone after RT - Osteogenous distraction

Buccal tumor surgery - local transoral tumorectomy : mucosal advancement flap, evt. Stensens duct transposition - resection of buccinator muscle : Bichat flap, + skin graft,. - full thickness resection : - free fasciocutaneous flaps (composites) - myocutaneous pedicled flaps, pectoralis major or latissimus dorsi - maxillectomy or mandibulectomy
Oral sulcus tumor surgery - local transoral tumorectomy : primary closure, mucosal advancement flap - alveolar resection : primary closure, Bichat flap, secondary healing, skin graft... - maxillectomy or mandibulectomy...

Maxillary reconstructions - obturator prosthesis - temporalis muscle flaps - Bichat flap - buccinator flap - free flaps - fasciocutaneous - vascularized bone

Anterior tongue and floor of the mouth reconstructions Type 3 -1. free fasciocutaneous flaps (sensate) - radial - brachial ext - cubital - 2. Myocutaneous or musculous pedicled flaps : pectoralis major or latissimus dorsi - 3. nasolabial flap, per secundary healing, skin graft

References
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CA Oral Cavity

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Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme

Oral Cavity carcinoma

Oral Cavity 1 Mar. 2006

Oral Cavity carcinoma

Standard clinical evaluation

Oral Cavity 3 Mar. 2006

Evidence Type C Type C Type C Type C Type C

Option Std. Std. Std. Std. Individ

Oral Cavity 4 Mar. 2006

Evidence Type C Type C

Option Std. Std.

Oral Cavity 5 Mar. 2006

Local imaging and metastatic work-up

See guidelines for loco-regional imaging

Oral Cavity 6 Mar. 2006

Oral Cavity carcinoma

Evidence Type C Type C

Option Std. Std.

Oral Cavity 8 Mar. 2006

TNM/AJCC 1997 Staging

Oral Cavity 9 Mar. 2006

TNM/AJCC 1997 Staging

TNM/AJCC 1997 Staging

Oral Cavity 11 Mar. 2006

Oral Cavity carcinoma

Treatment of lip carcinoma

Evidence Option Type 3 Type 3 Std. Std.

Oral Cavity 13 Mar. 2006

Oral Cavity 14 Mar. 2006

Treatment of oral sulcus carcinoma

Evidence Type 3 Type 3

Option Std. Std.

Treatment of upper alveolar rim carcinoma

Evidence Option Type 3 Type 3 Type 3 Std. Std. Std.

Oral Cavity 16 Mar. 2006

Oral Cavity 17 Mar. 2006

Treatment of hard palate carcinoma

Evidence Option Type 3 Std.

Oral Cavity 18 Mar. 2006

Type 3 Type 3 Type 3 Type 3

Std. Std. Std. Std.

Type 3 Type 3 Type 3 Type 3

Std. Std. Std. Std.

See guidelines for post-radiotherapy ND (slide 27)

Oral Cavity 19 Mar. 2006

Evidence Type 3 Type 3 Type3 Type 3 Type 3 Type 3

Option Std. Std. Std. Std. Std. Std.

Type 3 Type 3 Type 3 Type 3

Std. Std. Std. Std.

Oral Cavity 20 Mar. 2006

Evidence Type 3 Type 3 Type 3

Option Std. Std. Std.

Oral Cavity 21 Mar. 2006

Evidence Type 3 Type 3

Option Std. Std.

Oral Cavity 22 Mar. 2006

Evidence Type 3 Type 3

Option Std. Std.

Oral Cavity 23 Mar. 2006

Evidence Type 3 Type 3

Option Std. Std.

Oral Cavity 24 Mar. 2006