Cav PDF

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
Oral Cavity 2
Mar. 2006
References

Standard clinical evaluation

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Oral Cavity 3
Mar. 2006
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
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.

Advanced clinical evaluation
Oral Cavity 4
Mar. 2006
Dental examination by oral surgeon

Panendoscopy under general anesthesia
Prosthetic rehabilitation (if maxillectomy)
Nutritional assessment
PEG
Evidence
Option
Type C
Type C
Type C
Type C
Type C
Std.
Std.
Std.
Std.
Individ

Laboratory tests
l
Oral Cavity 5
Mar. 2006
Hemogram, ionogram, coagulation tests, liver

enzymes, Kidney function
Thyroid function: TSH (if radiotherapy scheduled)
Evidence
Option
Type C
Std.
Type C
Std.

Local imaging and metastatic work-up
Evidence Option
Orthopantomogram (+dental X-rays if
Type C
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
Oral Cavity 6
Mar. 2006
See guidelines for loco-regional imaging
Type C
Type C
Type C
Type C
Std.
Std.
Std.
Std.
Ind.
Std.
Type 3
Invest.


Work-up procedure
TNM staging
Primary treatment
Follow-up
Oral Cavity 7
Mar. 2006
References

Staging
l
l
Oral Cavity 8
Mar. 2006
TNM classification (5 th ed., 1997)

WHO International Classification of Diseases for
Oncology (ICD-O 9 or ICD-O 10)
Evidence
Option
Type C
Std.
Type C
Std.

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)
Oral Cavity 9
Mar. 2006

Oral Cavity 10
Mar. 2006
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
Oral Cavity 11
Mar. 2006


Work-up procedure
TNM staging
Primary treatment
Follow-up
Oral Cavity 12
Mar. 2006
References

Treatment of lip carcinoma

l
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
Oral Cavity 13
Mar. 2006
See guidelines for post-operative radiotherapy

Radical or extended neck dissection might be required (e.g. N3)
Evidence Option
Type 3
Type 3
Std.
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.

Treatment of buccal mucosa carcinoma
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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
1
2
Oral Cavity 14
Mar. 2006

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

Treatment of oral sulcus carcinoma

l
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
Bilateral neck dissection for midline tumors

3
2
Oral Cavity 15
Mar. 2006
Evidence
Option
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.

Treatment of upper alveolar rim carcinoma

l
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
Oral Cavity 16
Mar. 2006

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

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

3
Oral Cavity 17
Mar. 2006
Evidence Option
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.

Treatment of hard palate carcinoma

l
T1-T3 N0 :
Surgery T reconstruction post-operative
RxTh1
T1-T3 N1 :
Surgery T reconstruction + bilateral SOH ND
T4 N0-N1 :
Surgery T + reconstruction + bilateral SOH ND +
T1-T4 N2-N3 :
Surgery T reconstruction + bilateral radical
modified ND2 post-operative RxTh1
1
2
Oral Cavity 18
Mar. 2006

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

Treatment of mobile tongue (dorsum, apex, ventral side) carcinoma
l
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 +
Locally advanced RxTh protocols (T+N)3 ND4
T3-T4 N0-N3 :
Surgery T + reconstruction +bilateral ND + post-operative RxTh1

3
See guidelines for organ preservation protocols
2
Oral Cavity 19
Mar. 2006
See guidelines for post-radiotherapy ND (slide 27)
Evidence Option
Type 3
Type 3
Type 3
Std.
Std.
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Type 3
Std.
Std.

Treatment of mobile tongue (lateral border) carcinoma
l

3
4
2
Oral Cavity 20
Mar. 2006
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
T3-T4 N0-N3 :
Surgery T + reconstruction +unilateral ND2 + post-operative RxTh1
Evidence
Option
Type 3
Type 3
Type3
Std.
Std.
Std.
Type 3
Type 3
Std.
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Type 3
Std.
Std.

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
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
1

3
4
2
Oral Cavity 21
Mar. 2006
Evidence
Option
Type 3
Type 3
Std.
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.

Treatment of anterior floor of mouth carcinoma

l T3-T4 (no bone invasion), N0-N3 :
l T4 (bone invasion), N0-N3 :

3
4
2
Oral Cavity 22
Mar. 2006
Evidence
Option
Type 3
Type 3
Std.
Std.
Type 3
Std.

Treatment of posterior floor of mouth carcinoma
l T1 N0 :
Surgery T + unilateral SOH ND1
l T2 N0 :
Surgery T reconstruction + unilateral SOH ND
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
1

3
4
5
2
Oral Cavity 23
Mar. 2006
Evidence
Option
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.
Type 3
Std.

Treatment of posterior floor of mouth carcinoma

l T3-T4 (no bone invasion), N0-N3 :
l T4 (bone invasion), N0-N3 :
1

3
4
5
2
Oral Cavity 24
Mar. 2006
Evidence
Option
Type 3
Type 3
Std.
Std.
Type 3
Std.

Procedures for neck node treatment

Sentinel node biopsy
Comprehensive neck node dissection/irradiation
according to the recommendations for each subsites*
*See guidelines for target volumes on slide 27
Oral Cavity 25
Mar. 2006
Evidence
Option
Type 3
Type 3
Invest.
Std.

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
T1 N0-N1
T2 N0-N1
3
any T N2a-N3
4
2
Oral Cavity 26
Mar. 2006
Evidence Option
Type 3
Type 3
Std.
Invest.
Type C
Type C
Std.
Std.
Type 1
Invest.
Std.
Type 2
Std.

Target Volumes: oral cavity

Level of evidence : type 3 / option : standard
Stage
Ipsilateral neck
Controlateral neck
N0-N1
I-II1-III + IV for ant.

tongue tumor or oroph. ext.

N2a-N2b
I-II-III-IV-V2

N2c
According to N stage on
each side of the neck
According to N stage on
each side of the neck
N3
I-II-III-IV-V adjacent
structures according to clinical
and radiological data

1level
IIb could be omitted for N0 patients

2Level V could be omitted if only level I-III are involved
Oral Cavity 27
Mar. 2006

Primary treatment: neck dissection following a primary

radiotherapy
Planned
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
Oral Cavity 28
Mar. 2006
Evidence
Option
Type 3
Std.


Work-up procedure
TNM staging
Primary treatment
Follow-up
Oral Cavity 29
Mar. 2006
References

Follow-up
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l
l
l
Oral Cavity 30
Mar. 2006
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
Evidence Option
Type C
Std.
Type C
Std.
Type C
Type C
Type C
Std.
Invest.
Std.
Type C
Std.


Work-up procedure
TNM staging
Primary treatment
Follow-up
Oral Cavity 31
Mar. 2006
References

Salvage treatment for recurrent disease

l
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
Oral Cavity 32
Mar. 2006
Evidence Option
Type 3
Type 3
Std.
Std.
Type 3
Std.
Type 3
Type 3
Indiv.
Indiv.
Type 3
Std.


Work-up procedure
TNM staging
Primary treatment
Follow-up
Oral Cavity 33
Mar. 2006
References


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 ...
Oral Cavity 34
Mar. 2006


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)
Oral Cavity 35
Mar. 2006


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
Oral Cavity 36
Mar. 2006


- 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
Oral Cavity 37
Mar. 2006


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 Cavity 38
Mar. 2006

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...
Oral Cavity 39
Mar. 2006


Maxillary reconstructions
- obturator prosthesis
- temporalis muscle flaps
- Bichat flap
- buccinator flap
- free flaps
- fasciocutaneous
- vascularized bone
Oral Cavity 40
Mar. 2006


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
Oral Cavity 41
Mar. 2006


Work-up procedure
TNM staging
Primary treatment
Follow-up
Oral Cavity 42
Mar. 2006
References

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Oral Cavity 43
Mar. 2006
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Catholic University of Louvain, St - Luc University Hospital

Head and Neck Oncology Programme

Oral Cavity carcinoma

Catholic University of Louvain, St - Luc University Hospital

Oral Cavity carcinoma

Catholic University of Louvain, St - Luc University Hospital

Standard clinical evaluation

Complete history of the disease

Catholic University of Louvain, St - Luc University Hospital

Advanced clinical evaluation

Dental examination by oral surgeon

Catholic University of Louvain, St - Luc University Hospital

Hemogram, ionogram, coagulation tests, liver

Catholic University of Louvain, St - Luc University Hospital

Local imaging and metastatic work-up

Orthopantomogram (+dental X-rays if

See guidelines for loco-regional imaging

Catholic University of Louvain, St - Luc University Hospital

Oral Cavity carcinoma

Catholic University of Louvain, St - Luc University Hospital

TNM classification (5 th ed., 1997)

Catholic University of Louvain, St - Luc University Hospital

TNM/AJCC 1997 Staging

Catholic University of Louvain, St - Luc University Hospital

TNM/AJCC 1997 Staging

N0: no regional node metastasis

Catholic University of Louvain, St - Luc University Hospital

TNM/AJCC 1997 Staging

Catholic University of Louvain, St - Luc University Hospital

Oral Cavity carcinoma

Catholic University of Louvain, St - Luc University Hospital

Treatment of lip carcinoma

See guidelines for post-operative radiotherapy

Catholic University of Louvain, St - Luc University Hospital

Radical or extended neck dissection might be required (e.g. N3)

Catholic University of Louvain, St - Luc University Hospital

Treatment of oral sulcus carcinoma

Bilateral neck dissection for midline tumors

Catholic University of Louvain, St - Luc University Hospital

Treatment of upper alveolar rim carcinoma

See guidelines for post-operative radiotherapy

Catholic University of Louvain, St - Luc University Hospital

Bilateral neck dissection for midline tumors

Catholic University of Louvain, St - Luc University Hospital

Treatment of hard palate carcinoma

See guidelines for post-operative radiotherapy

Catholic University of Louvain, St - Luc University Hospital

See guidelines for post-operative radiotherapy

See guidelines for post-radiotherapy ND (slide 27)

Catholic University of Louvain, St - Luc University Hospital

See guidelines for post-operative radiotherapy

Catholic University of Louvain, St - Luc University Hospital

See guidelines for post-operative radiotherapy

Catholic University of Louvain, St - Luc University Hospital

Treatment of anterior floor of mouth carcinoma

See guidelines for post-operative radiotherapy

Catholic University of Louvain, St - Luc University Hospital

Bilateral neck dissection for midline tumors

Catholic University of Louvain, St - Luc University Hospital

Treatment of posterior floor of mouth carcinoma

Bilateral neck dissection for midline tumors

Catholic University of Louvain, St - Luc University Hospital

Procedures for neck node treatment