2. INTRODUCTION
⢠Oral cavity cancers are approximately 30% of head and
neck cancers.
⢠Occurs after the 5th decade of life
⢠80% cases are tobacco related
⢠Oral leukoplakia (4â18%) and erythroplakia (30%) can
proceed to cancer
⢠1.5%will have synchronous cancers
⢠10-40% will develop second primaries
6. PATHOLOGICAL CLASSIFICATION
⢠Normally, Oral cavity is lined by non-keratinized stratified squamous
epithelium except dorsum of the tongue, hard palate and attached
gingiva lined by keratinized squamous epithelium.
⢠Squamous cell carcinoma >95%
⢠Basaloid â worse prognosis
⢠Verrucous
⢠Sarcomatoid
⢠Minor salivary gland tumors â adenoid cystic carcinoma, muco-epidermoid
carcinoma, and adenocarcinoma
⢠Soft tissue tumors
⢠Lymphoepithelial carcinoma
⢠Haematolymphoid tumors
⢠Secondary tumors
7. CLINICAL PRESENTATION
⢠Non-healing painful ulcer
⢠Neck lymphadenopathy â 30-40% (frequency of neck metastases can
range from 15% to 75%, depending on the size of the primary lesion)
⢠Dysphagia (difficulty in swallowing)/ Odynophagia (pain while swallowing)
⢠Speech alteration or hoarseness
⢠Trismus (extension into pterygoid muscles)
⢠Otalgia (CNV)
⢠Facial Numbness(CNV)
⢠Hypoesthesia of the face, lips, or mandible (perineural spread along
inferior alveolar nerve after penetration of the mandible)
⢠Hyper salivation
⢠Limited tongue movements
8. DIAGNOSTIC STUDY
⢠Proper history and complete clinical examination.
⢠Routine blood investigations-CBC, LFT, KFT
⢠Dental examination and orthopantogram
⢠Chest X-Ray â to see pulmonary metastasis.
⢠Biopsy- incisional biopsy of most suspicious part with normal adjoining mucosa is
mandatory before planning treatment. Biopsy can be taken under LA.
⢠FNAC â from neck nodes if any.
9. ďś CT SCAN - for cervical metastasis infiltration of mandible.
Sensitivity 74% And Specificity-85%
ďś MRI â investigation of choice for imaging soft tissue infiltration.
Can detect peri-neural invasion.
Sensitivity-82% Specificity-66.7%
ďś PET-CT- not routinely recommended
ďś optional use in detection of distant metastasis in advance case
sensitivity 83%, specificity 88%
13. N1 N2 N3
<=3cm >3-6cm
>6cm
N1-Ipsilateral single LN â¤3cm N2A â Ipsilateral LN > 3cm. - 6 cm.
N2b â Ipsilateral multiple LN ⤠6 cm.
N2c â Bilateral / contralateral LN ⤠6 cm
N3a-Any node > 6 cm.
N3b- any node, ENE+
14. â˘DISTANT METASTASIS
Mx â Can not be assessed.
M0 â No detectable distant metastasis.
M1 â Distant metastasis present.
15. STAGE GROUPING
STAGE T N M
I T1 N0 M0
II T2 N0 M0
III T1 N1 M0
T2 N1 M0
T3 N0/N1 M0
IV A T4 N0 M0
T4 N1 M0
ANY T N2 M0
IV B ANY T N3 M0
IV C ANY T ANY N M1
16. PROGNOSTIC FACTORS
⢠Location/thickness/depth of primary tumor
⢠Staging
⢠Type of histology
⢠Grading
⢠Presence of perineural spread
⢠Mandibular invasion
⢠LN extension (Level, size, extracapsular)
17. TREATMENT
AIM :
⢠Highest loco-regional control (anatomical) with functional preservation and
minimize sequelae of treatment
ďśChoice depends on:
⢠Tumor factors - Site, Size, Type
⢠Patient factors
⢠Facilities available
⢠Stage I / II disease - Single modality ( Surgery or RT )
⢠Stage III / IV disease â Combined modality
19. COMBINED MODALITY
1. RT (Pre-op RT) Surgery
2. Surgery + RT (Intra-operative RT)
3. Surgery RT (Post-op RT) â standard of care
4. Radical RT Salvage Surgery
20. CHOICE OF TREATMENT DEPENDS UPON
VARIOUS FACTORS
ďśSite of disease
ďśStage of disease:
â˘Early â Surgery
â˘Intermediate â Both (surgery & RT)
â˘Advance â BOTH (surgery & RT+/-CT)
ďśPrevious irradiation
ďśPatients physical / social & personal status
21. SURGICAL TREATMENT
AIMs OF SURGERY
⢠Complete excision of primary, three dimensionally with Ro
(microscopically clear) margins.
⢠Treatment of LN.
⢠Reconstruction of tissue loss to provide rapid healing, restoration of
function & appearance to improve quality of life.
22. NECK DISSECTION
⢠Depend on nodal status.
⢠MRND give better cosmetic & functional result.
⢠Classic RND : 5 level LN with SAN, IJV, SCM.
⢠MRND : 5 level LN with preservation of the structure.
⢠Type-1 preserve SAN.
⢠Type-2 preserves SAN & IJV.
⢠Type-3 preserves SAN , SCM & IJV.
26. INDICATION OF RADIOTHERAPY
â˘Pre-operative RT:
o Inoperable
o Unfit for surgery
o Down staging
â˘Post-operative RT
oT3/T4 primary
oPositive surgical margins
oPerineural , peri-lymphatic vascular invasion
oMicroscopic gross residual tumor
oExtra capsular spread
oPathologically positive LN after SOHND
27. Role Of Radiotherapy
For T1- T2 lesion
ďśSingle-modality treatment (i.e., surgery or radiation) for early-
stage.
ďśTransoral surgical resection - Small, well define lesion
involving the tip and anterolateral border of tongue.
ďśRT (60 TO 65 Gy in 6 to 7 week) â Small, posteriorly situated,
ill define, inaccessible for surgical excision.
ďśRT (70Gy in 7 week) - Superficial exophytic T1,T2 with
muscle invasion.
28. T3-T4 lesion
ďśMulti modality approach is recommended
ďśBest managed by radiotherapy with surgery.
ďśPost-operative irradiation is recommended for larger lesions.
ďśAdjuvant radiation proceed as soon as surgical wounds are well
healed, optimally 4 to 6 weeks after completion of surgery.
29. Pre op vs. Post op RT
Pre op RT Post op RT
⢠Decreases viability of tumor, ⢠Pathologic information to modify
wound implantation dose or treatment portals
⢠Improves resectibility ⢠Allows proper wound healing
⢠Allows delivery of dose of
radiation
⢠Post op RT superior to pre op RT in H&N Cancer
⢠Timing of post op RT critical-Within 4-6 weeks of surgery.
30. Steps of Radiotherapy
â˘Position â Supine position with a bite block
⢠Neck- support by head rest
â˘Immobilization in supine position with custom thermoplastic mold.
31. EBRT
2D Conventional radiotherapy
â˘A two phase technique is used with large lateral fields
for phase I. 44Gy / 22#
â˘Smaller lateral fields matched to posterior electron
fields for phase II. 26Gy / 13#
⢠A matched anterior neck field treats lower neck nodes with midline
shielding to reduce dose to the larynx, pharynx and spinal cord.
32. Total dose 50-70Gy/25-35 fractions by conventional radiotherapy
LN
Phase I: 44Gy/22#
LN
Primary
Phase I : 44Gy / 22#
Phase II : 26Gy / 13#
Ant. Neck : 50Gy/25#
CONVENTIONAL RADIOTHERAPY
33. 3D CRT
ďComputed tomography imaging for three dimensional
planning.
ď Target and critical structure delineation, Contouring of the
target volume including gross tumour volume , clinical target
volume, planning target volume /OAR.
34.
35. IMRT
⢠More conformal dose distribution
⢠Better sparing of organs at risk
o Allow for dose escalation
o Limit dose to organs at risk (OAR)
o Less toxicity, improved QOL
36.
37. DEFINITIVE:
RT Alone
High risk: Primary tumor and involved lymph nodes [this includes possible local subclinical
infiltration at the primary site and at the high- risk level lymph node(s)
â Fractionation:
⢠66 Gy (2.2 Gy/fraction) to 70 Gy (2.0 Gy/fraction); daily MondayâFriday in 6â7 weeks
⢠72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during
last 12 treatment days)
Low to intermediate risk:
Sites of suspected subclinical spread
â 44â50 Gy (2.0 Gy/fraction) to 54â63 Gy (1.6â1.8 Gy/fraction)
38. POSTOPERATIVE
RT or Concurrent Systemic Therapy
High risk:
⢠Adverse features such as positive margins
⢠60â66 Gy (2.0 Gy/fraction)
⢠MondayâFriday in 6â6.5 weeks
Low to intermediate risk:
⢠Sites of suspected subclinical spread
⢠44â50 Gy (2.0 Gy/fraction) to 54â63 Gy (1.6â1.8 Gy/fraction)
39. PALLIATIVE RADIOTHERAPY
ď§Some recommended RT regimens include:
â 50 Gy in 20 fractions
â 37.5 Gy in 15 fractions
â 30 Gy in 10 fractions
â 30 Gy in 5 fractions
â 44.4 Gy in 12 fractions
42. CHEMOTHERAPY
1. TPF Induction Chemotherapy Carboplatin + Radiation
Therapy
⢠Docetaxel: 70 mg/m2 IV on day 1
⢠Cisplatin: 75â100 mg/m2 IV on day 1
⢠5-Fluorouracil: 1000 mg/m2/day IV continuous infusion on days
1â4
⢠Repeat cycle every 3 weeks for 3 cycles followed by:
⢠Carboplatin: AUC of 1.5, IV weekly for 7 weeks during radiation therapy
⢠Radiation therapy: 200 cGy/day to a total dose of 7000 cGy
⢠At the completion of chemo-radiotherapy, surgical resection as
indicated
47. ⢠Brachytherapy â brachy Greek for âshort distance.â
⢠Radiation sources placed close to the tumor so large doses can hit the
cancer cells.
⢠Allows minimal radiation exposure to normal tissue.
⢠Radioactive sources used are thin wires, ribbons, capsules or seeds.
⢠These can be either permanently or temporarily placed in the body.
LDR brachytherapy (0.4â0.5 Gy per hour):
â Consider LDR boost 20â35 Gy if combined with 50 Gy EBRT or 60â70
Gy over several days if using LDR as sole therapy.
HDR brachytherapy:
â Consider HDR boost 21 Gy at 3 Gy/fraction if combined with 40â50 Gy
EBRT or 45â60 Gy at 3â6 Gy/fraction if using HDR as sole therapy.
48. squamous-cell carcinoma involving the left lateral oral tongue. B: Submental
view of interstitial implantation catheters housing 192Ir seeds for delivery of 25-Gy tumor
boost following external beam radiation of 50 Gy. C: Implantation bed mucositis
conforming to the tumor distribution seven days following 25-Gy implant boost.
49.
50.
51. FOLLOW-UP
â˘Clinical examination of head and neck mucosa (including
fiberoptic ) and neck palpation / performance status /
nutritional assessment
ďźevery 2 months (first 2 years),
ďźevery 6 months (years 3-5),
ďźonce a year (> 5 year)
â˘Dental examination and orthopantomogram every 6 months
â˘Chest X-ray every year
â˘Chest spiral CT every year
â˘Laboratory tests: TSH every year (if Radiotherapy delivered)
â˘Evolution of late toxicity.