Download Oral Cavity - MD Anderson Cancer Center

This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
INITIAL EVALUATION
Confirm outside pathology
History:
● Chief complaint
● History of present illness and previous treatment
Past Medical History:
● Medical illnesses
● Surgeries
● Medication allergies
● Family history
● Social history (including tobacco and alcohol use)
● Medications
● Review of systems
Physical Examination:
● Full head and neck exam
● General medical examination
Stage T and N (AJCC)
Imaging studies:
● High resolution CT with thin cuts and contrast and
bone windows
● Chest Imaging as clinically indicated
● Consider PET scan for Stage III or IV
1
Consider Dental Extraction based on
results of dental evaluation prior to
initiation of primary treatment
PRE-TREATMENT
EVALUATION
CONSULTATIONS
Dental oncology1
● Radiation oncology
● Medical oncology for patients with
Stage III or IV
● Speech pathology for patients
whose treatment may impact
swallowing and/or speech
● Plastic surgery for patients who
will require major reconstruction
(pharyngeal or bony reconstruction)
● Nutrition
● Smoking cessation for active
smokers only
2
● Pre-Op Internal Medicine Consult
● Audiogram, if receiving
chemotherapy
●
Primary Tumor
● T1-T2,N0
Patient information
presented at
Multidisciplinary
Planning Conference
Primary Tumor
● T1-2, N1-3
See page 2
Primary Tumor
● T3-4a, N0-1
Primary Tumor
● T4b, Any N
2
Conditions for pre-op internal medicine consult:
Hypertension
● Uncontrolled or newly diagnosed
● Poorly compliant patient
● Multi-drug regimen for control
Cardiac Disease
● History of MI or angina
● History of cardiac or vascular surgery
● Cardiac murmur or valvular heart disease
● CHF
Copyright 2015 The University of Texas MD Anderson Cancer Center
Pulmonary Disease
● 20 or more pack per year smoking history
● Moderate to severe COPD with less than 2
flight exercise tolerance
● Reactive airway disease
● Previous lung resection
● Multiple history of pneumonias
● History of TB
CerebrovascularDisease
● Previous CVA
● History of TIA
● Carotid bruit or known
stenosis
Hepatic Disease
● History of cirrhosis
● Laboratory of hepatic
dysfunction
Diabetes
● Type
● Type II
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
CLINICAL
EVALUATION
Primary Tumor
● T1-T2, N0
PRIMARY TREATMENT
Excision of primary tumor or
sentinel node biopsy with
selective neck dissection if
clinically indicated1
Yes
Presence
of pathological risk
features2?
●
●
Radiation therapy
Consider chemoradiation3
No
Yes
Primary Tumor
● T1-2, N1-3
No
Initial
stage greater than
N1?
Glossectomy and
neck dissection 4
SURVEILLANCE
ADJUVANT TREATMENT
Consider radiation
Node
positive?
Surveillance
(See Page 4);
13
Medical Oncology (optional)
for chemoprevention trials
No
Yes
Primary Tumor
● T3-4a, N0-1
Radiation therapy
3
● Consider chemoradiation
Glossectomy and
neck dissection 4
●
Surgery (preferred for bone invasion)4
Yes
Primary Tumor
● T4b, Any N
Primary
tumor
resectable?
Yes
No
● Chemotherapy/
Radiation
● Consider for
clinical trial
Complete
response at
primary
site?
No
Copyright 2015 The University of Texas MD Anderson Cancer Center
1
Depth of invasion greater than or equal to
4 mm depth invasion)
2
Pathological Risk Features include:
Primary pathology:
● Any T1 or T2 with positive or close
(less than 1 mm) margins, perineural
Neck dissection
invasion, OR lymphovascular invasion
Yes
(re-excision to clear margins is preferred)
Residual
● Any T3 or T4
Neck
Nodal
Yes
Regional pathology:
dissection
Disease?
● Multiple lymph nodes (any N2, N3)
Stage
No
● Lymph node(s) with extracapsular extension
N3?
● Lymph node(s) in Level IV or V
3
Pathological Risk Factors include:
Observe
No
● Positive margins (re-excision to clear
margins is preferred)
Salvage surgery with neck
● Extracapsular extension
4
dissection as clinically indicated
Bilateral neck dissection for N2c neck disease.
Consider bilateral neck dissection for midline lesion.
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
CLINICAL PRESENTATION
RECURRENT TREATMENT
● Consider
Systemic Therapy/Phase I Clinical Trial
● Palliative Care as clinically indicated
Recurrent
disease
Restage
● CT of Head and Neck
● CT Chest or PET to
evaluate for Metastatic
Disease
Yes
Previous
radiation
therapy?
Presence
of distant metastatic
disease?
Salvage Surgery as
clinically indicated,
● Consider postoperative radiation
therapy as clinically
indicated1
●
No
Yes
No
Consider Salvage Surgery
as clinically indicated
● Palliative Care as
clinically indicated
●
Yes
Is
recurrence
resectable?
Surveillance
(See Page 4)
Consider re-irradiation if
clinically indicated
● Palliative Care
●
No
Yes
Previous
radiation
therapy?
No
1
Pathological Risk Factors should be taken into consideration when making concurrent treatment decisions
Copyright 2015 The University of Texas MD Anderson Cancer Center
Consider chemotherapy and
radiation therapy
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
ORAL CAVITY CANCER SURVEILLANCE
Total Years for
Surveillance
Frequency of
Surveillance
by month
Yr
1
Yr
2
Yr
3
Yr
4
Yr
5
2-3
6
9
12
16
20
24
36
48
60
Head and Neck
History and Physical
Exam
x
x
x
x
x
x
x
x
x
x
Baseline CT
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Consider Surveillance
CT if clinically
indicated
Thyroid function, if
XRT
CXR yearly
(CT chest if smoker)
Copyright 2015 The University of Texas MD Anderson Cancer Center
x
x
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
SUGGESTED READINGS
Bernier J, Domenge C, Ozsahin M, et al.(2004). European Organization for Research and Treatment of Cancer Trial 22931. Postoperative Irradiation with or without Concomitant
Chemotherapy for Locally Advanced Head and Neck Cancer. N Engl J Med, 350,1945-52.
Bernier J, Cooper JS, Pajak TF, et al. (2005). Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy
trials of the ORTC (#22931) AND RTOG (#9501). Head Neck, 27, 843– 850.
Byers RN, Weber RS, Andrews T, et al. (1997). Frequency and therapeutic implications of “skip metastasis” in the neck from squamous carcinoma of the oral tongue. Head Neck,
19(1),14-19.
Cooper JS, Pajak TF, Forastiere AA, et al. (2004). Radiation Therapy Oncology Group 9501/Intergroup. Postoperative Concurrent Radiotherapy and Chemotherapy for High-Risk
Squamous-Cell Carcinoma of the Head and Neck .N Engl J Med,350,1937-44.
Huang DT, Johnson CR, Schmidt-Ullrich R, et al. (1992). Postoperative radiotherapy in head and neck carcinoma with extracapsular lymph node extension and/or positive resection
margins: a comparative study. Int J Radiat Oncol Biol Physics, 23,737–742.
Myers JN, Greenberg JS, Mo V, et al.(2001). Extracapsular Spread A Significant Predictor of Treatment Failure in Patients with Squamous Cell Carcinoma of the Tongue. Cancer,
92,3030–6.
Spiro RH, Huvos AG, Wong GY, et al.(1986). Predictive value of tumor thickness in squamous carcinoma confined to the tongue and floor of mouth. Am J Surgery, 152(4), 345-350.
Yuen AP, Lam KY, Wei WI. (2000). A comparison of the prognostic significance of tumor diameter, length, width, thickness, area, volume and clinicopathological features of oral
tongue carcinoma. Am J Surg 180(2), 139-143.
Copyright 2015 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson, including the
following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not intended to replace the independent
medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant women.
Note: If available, clinical trials should be considered as preferred treatment options for eligible patients.
DEVELOPMENT CREDITS
This practice consensus algorithm is based on majority expert opinion of the Head and Neck Center faculty at the University of Texas, MD Anderson Cancer Center.
It was developed using a multidisciplinary approach that included input from the following medical, radiation and surgical oncologists:
Beth Beadle, MD, PhD
Lauren Byers, MD
Gregory Chronowski, MD
Gary L Clayman, DMD, MD, FACS
Renata Ferrarotto, MD
Steven J Frank, MD
Clifton Fuller, MD PHD
Adam S Garden, MD
Paul W Gidley, MD
Ann M Gillenwater, MD, FACS
Bonnie S Glisson, MD, FACP
Kathryn Gold, MD
Neil Gross, MD
Brandon Gunn, MD
Ehab Y Hanna, MD, FACS
Amy C Hessel, MD‡
Waun Ki Hong, MD
Merrill S Kies, MD
Michael E Kupferman, MD
Stephen Y. Lai, MD, PhD
Carol Lewis, MD
Charles Lu, MD
William H Morrison, MD
Jeffrey N Myers, MD, PhD, FACS
Vassiliki Papadimitrakopoulou, MD
Jack Phan, MD, PHD
Kristen B Pytynia, MD
David I Rosenthal, MD
Shalin Shah, MD
Shirley Y. Su, MBBS
Erich Madison Sturgis, MD, MPH,FACS
Randal S Weber, MD, FACS
Mark Zafereo, MD‡
‡Development Lead
Copyright 2015 The University of Texas MD Anderson Cancer Center
Department of Clinical Effectiveness V5
Approved by the Executive Committee of the Medical Staff on 10/27/2015