Download ORAL CANCER

10/4/2013
GOALS
C ecelia E. Sch malb ach , MD , MS, FA C S
Associate Professor
Program Director
Head & Neck- Microvascular Surgery
T h e U n i v. o f A l a b a m a i n B i r m i n g h a m
• Oral Cavity Anatomy
• Staging
• Elective ND
• Sentinel Lymph Node Biopsy
ORAL CANCER
• Treatment
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Surgery vs. XRT +/- Chemotherapy
Managing the Neck
Adjuvant therapy
Tx of Lip Cancer
• Reconstruction
• Pearls
Sisson 2013
ORAL CAVITY SUBSITES
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Mucosal Lip
Buccal Mucosa
Lower Alveolar Ridge
Upper Alveolar Ridge
Retromolar Trigone (RMT)
Floor of Mouth (FOM)
Hard Palate (HP)
Oral Tongue
• LIP CANCER ACCOUNTS FOR 25-30%
OF ALL ORAL CAVITY MALIGNANCIES
WORK-UP
• History & Physical
• Biopsy
• HPV NOT routine (<5%)
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Neck CT or MRI as indicated
Chest Imaging
Consider PET for Stage III/IV
EUA & endoscopy as clinically indicated
Preanesthesia work-up
Dental evaluation
Speech & nutrition evaluation
NCCN Practice Guidelines in Oncology v.2.2013
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WORK-UP
WORK-UP
Assessing Bony Involvement
Assessing Regional Metastasis: PET
• Assessing mandible invasion:
• Bone Scan & MRI:
• N+ Neck:
• PET & CT scan are complementary
• High false positive rate
• CT & Panorex:
• Best for gross invasion
• High false negative rate
(cortical erosion)
• N-Zero Neck:
• PET is NOT sensitive
• Not advocated for early disease
Clinical Judgment
Most Important!
WORK-UP
Assessing Regional Metastasis: SLNB
• Sentinel Lymph Node Biopsy (SLNB)
• Minimally invasive procedure
• Thoroughly assess nodes most at risk for occult disease
• Identify patients who may benefit from adjuvant XRT while
sparing the remaining 50 – 80% a ND
• Civantos FJ, et al. Eur Archive Otolaryngol.
2010;367:839.
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> 60 Clinical Trials
Predictive value of (-) SLN: 90 – 100%
Excellent safety record
Ability to identify aberrant nodal drainage
WORK-UP
Assessing Regional Metastasis: SLNB
• Broglie MA, et al. Ann Surg Oncol. 2011;18(10):2732
• Prospective trial 79 pts (OC & OP)
• 5 year regional control
• 96% for SLN –
• 74% SLN+
• Safe and accurate
for T1/T2 tumors
• SLNB Take Home Points
• Remains investigational
• Not part of NCCN guidelines
• May have a future role for T1/2 tumors
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WORK-UP
Assessing Regional Metastasis
WHEN DO YOU PERFORM AN END?
• Low risk patients
• High incidence of occult nodal disease
• < 2cm (T1)
• Minimal depth of invasion (< 4mm)
• Favorable histology
• >20% risk
• Depth of invasion > 4mm
• High risk patients
• Retrospective studies demonstrate decreased regional &
distant recurrence with ND
• Yuen. Head Neck 1997;19:583
• Oreste. Head Neck 1996;18:566
• Need for surgical violation of the neck
• Poor patient compliance
• Obese or muscular neck (difficult to follow
clinically)
• 1/3 N-zero H&N patients had occult disease (1/3 with ECS)
• Pitman. Arch Otolaryngol. 1997;123:917.
• “Watchful waiting” leads to increased regional recurrence
(33% vs 12%) and were often unresectable (76%)
• Kligerman. Am J Surg. 1994;168:391.
ORAL CAVITY SCCA:
SPECIFIC ORAL CAVITY SUBSITES
INCIDENCE OF OCCULT REGIONAL DISEASE
• Hard Palate/Maxillary Alveolar Ridge
SITE
Oral Tongue
OCCULT DZ
50-60%
Floor of Mouth
30%
Buccal Mucosa
27%
Lower Alveolar Ridge
19%
Hard Palate
10%
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Yang Z, et al. Head Neck. 2013 Jun 4; epub
Nodal Mets: 17%; Occult: 10%
Associated with T-stage
Advocate END for pT4 tumors
Observation pT1-T3
• Buccal Mucosa
• Diaz EM, et al. Head Neck.
2003;25(4):267
• Aggressive cancer
• High locoregional failure rate
Buccal SCC
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OC SCC: SND (I – III)
CERVICAL LEVELS
TNM Staging of H&N Cancer and Neck Dissection
Classification. Online: entnet.org
I.
Submental/
Submandibular
II.
Upper Jugular Chain
III.
Middle Jugular Chain
IV.
Lower Jugular Chain
V.
Posterior Triangle
VI.
Anterior Compartment
T
STAGING:
0: TisN0M0
I: T1N0M0
II: T2N0M0
III: T3N0M0
T1-3N1M0
IV: T4N0M0
T4N1M0
T1-4N1M0
M1
M
PRIMARY
• Based on tumor depth
• Reconstruction
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Secondary intention
Primary closure
Split thickness skin graft
Pectoralis Flap (bulky)
Free flap
ADJUVANT XRT
• ECS +/- Positive Margin
(Preferred)
• Adverse Features:
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T3/4
N2/3
+ LN Level IV/V
Perineural Invasion
Vascular Embolism
• M0: No Distant mets
• M1: + Distant mets
ADVANCED STAGE ORAL CANCER:
T3-4; ANY N+ (STAGE III & IV)
T3SURGERY
• 1+ LN (Optional)
ADJUVANT CHEMO/XRT
N1: 1 node, ≤ 3cm
N2a: ips node >3, ≤ 6
N2b: mult ips nodes,
≤ 6cm
N2c: Cont / Bilat
nodes, ≤6
N3: > 6cm
AJCC Staging, 7th Ed., 2010
EARLY STAGE ORAL CANCER:
T1
T1--2; N0
• Surgery (Preferred)
or XRT
• Neck Dissection
N
T1: ≤ 2cm
T2: >2cm, ≤ 4cm
T3: > 4cm
T4a: Through bone,
Inferior alveolar n.,
FOM, Extrinsic
tongue musculature;
Maxillary sinus
Skin of face
T4b: Masticator Space
Pterygoid Plates
Skull base
Encasing ICA
• Surgery Preferred
• Neck Dissection
• Based on tumor depth
• Reconstruction
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Secondary intention
Primary closure
Split thickness skin graft
Pectoralis Flap (bulky)
Free flap
or
MULTIMODALITY
CLINICAL TRIAL
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LIP CANCER:
LIP CANCER
Begins at vermilion border & includes that portion of the lip that comes into contact with
the opposing lip
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Males : Females (6:1)
Age > 50 yrs
Sun / Photo damage
Outdoor occupation
Lower Lip > Upper Lip
SCCA > BCC
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• Lymph Node Metastasis is rare (<10%)
• No need for elective ND in early-stage tumors
• Associated with tumor size, grade & location
• Location matters
• Tumors of upper lip & commissure more likely to be N+
verrucous SCC
Spindle cell (SCC)
Adenoid SCC
BCC (skin CA!!)
Melanoma
Salivary gland CA
• Distant Metastasis
• Rare
• Usually in setting of uncontrolled
locoregional disease
• Overall Good Prognosis (>90% at 5yrs if dx’ed in early stages)
EARLY STAGE LIP CANCER:
T1
T1--2; N0
PRIMARY
• Surgery (Preferred)
• Neck Dissection
• NOT recommended
or
• XRT to primary tumor
• Large, superficial cancer
involving entire lip
ADJUVANT XRT
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Positive margin
Perineural invasion
Vascular embolism
Lymphatic invasion
ADVANCED STAGE LIP CANCER:
T3-4; ANY N+ (STAGE III & IV)
T3-
SURGERY
• Surgery Preferred
• Neck Dissection
• Reconstruction
• Primary
• Local Flap
• Free flap
Primary Radiation +/+/Chemotherapy
or
• Poor surgical
candidate
• Unresectable disease
• RFFF
• Gracilus
• Adjuvant XRT
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ORAL CAVITY
RECON.
ORAL CAVITY
RECON.
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Must prevent
tethering
FOM and tongue 2
separate subunits
Vascularized
Tissue
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Tongue Recon:
Primary Closure
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RFFF
ALT (thin pt)
Must prevent
tethering
FOM and tongue 2
separate subunits
Vascularized
Tissue
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RFFF
ALT (thin pt)
Radial Forearm Free
Flap
FOM Recon:
Pectoralis Major Flap
LIP
RECONSTRUCTION
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Midline
Defect < ½ lip
width
Bilateral
advancement
flaps
KARAPANDZIC
FLAP
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Near total loss of
lip
Full-thickness
pedicled flap
Nasolabial fold
Neurovascular
pedicle intact
Microstomia
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ORAL CAVITY SCC PEARLS
1. Surgery is preferred primary choice
2. Depth of invasion (4mm) dictates and 20% risk of
nodal metastasis = need for prophylactic neck
treatment
• Selective ND (I – III)
• XRT to the neck
3. Oral tongue with floor of mouth defects require
vascularized tissue for reconstruction.
LIP CANCER PEARLS
• Lower lip
• Presents early
• Excellent prognosis; high cure rate
• Upper lip & commissure
• More aggressive disease
• Lymph node metastasis rare: END only for
advanced stage disease
• Surgery and XRT have comparable cure rates for
early stage disease
QUESTIONS ???
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