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LIP AND ORAL CAVITY SQUAMOUS CELL CARCINOMAS Guy ANDRY, M.D. Dept of Surgery Institut Jules Bordet, U.L.B. Statements 2008 on Head and Neck Cancer Frankfurt, 1st & 2nd February 2008 5 Years Survival and Cause Specific Survival % LIP ORAL CAVITY S CSS S CSS St I 73 83 60 68 St II 64 73 46 53 St III 56 62 36 41 St IV 41 47 23 27 ∆ 15 20 After SEER database LIP CANCER The most common primary (~ 25 % of oral cavity cancer) ~ 12/100.000 habitants per year USA & Europe Solar-radiation, tobacco smoking, HPV, immunosuppression LIP CANCER SURGERY IS FIRST CHOICE < 2/3 invasion : – full-thickness pedicled flaps (Abbe or Estlander) > 2/3 invasion : – musculo mucosalflaps (Camille Bernard…) – free flaps – frontal flap → irradiation in debilitated PTS LIP CANCER PROGNOSTIC FACTORS Maximum tumor thickness (cf. MartinezGimeno Scoring System) Site (upper & commissure more rapid growth and preauricular, submandibular lymph node metastases) LIP CANCER Scoring system → probability of lymph node invasion Tumor thickness Martinez-Gimeno Scoring System T stage, Tumor thickness, microvascular, perineural invasion histologic grade of differentiation, presence of inflammatory infiltrate Group I : Group II : Group III : Group IV : 0 % of lymph node invasion 21 % 50 % 67 % LIP CANCER Mohs micrographic surgery has been successfully used – No tumor related deaths or metastases at 5 yrs – All PTS with recurrent disease were successfully salvaged LIP CANCER T1 T2 Surgery if + margins + lymph nodes Adjuvant radiation if recurrence local regional Radiation External beam Brachytherapy Salvage surgery or both 98 % local control 5 yrs LIP CANCER There are no published randomized trials on • the use of sequential surgery + radiation • the use of chemotherapy NB : one preliminary study on super selective intraarterial chemo (CDDP based) in six PTS with T1, T2 or local recurrence by Kishi & al, Radiology 213, 1999 FLOOR OF MOUTH CANCER High risk tumors (even in early stages) Proximity to the mandible – Adhesion or invasion (by the alveolar ridge) – Risk of radiation induced bone necrosis No mechanical barrier in soft tissues – Blurred vision of margins, Even with high resolution MRI Early lymph node metastases – 20 % of occult invasion in T1 – 62 % of occult invasion in T2 Will develop second primary tumors (~ 20 % in T1 – T2) “field cancerization” effect of carcinogens FLOOR OF MOUTH CANCER Surgery is generally preferred for T1 T2 (primary & necks) + radiation if margins are close or involved if lymph nodes are involved (CR) if mandible is invaded if perineural or/and vascular invasion (or chemo radiation) Role of sentinel node biopsy is under study FLOOR OF MOUTH CANCER Primary ERT Surgery S 5 yrs Control rate T1 95 % 90 % ← negative margins T2 86 % 62 % ← positive margins Control rate 90 % T1 77 % T2 Neck surgery when invasion depth ≥ 5 mm level I to III unilateral for lateral tumors bilateral for anterior/midline ORAL TONGUE CANCER T1 T2 SURGERY Partial glossectomy (negative margins > 1 cm) → thickness, depth invasion, perineural spread, vascular invasion Elective neck node dissection - T1 N+ 6 % T2 T3 T4 36 % 50 % 67 % N0 After Hickx WL. & al, Am J Otolaryngol 1998 Staging is crucial in defining the postsurgical treatment ERT + CHEMO ORAL TONGUE CANCER Role of elective neck dissection for T1 N0 ? No randomized Trial Retrospective studies remain controversial Yii (RoyalMarsden) REC 1999 S Haddadin (Canniesburn) 1998 S T1-2 N0 ELN TND 77 27 % 50 % (p.025) 75 % 65 % (NS) ELN TND 81 % 45 % (p.001) 5yrs 5yrs 137 But bias in the initial treatments (various types of surgery, RT or no RT to the primary and/or to the neck) ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERS Randomized trial T1-3 N0 DFS 5 yrs 39 ELND 36 observations 49 % N+ 47 % N+ : TND 13 % CR 25 % CR 57 % 60 % NS NB : 16 % of second primaries 45 % of deaths met caused by the original tumor After Vandenbrouck & al, Cancer 46 ; 1980 ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERS Randomized trial 30 hemiglossectomy + RND 10 N + 20 N- 40 hemiglossectomy 23 N+ ↓ 4 contralat + 47 % N+ DFS 57 % N+ 63 % N.S 52 % (T1 : 70 % ; T2 : 60 %) (T1 : 64 % ; T2 : 46 %) After Fakih & al, Am. J. Surg. 158; 1989 ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERS Randomized trial : effect of tumor depth in 51 PTS 21 Hemiglossectomy + ELN 9 (≥ 4 mm) 12 (< 4 mm) 30 hemiglossectomy 21 (≥ 4 mm) ↓ 9 (< 4 mm) ↓ ↓ ↓ 6 N+ (67 %) 1 N+ (8 %) 15 N+ (76 %) 2 N+ (22 %) S 43 % (p < 0.01) S 81 % After Fakih & al, Am. J. Surg. 158; 1989 LOWER ALVEOLAR RIDGE & RETROMOLAR TRIGONE T1-2 cancers SURGERY Wide local excision with marginal mandibulectomy - close proximity to bone - infiltration into the masticator space - nodal involvement RADIATION Adjuvant for close or positive margins for lymph node invasion OR if used as first modality UPPER ALVEOLAR RIDGE & HARD PALATE CANCERS SURGERY Resection of part of the palatine process → maxillectomy followed by flap reconstruction or prosthetic rehabilitation - St I (9) CSS 75 % St II (19) 46 % St III (14) 36 % St IV(20) 11 % * - neck dissection in Stage III RADIATION : alone or used for close margins, bulky & infiltrating tumors, nodal spread After Evans & Shah, Am J Surg 1981 BUCCAL MUCOSA CANCERS SURGERY transoral resection + check flaps + mandibular resection + free flaps + maxillectomy - Neck : advocated for T2 or invasion > 5 mm, muscle S 5yrs St I 78 % St II 66 % S 5yrs St III 62 % St IV 50 % * N0 necks : 70 % → rec rate if no END or RT : 25 % vs 10 % (p<.05) N+ necks : 49 % (no CR : 69 % vs +CR : 24 %) After Diaz & al, Head & Neck 2003 BUCCAL MUCOSA CANCERS (2) RADIATION : Used primarily for cure of T 1-2 → S3yrs : St I = 85 % ; St II = 63 % * Postop advocated for high risk - margins < 2 mm - perineural invasion - lymph node involvement After Nair & al, Cancer, 1988 CONCLUSIONS (1) Prognostic factors in oral cavity SCCA T size remains an «old timer» Depth of invasion is more informative – as are perineural spread vascular invasion N involvement is a state of emergency from prompt an multidisciplinary aggressive treatment CONCLUSIONS (2) No neck should not be a cause of debate on what is to be done in a randomized trial Depth of invasion of the primary Status of margins (close, involved, dysplasia,… molecular markers) Perineural spread Vascular invasion – Should be routinely reported and be the basis of planned treatment