Download Module 8: Treatment Options - Institute for Health Research and Policy

Module 7:
Treatment Options
Surgery and/or Radiation
• Treatment usually involves surgery or
radiation or both
• Chemotherapy primarily used as an
adjunctive procedure in advanced cases
• Advanced lesions < 30% 5-year survival
rate
• 9 - 25% of patients develop additional
mouth or throat cancer
Treatment
• Oropharyngeal lesions: radiation therapy
• Lip lesions: surgically excised
• Tongue lesions: hemiglossectomy; then
radiation
• Alveolar ridge cancer: segmental resection
• Metastasis to local lymph nodes: radical or
modified radical neck dissection
Considerations Regarding
Treatment Options
• The oral cavity is a complex structure
composed of muscles, nerves, jaws,
tongue and lubricated by the salivary
glands.
• Rehabilitation must be considered prior to
surgical or radiographical intervention.
Quality of Life Issues
• Nutrition
• Speech
• Appearance
• All functions must be addressed in
treatment planning
Surgery
• Type depends upon the extent and
location of cancer
• Wide local excision: soft tissue
• Resection: invaded bone
• Marginal resection: inferior border of
mandible intact
Surgery
• Segmental resection: full height of
mandible removed
• Composite resection: hard and soft
tissue (nodes, mandible, and soft
tissues--tongue or floor of the mouth)
Wide Local Excision
Silverman, 2003
Squamous Cell Carcinoma / Reconstruction
Silverman, 2003:98,100
Squamous Cell
Carcinoma (SCC)
SCC of anterior
maxillary gingiva
and bone
One month
post-surgical
Silverman, 2003
Neck Dissections
• Comprehensive neck dissections
include radical neck dissection and
modified neck dissection.
• Radical neck dissection removes
lymph nodes of the neck, the
sternocleidomastoid muscle, the internal
jugular vein, and the spinal accessory
nerve.
Neck Dissections
• Modified neck dissection preserves the
sternocleidomastoid muscle or internal
jugular vein, or the spinal accessory
nerve.
• Selective neck dissections remove
lymph nodes only, preserving the
sternocleidomastoid muscle, the internal
jugular vein, and the spinal accessory
nerve.
Radiation Therapy
• Radiation therapy is indicated following surgery if:
– soft tissue margin positive
– one or more lymph nodes exhibit extracapsular
invasion
– bone invasion present
– more than one lymph node positive in the absence
of extracapsular invasion
– comorbid immunosuppressive disease present, or
– perineural invasion occurred
Radiation Therapy
• CT and/or MRI scan, PET scanning
• Dental panoramic
Radiation Therapy
• Dental consult
• Extractions prior to beginning
• Fluoride
• Meticulous oral hygiene
• Osteoradionecrosis
Types of Radiation Therapy
• (EBRT) primary external-beam
radiotherapy
• (IMRT) intensity-modulated radiotherapy
• (ISRT) brachytherapy or interstitial
radiotherapy
Radiation Therapy
Squamous cell carcinoma
Silverman, 2003
One month postradiotherapy
Radiation Therapy
Silverman, 2003
Brachytherapy
Silverman, 2003:105
Chemotherapy
• Chemotherapy was primarily used as a
palliative measure until fairly recently. It
was typically administered before, during
or after radiotherapy or surgery
– neoadjuvant (before irradiation)
– concurrent (during irradiation)
– adjuvant (after irradiation)
Chemotherapy
• Several drugs currently being used include:
–
–
–
–
–
Paclitaxel (Taxol, Bristol-Myers Squibb)
Methotrexate
Bleomycin
Cisplatin
5-Fluorouracil
• Other research includes the use of:
– Intraarterial chemotherapy
– Intralesional chemotherapy
Care Prior to Cancer Therapy
• Comprehensive oral examination
• Understand cancer
diagnosis/location/stage/planned
treatment (prognosis, chemotherapy??,
radiation field)
• Stabilize/resolve oral disease and institute
preventive program
Care Prior to Cancer Therapy
Goal:
• Eliminate dental disease that cannot be
maintained lifelong in radiated field or that may
cause infection of become symptomatic during
chemotherapy
• High dose radiation therapy causes
PERMANENT change in vascularity, cellularity
of soft tissue, salivary gland and bone
• Chemotherapy causes reversible changes,
highest risk if caused neutropenia
Telangiectasia and
Mucosal Fibrosis
Silverman, 2003: 115
Care Prior to Cancer Therapy
• Oral Disease Status
–
–
–
–
–
–
–
–
–
–
Mucosal and periodontal health
Caries risk
Unerupted/impacted teeth
Root tips
Endodontic lesions
Past dental disease: caries / restorations / endo
Dental prostheses: condition / fit / function
Salivary function
Temporomandibular function
Oral hygiene effectiveness / patient motivation
Care Prior to Cancer Therapy
• At risk teeth in radiation field
– Periodontal status (pockets > 5 mm,
advanced attachment loss
– Caries / restoration status
– Partially erupted third molars
– Endodontic lesions
Goal: 1 – 2 weeks healing prior to radiation
Atraumatic extraction with primary closure,
no dressing in socket
Care Prior to Cancer Therapy
• Dental extractions of symptomatic teeth
due to infection, if sufficient time for
healing of extraction site prior to
neutropenia; if insufficient healing time,
cover with antibiotics
• Dental extractions considered if required
between courses of multi-course
chemotherapy, at time of count recovery
Care Prior to Cancer Therapy
•
Preventive Program:
1. Gingival health: oral hygiene, chlorhexidine
2. Caries risk: oral hygiene, diet, fluoride carriers,
chlorhexidine, saliva function
3. Mucosal health: mucositis preventive program
4. Mucosal infection: antifungal, oral hygiene
5. Saliva: sialogogue, mucolytic, mouth wetting
6. Lip lubrication
7. Reinforce tobacco / alcohol cessation
Oral Care During Cancer Therapy
• Mucositis: preventive program, pain
management, diet instruction
• Oral hygiene
• Caries prevention
• Saliva management
• Lip lubrication
• Manage dental emergencies
• Manage oral mucosal infections
• Range of motion exercises for radiation patients
• Reinforce tobacco / alcohol cessation
Complications from Radiation
•
•
•
•
•
•
•
•
•
•
•
•
Pain; neuropathy
Xerostomia: low flow rate, thick consistency
Loss of taste
Cervical caries
Epithelial atrophy
Fibrosis of soft tissue and muscles
Focal alopecia
Focal hyperpigmentation
Osteroradionecrosis
Telangiectasias
Dental prostheses fit / function
Esthetic, speech concerns
Complications
Acute mucositis 5th week after
radiation for base of the tongue
squamous cell carcinoma
Silverman, 2003: 114, 119
Oral candidiasis in a patient with
marked xerostomia
Mucositis Management
• Treatment of mucositis:
– Symptomatic management: topical
analgesics; systemic analgesics
– Nutritional support
– Developing therapies: cytokines/growth
factors
Management of Hyposalivation
• Fluid intake, sugar free gum / candy
• Sialogogues:
– Salagen
– Evoxac
– Bethanechol
– Sialor
• Caries prevention
• Symptomatic (mouth wetting agents)
Oropharyngeal / Head / Neck Pain
•
•
•
•
•
•
•
Treat cause when possible
Topical analgesics / anesthetics
Systemic analgesics
Adjunctive medications (e.g. tricyclics)
Muscle relaxants (myogenic pain)
Physiotherapy (TMD, neck pain)
Oral prostheses (TMD)
Follow-up of Cancer Patients
• Thorough head and neck and oral exam
• Salivary function, caries, demineralization
risk, denture fit / function, oral hygiene,
diet, mucosal condition, cancer risk
• Tobacco / alcohol cessation
• Risk of osteonecrosis with H&N RT;
myelosuppression/immunosuppression
• Know medical therapy, prognosis, change
in risk factors prior to treatment planning
Osteonecrosis
Two years after radiotherapy
Silverman, 2003:121
Three years after radiotherapy
Care Following Radiation Therapy
• Osteonecrosis:
– Prevention:
•
•
•
•
Pretreatment oral care
Cancer therapy
Amputation of crown, endodontics
Atraumatic extraction if needed
– Therapy:
• Hyperbaric oxygen, trental, Vitamin E
• Surgery – vascularized flaps
Complications
• National Institutes for Dental and
Craniofacial Research (NIDCR) offers
excellent free materials for patients
• Ordering information included in
Resources section
Reconstruction
• Various methods of reconstruction follow surgery
• Deltopectoral flaps and pectoralis major
muocutaneous flaps
• Bone and soft tissue grafts
provide good cosmetic
appearance and function
• Osseointegrated implants
and dentures
• The fibula can be used to
reconstruct the mandible
Reconstruction
Silverman, 2003: 147
Reconstruction
Silverman 2003:146
Summary
• Early detection of lesions is critical to allow
conservative treatment and protect the patient’s
quality of life.
• Many avenues are available to treat oral
cancers, with improved methods constantly
under investigation.
• A multidisciplinary team can help oral cancer
patients deal with the aftermath of treatment.