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    Surgical options for the treatment of oral cancer

    .

    Chairman Dept. of Maxillofacial / Head and Neck Surgery

    ,

    Athens Greece

    Surgery has traditionallybeen the treatment of

    choice of squamouscell carcinoma of the

    oral mucosa.

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    Contemporary

    oncological surgery ispart of a

    multidisciplinarytherapeutic team thatprovides treatment for

    head and neck

    malignancies.

    Surgical treatment of early (Stage I and II) disease

    Surgery remains the mainstay oftreatment for early (Stage I and II)

    squamous an non-squamouscarcinomas of the oral cavity

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    Tongue CarcinomasPrimar A roaches

    -

    Local excision and skin grafting

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    Local excision and neck dissection

    Local excision and neck dissection

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    Local excision, neck dissection and grafting

    Local excision, neck dissection and grafting

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    Local excision, neck dissection and grafting

    Local excision, neck dissection and grafting

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    Marginal resection

    Marginal resection

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    General principles regarding management of early oral cavity stage diseases

    , ,

    Frozen section analysis of all margins First surgery should be the best and only surgery

    Initial biopsy should be limited and not sutured

    Elective management of the neck utilized forinvasive carcinomas of the ton ue and floor ofmouth and other sites when ultrasound, FNA or

    CT evidence su est l m h node involvement

    Early Stage Oral Cavity Indications for Post Operative Adjunctive Treatment

    Radiation Therapy Only When

    Positive margins (note: radiotherapy is not a

    Multiple positive nodes Multiple levels of lymph node metastases

    Concomitant Chemoradiotherapy-Intensification

    Extracapsular lymph node extension

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    disease

    UICC/AJCC Staging for advanced oral cavity cancer

    T3-4, any N

    T3 > 4cm T4a invasion of ad acent structures cortical

    bone, deep tongue muscles, maxillarysinus, skin

    T4b unresectable invasion of masticator, , ,

    carotid encasement

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    UICC/AJCC Staging for advanced oral cavity cancer

    Regionally advanced

    T1-T2 N2-3

    metastases, one or more contralateral cervical

    ,

    Primary surgery + radiation indicated for advanced oral cavity cancer:

    advanced oral cavity (30-40%) and poor survival

    Increased local control with surgery +

    Zelefsky et al, Head Neck. 1990 Nov-Dec;12(6):470-5

    Local control significantly improved for locallyadvanced T3, T4 oral cancers using surgery +pos opera ve ra o erapy vs. pr mary Fein et al. Head Neck. 1994 Jul-Aug;16(4):358-65

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    Therapeutic management of advanced oral cavity cancer

    radiotherapy +/- chemotherapy

    eligible patients with good performance status Multi le nodes ECS

    Positive margins, neural/vascular invasion

    T3 or greater, N2 or greater

    Oral/Oropharyngeal sites with level IV,V disease

    Novel molecular directed therapies incorporatedinto next generation trials

    The role of reconstruction in advanced cancer of the oral cavity

    Without rec onstruc tion trea tment may be asc r pp ng as e sea se se

    Allows more rad ic a l surgery and rad iotherapy

    Breathing

    Swa llowing

    Speec h

    mproves qua y o e n pa en s w owere eexpectancy

    Allows a tient to soc ia ll re-inte ra te

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    The evolution of reconstructive surgery in the head and neck region

    Tube Pedicles1960s

    D.P. Flap1965 - 1975

    P.M.M.C. Flap1978 - 1990

    Free Flaps Fibula

    1990 - 2007

    Radial forearm

    Lateral thigh Rectus abdominis Latissimus Dorsi

    to p lastic surgery can be ap tly

    c ompared to the a dvent of avia tion

    arry . unceClinical Professor of Sur er Universit of

    California, San Francisco

    July 16, 1922 - May 18, 2008

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    Microsurgical free tissue transfer

    More than 20free fla donor sites have been described for the head and neck

    Reconstructive guidelinesReconstructive guidelines

    FreeFree--tissue transfer is a successful methodtissue transfer is a successful methodfor repairing oral cavity defects and is safe evenfor repairing oral cavity defects and is safe evenin previously irradiated areasin previously irradiated areas

    Most of the defects needing microsurgicalMost of the defects needing microsurgicalreconstruction can be successfull rehabilitatedreconstruction can be successfull rehabilitatedusing one of five major freeusing one of five major free--flap donor sitesflap donor sites

    Microvascular success is very high (aboveMicrovascular success is very high (above95%) due to the vast experience gained over the95%) due to the vast experience gained over theyearsyears

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    Free flaps used for head and neck reconstruction in the

    1. soft tissues

    ra a orearm, rec us a om n s, a ss mus ors

    2. hard tissuesmandibular reconstruction fibula, composite radial forearm

    maxillary reconstruction composite radial forearm, scapula, rectus abdominis

    Tongue CarcinomasPrimar A roaches

    Trans-oral

    Mandibulotom

    -

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    Tongue CarcinomasPrimar A roaches

    Trans-oral

    Mandibulotom

    -

    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

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    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

    Shah JP 2003

    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

    Shah JP 2003

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    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

    Shah JP 2003

    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

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    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

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    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

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    Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

    Reconstruction of soft tissues of the head and neck

    Hemiglossectomy: radial forearm

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    Reconstruction of soft tissues of the head and neck

    Hemiglossectomy: radial forearm

    Reconstruction of soft tissues of the head and neck

    Hemiglossectomy: radial forearm

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    Tongue CarcinomasPrimar A roaches

    -

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Shah JP 2003

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

    Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap

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    Surgical Approaches

    Transoral and Visor Approaches

    Cosmetic but ma limit ex osure

    Lip Splitting

    o est cosmet c sa vantage w t exce entposterior exposure for mandibulotomy

    Paramedian or midline mandibulotomy

    reconstructiveoptions

    1. Combination of soft tissuefree flaps and alloplasticmaterials

    Lack ofLack of bonebonereconstruction roblems durin RTRT

    2. Combination of freefreeand regional pedicledregional pedicledflaps

    Insufficient regionalregionalflap versatility

    na y o recons ruc aw e ec s

    3.3. DualDualfree flap transfer

    ProlongationProlongationof operation time

    Need of two pairstwo pairsof anastomoses

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    ,

    control of disease or survival of patients with either

    It is clear that advances in the management of oralcavity carcinomas require the development of definedmolecular biologic, cellular and or humoral predictors

    which provide biologic predictive assays and

    mechanisms for novel targeted therapy

    Rules and guidelines regarding the role of surgery in themanagement of squamous cell carcinoma of the oral cavity

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    Surgical treatment ofcarcinoma of the oral cavit :

    Is there any basic rule we must follow?

    There is only one rule.

    The rule is there is no rule. Each and everypatient should be treated individually to his

    particular disease profile using all therapeuticoptions and treatment should follow the

    guidelines set for him by the combinedoncological team.

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    Second World Con ress of the

    International Academy of Oral Oncology

    IAOO

    July 8 11, 2009

    Sheraton Centre Toronto