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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


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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


Trans-oral

Mandibulotom

-

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Trans-oral

Mandibulotom

-

Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm

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Shah JP 2003


Shah JP 2003

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Shah JP 2003


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Reconstruction of soft tissues of the head and neck

Hemiglossectomy: radial forearm

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-

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

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Shah JP 2003

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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

greco 2009

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