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C e c e l i a E . S c h m a l b a c h , M D , M S , FA C S

A s s o c i a t e P r o f e s s o r

P r o g r a m D i r e c t o r

H e a d & N e c k - M i c r o v a s c u l a r S u r g e r y

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 CANCER

Sisson 2013

GOALS

• Oral Cavity Anatomy

• Staging• Elective ND

• Sentinel Lymph Node Biopsy

• Treatment• Surgery vs. XRT +/- Chemotherapy

• Managing the Neck

• Adjuvant therapy

• Tx of Lip Cancer

• Reconstruction

• Pearls

ORAL CAVITY SUBSITES

• 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%)

• 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-UPAssessing Bony Involvement

• Assessing mandible invasion:

• Bone Scan & MRI:

• High false positive rate

• CT & Panorex:

• Best for gross invasion

• High false negative rate

(cortical erosion)

Clinical Judgment

Most Important!

WORK-UPAssessing Regional Metastasis: PET

• N+ Neck:

• PET & CT scan are complementary

• N-Zero Neck:

• PET is NOT sensitive

• Not advocated for early disease

WORK-UPAssessing 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.• > 60 Clinical Trials

• Predictive value of (-) SLN: 90 – 100%

• Excellent safety record

• Ability to identify aberrant nodal drainage

WORK-UPAssessing 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-UPAssessing Regional Metastasis

• Low risk patients

• < 2cm (T1)

• Minimal depth of invasion (< 4mm)

• Favorable histology

• High risk patients

• Retrospective studies demonstrate decreased regional &

distant recurrence with ND • Yuen. Head Neck 1997;19:583

• Oreste. Head Neck 1996;18:566

• 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.

WHEN DO YOU PERFORM AN END?

• High incidence of occult nodal disease

• >20% risk

• Depth of invasion > 4mm

• Need for surgical violation of the neck

• Poor patient compliance

• Obese or muscular neck (difficult to follow clinically)

ORAL CAVITY SCCA:INCIDENCE OF OCCULT REGIONAL DISEASE

SITE OCCULT DZ

Oral Tongue 50-60%

Floor of Mouth 30%

Buccal Mucosa 27%

Lower Alveolar Ridge 19%

Hard Palate 10%

SPECIFIC ORAL CAVITY SUBSITES

• Hard Palate/Maxillary Alveolar Ridge• 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

I. Submental/

Submandibular

II. Upper Jugular Chain

III. Middle Jugular Chain

IV. Lower Jugular Chain

V. Posterior Triangle

VI. Anterior CompartmentTNM Staging of H&N Cancer and Neck Dissection

Classification. Online: entnet.org

T

N

M • M0: No Distant mets

• M1: + Distant mets

STAGING:

0: TisN0M0

I: T1N0M0

II: T2N0M0

III: T3N0M0

T1-3N1M0

IV: T4N0M0

T4N1M0

T1-4N1M0

M1

AJCC Staging, 7th Ed., 2010

T1: ≤ 2cm T2: >2cm, ≤ 4cm

T3: > 4cm T4a: Through bone,

Inferior alveolar n., FOM, Extrinsic

tongue musculature;

Maxillary sinusSkin of face

T4b: Masticator SpacePterygoid Plates

Skull baseEncasing ICA

N1: 1 node, ≤ 3cmN2a: ips node >3, ≤ 6

N2b: mult ips nodes, ≤ 6cm

N2c: Cont / Bilatnodes, ≤6

N3: > 6cm

EARLY STAGE ORAL CANCER: T1T1--2; N02; N0

PRIMARYPRIMARY

• Surgery (Preferred)

or XRT

• Neck Dissection• Based on tumor depth

• Reconstruction• Secondary intention

• Primary closure

• Split thickness skin graft

• Pectoralis Flap (bulky)

• Free flap

ADJUVANT XRTADJUVANT XRT

• 1+ LN (Optional)

ADJUVANT CHEMO/XRTADJUVANT CHEMO/XRT

• ECS +/- Positive Margin (Preferred)

• Adverse Features:

• T3/4

• N2/3

• + LN Level IV/V

• Perineural Invasion

• Vascular Embolism

ADVANCED STAGE ORAL CANCER: T3T3--4; ANY N+ (STAGE III & IV) 4; ANY N+ (STAGE III & IV)

SURGERYSURGERY

• Surgery Preferred

• Neck Dissection

• Based on tumor depth

• Reconstruction

• Secondary intention

• Primary closure

• Split thickness skin graft

• Pectoralis Flap (bulky)

• Free flap

MULTIMODALITY MULTIMODALITY

CLINICAL TRIALCLINICAL TRIAL

or

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LIP CANCER:Begins at vermilion border & includes that portion of the lip that comes into contact with

the opposing lip

• Males : Females (6:1)

• Age > 50 yrs

• Sun / Photo damage

• Outdoor occupation

• Lower Lip > Upper Lip

• SCCA > BCC

• verrucous SCC

• Spindle cell (SCC)

• Adenoid SCC

• BCC (skin CA!!)

• Melanoma

• Salivary gland CA

• Overall Good Prognosis (>90% at 5yrs if dx’ed in early stages)

LIP CANCER

• 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+

• Distant Metastasis

• Rare

• Usually in setting of uncontrolled

locoregional disease

EARLY STAGE LIP CANCER: T1T1--2; N02; N0

PRIMARYPRIMARY

• Surgery (Preferred)

• Neck Dissection

• NOT recommended

or

• XRT to primary tumor• Large, superficial cancer

involving entire lip

ADJUVANT XRTADJUVANT XRT

• Positive margin

• Perineural invasion

• Vascular embolism

• Lymphatic invasion

ADVANCED STAGE LIP CANCER: T3T3--4; ANY N+ (STAGE III & IV) 4; ANY N+ (STAGE III & IV)

SURGERYSURGERY

• Surgery Preferred

• Neck Dissection

• Reconstruction

• Primary

• Local Flap

• Free flap

• RFFF

• Gracilus

• Adjuvant XRT

Primary Radiation +/Primary Radiation +/--ChemotherapyChemotherapy

or • Poor surgical candidate

• Unresectable disease

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FOM Recon:

Pectoralis Major Flap

• Must prevent

tethering

• FOM and tongue 2

separate subunits

• Vascularized

Tissue

• RFFF

• ALT (thin pt)

ORAL CAVITY ORAL CAVITY

RECON.RECON.

Tongue Recon:

Primary Closure

Radial Forearm Free

Flap

• Must prevent

tethering

• FOM and tongue 2

separate subunits

• Vascularized

Tissue

• RFFF

• ALT (thin pt)

ORAL CAVITY ORAL CAVITY RECON.RECON.

• Midline

• Defect < ½ lip

width

• Bilateral

advancement

flaps

LIP LIP

RECONSTRUCTIONRECONSTRUCTION

• Near total loss of

lip

• Full-thickness

pedicled flap

• Nasolabial fold

• Neurovascular

pedicle intact

• Microstomia

KARAPANDZICKARAPANDZIC

FLAPFLAP

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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 ???