Dr Sapna Nangia Chief Radiation Oncologist International Oncology Centre Fortis Hospital Noida Adjuvant Therapy Of Oral Cancers
May 26, 2015
Dr Sapna Nangia
Chief Radiation Oncologist
International Oncology Centre
Fortis Hospital
Noida
Adjuvant Therapy Of Oral Cancers
Oral Cavity Subsites : Adjacent But Disparate
4.70%
0.70%
0.30%
0.90%
4.30%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
Relative Proportion
Tongue
FOM
LIP
Gingivum
Others ( Buccal, RMT,palate)
Number of Incident Cancers by Five Year Age Group and Site Males, Chennai
National Cancer Registry
Factors That Determine Adjuvant Treatment
Adequacy of Surgery
Margin
Lymph nodes dissected
Gross & microscopic characteristics of the primary
lesion
Gross & microscopic characteristics of dissected lymph
nodes
Patterns of spread
Frequency and pattern of lymph node involvement
Factors That Determine Adjuvant Treatment
Patterns of spread
Frequency and pattern of lymph node involvement
Site
Size
Location, especially with relation to midline
Histomorphological features , endophytic vs exophytic,
tumour thickness, differentiation
Buccal Mucosa, Alveolar &
Retromolar Trigone Lesions
Buccal Mucosa , Alveolar, and Retromolar Trigone
Lesions
Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
Alveolar and retromolar trigone lesions
involve bone early;
Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
INTRATEMPORAL FOSSA
Buccal Mucosa , Alveolar, and Retromolar Trigone
Lesions
Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
Alveolar and retromolar trigone lesions
involve bone early;
Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
INTRATEMPORAL FOSSA
Buccal Mucosa , Alveolar, and Retromolar Trigone
Lesions
Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
Alveolar and retromolar trigone lesions
involve bone early;
Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
INTRATEMPORAL FOSSA
Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions
Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
Alveolar and retromolar trigone lesions
involve bone early;
Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
INTRATEMPORAL FOSSA
Yao et al IJROBP 2007
55 pts, oral cancer alone. Mostly
postoperative IMRT
2/9 locoregional failures in the
infratemporal fossa
Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions
MDSCC Rt Gingivum
Bone Involvement Present
Margins & Lymph Nodes
Free
Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – Lymph Node Involvement in N0 neck
Level I Level II Level III Level IV Level V
Buccal
Mucosa
44 11 0 0 0
Alveolus 27 21 6 4 2
Retro Molar
Trigone
19 12 6 6 0
Gregoire, R O 2000, 56, 135 A minimum ?? nodes must be removed in an adequate SOND
Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – Lymph Node Involvement in N+ neck
Level I Level II Level III Level IV Level V
Buccal
Mucosa
82 42 65 65 0
Alveolus 54 46 19 17 4
Retro Molar
Trigone
50 60 40 20 0
Gregoire, R O 2000, 56, 135
Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – The Contralateral Neck
Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – The Contralateral Neck
145 patients
77% had Stage III – IV disease
120 patients ( 83%) received
unilateral radiotherapy
CCRT for ECS, N2 disease and
positive margin
3/120 failures in contralateral neck
Author’ conclusion : Do not treat
contralateral neck for buccal
mucosa lesions
However
Unilateral RT Bilateral RT
N2 38 pts 15 pts
ECE 84 pts 11 pts
Conclusion : Do not treat contralateral neck routinely, except in lesions close to midline . Evidence
unclear for N2 neck
Buccal Mucosa, Alveolar and Retromolar
Trigone Lesions – a Summary
Indications Doses
T3, T4, Some T2
Bone involvement
Skin involvement
Close or positive margins
Inadequate neck dissection
Positive neck nodes
Lymphovascular space involvement
Perineural Spread
Extracapsular spread
66Gy /33/fx for positive margins,
ECE.
60 Gy/30 fx for primary and involved
lymph node levels.
50Gy/ 25fx – 60 Gy/30 fx for
elective nodal irradiation.
ChemoRT for positive margins / ECE
Consider for T3, 4, LVSI, PNI, N2+,
Level IV, V disease
Buccal Mucosa, Alveolar and Retromolar
Trigone Lesions
Ca Left RMT, post WLE
marginal mandibulectomy,
Margin Positive,
2/26involved, ECE Nil,
Bone free
Oral Tongue
Oral Tongue: Indications of post operative
radiotherapy
T3 T4 tumours ? T2
Positive nodes
Extracapsular involvement
Close or positive margins
Lymphovascular space involvement
Perineural spread
Oral Tongue- Lymph Node Involvement in N0 &
N+ neck
Level I LevelII Level III LevelIV Level V
BuccalMucosa 44 11 0 0 0
Oral Tongue
N0
14 19 16 3 0
Oral Tongue N1 32 50 40 20 0
Gregoire, R O 2000, 56, 135
Oral Tongue : Impact of Tumour Type on
Lymph Node Involvement
0%
10%
20%
30%
40%
50%
60%
70%
Exophytic/Nodular
Superficial Ulcerative/Invasive
35%
20%
62%
LN Involvement
LN Involvement
Oral Tongue – When can nodal irradiation
be avoided
< 8mm ( Matsuura) ,< 5 mm( O Charoenrat), < 4 cm (
Fakih) < 2 mm ( Spiro)
Adequate nodal dissection that includes Level IV lymph
nodes and pathologically negative
0
10
20
30
40
50
60
All T2N1 FOM
41.4 37.9
17.7
51.2 52.3
39.9
Surgery
Surgery + RT
OS
Shrime et al cta Otolary Head
Neck Surg 2010
Retrospectiev analysis of 1539 pts
with T1,T2,N1 disease
Oral Tongue – Local Radiation Alone, In Very Select Situations.
May Use Brachy therapy Instead
Oral Tongue – Dose Painting with Neck
Irradiation
Ca left lat border tongue,
1.5cm, all margins free,
LVSI +, PNI +, 2/26 Lymph
Nodes Positive
Oral Tongue – Dose Painting with Neck
Irradiation
Ca left lat border tongue,
1.5cm, all margins free,
LVSI +, PNI +, 2/26
Lymph Nodes Positive
Oral Tongue – When to Irradiate The
Contralateral Neck
Fakih et al ( 1989) Contralateral failure higher in patients
who have undergone neck dissection along with surgery.
Kowalski ( 1999) Tumours >4 cm in size, poorly
differentiated, ipsilateral positive nodes and floor of mouth
involvement have contralateral spread
Bier Lanning et al( 2009) Treat the contralateral neck if
thickness of primary > 3.75mm
Lip
Lymph Node Involvement lower than other oral cavity
sites
Avoid elective lymph node irradiation in T1 T2 lesions
Include facial and preauricular nodes for upper lip
lesions
Perineural spread an issue in advanced tumours
Status of chemoradiotherapy
EORTC 22931 Both RTOG 9501
Stage III & IV disease
Positive Level IV /V
lymph nodes in Oc/Op
primaries
Vascular embolisation
Perineural spread
ECE
Surgical margins
involved
Two or more positive
nodes
Bernier & Cooper, The Oncologist
Stauts of chemoradiotherapy
0%
10%
20%
30%
40%
50%
60%
DFS OS LRF
36% 40%
31%
47%
53%
17%
RT
ChemoRT
EORTC trial. ( RTOG trial : No impact on OS, differnence in no. of N2,3 and margin +ve patients )
Early reactions higher, other parameters : No significant impact.
Mandibular health in the era of IMRT ( & ? Improved dental prophylaxis)
Ben David et al ( IJROBP 68(2) 396
176 patients, 50 % receiving > 70 Gy to > 1 % of
mandible
Sharp dose gradient across mandible ( average 11 Gy)
Strict protocol based dental prophylaxis
No osteoradionecrosis at a median of 34 months
Special Thanks to Dr Anchal Agarwal