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Dr Sapna Nangia Chief Radiation Oncologist International Oncology Centre Fortis Hospital Noida Adjuvant Therapy Of Oral Cancers
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Page 1: Adjuvant Therapy Of Oral Cancers

Dr Sapna Nangia

Chief Radiation Oncologist

International Oncology Centre

Fortis Hospital

Noida

Adjuvant Therapy Of Oral Cancers

Page 2: Adjuvant Therapy Of Oral Cancers
Page 3: 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

Page 4: Adjuvant Therapy Of Oral Cancers

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

Page 5: Adjuvant Therapy Of Oral Cancers

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

Page 6: Adjuvant Therapy Of Oral Cancers

Buccal Mucosa, Alveolar &

Retromolar Trigone Lesions

Page 7: Adjuvant Therapy Of Oral Cancers

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

Page 8: Adjuvant Therapy Of Oral Cancers

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

Page 9: Adjuvant Therapy Of Oral Cancers

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

Page 10: Adjuvant Therapy Of Oral Cancers

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

Page 11: Adjuvant Therapy Of Oral Cancers

Buccal Mucosa, Alveolar and Retromolar Trigone

Lesions

MDSCC Rt Gingivum

Bone Involvement Present

Margins & Lymph Nodes

Free

Page 12: Adjuvant Therapy Of Oral Cancers

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

Page 13: Adjuvant Therapy Of Oral Cancers

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

Page 14: Adjuvant Therapy Of Oral Cancers

Buccal Mucosa, Alveolar and Retromolar Trigone

Lesions – The Contralateral Neck

Page 15: Adjuvant Therapy Of Oral Cancers

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

Page 16: Adjuvant Therapy Of Oral Cancers

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

Page 17: Adjuvant Therapy Of Oral Cancers

Buccal Mucosa, Alveolar and Retromolar

Trigone Lesions

Ca Left RMT, post WLE

marginal mandibulectomy,

Margin Positive,

2/26involved, ECE Nil,

Bone free

Page 18: Adjuvant Therapy Of Oral Cancers

Oral Tongue

Page 19: Adjuvant Therapy Of Oral Cancers

Oral Tongue: Indications of post operative

radiotherapy

T3 T4 tumours ? T2

Positive nodes

Extracapsular involvement

Close or positive margins

Lymphovascular space involvement

Perineural spread

Page 20: Adjuvant Therapy Of Oral Cancers

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

Page 21: Adjuvant Therapy Of Oral Cancers

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

Page 22: Adjuvant Therapy Of Oral Cancers

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

Page 23: Adjuvant Therapy Of Oral Cancers

Oral Tongue – Local Radiation Alone, In Very Select Situations.

May Use Brachy therapy Instead

Page 24: Adjuvant Therapy Of Oral Cancers

Oral Tongue – Dose Painting with Neck

Irradiation

Ca left lat border tongue,

1.5cm, all margins free,

LVSI +, PNI +, 2/26 Lymph

Nodes Positive

Page 25: Adjuvant Therapy Of Oral Cancers

Oral Tongue – Dose Painting with Neck

Irradiation

Ca left lat border tongue,

1.5cm, all margins free,

LVSI +, PNI +, 2/26

Lymph Nodes Positive

Page 26: Adjuvant Therapy Of Oral Cancers

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

Page 27: Adjuvant Therapy Of Oral Cancers

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

Page 28: Adjuvant Therapy Of Oral Cancers

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

Page 29: Adjuvant Therapy Of Oral Cancers

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.

Page 30: Adjuvant Therapy Of Oral Cancers

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

Page 31: Adjuvant Therapy Of Oral Cancers
Page 32: Adjuvant Therapy Of Oral Cancers

Special Thanks to Dr Anchal Agarwal