C e c e l i a E. S c h m a l b a c h, M D, M S, F A C S Associat e Prof essor Program Direct or Head & Neck- Microvascul ar Surgery 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 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 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 1
Assessing Bony Involvement Assessing Regional Metastasis: PET Assessing mandible invasion: Bone Scan & MRI: High false positive rate CT & Panorex: Best for gross invasion High false negative rate (cortical erosion) N+ Neck: PET & CT scan are complementary N-Zero Neck: PET is NOT sensitive Not advocated for early disease Clinical Judgment Most Important! Assessing 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 Assessing 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 2
Assessing Regional Metastasis WHEN DO YOU PERFORM AN END? 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. 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 SPECIFIC ORAL CAVITY SUBSITES SITE OCCULT DZ Oral Tongue 50-60% Floor of Mouth 30% Buccal Mucosa 27% Lower Alveolar Ridge 19% Hard Palate 10% 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 3
TNM Staging of H&N Cancer and Neck Dissection Classification. Online: entnet.org OC SCC: SND (I III) CERVICAL LEVELS I. Submental/ Submandibular II. III. IV. Upper Jugular Chain Middle Jugular Chain Lower Jugular Chain V. Posterior Triangle VI. Anterior Compartment STAGING: 0: TisN0M0 I: T1N0M0 II: T2N0M0 III: T3N0M0 T1-3N1M0 IV: T4N0M0 T4N1M0 T1-4N1M0 M1 AJCC Staging, 7 th Ed., 2010 T M N T1: 2cm T2: >2cm, 4cm T3: > 4cm T4a: Through bone, Inferior alveolar n., FOM, Extrinsic tongue musculature; Maxillary sinus Skin of face T4b: Masticator Space Pterygoid Plates Skull base Encasing ICA N1: 1 node, 3cm N2a: ips node >3, 6 N2b: mult ips nodes, 6cm N2c: Cont / Bilat nodes, 6 N3: > 6cm M0: No Distant mets M1: + Distant mets EARLY STAGE ORAL CANCER: T1-2; N0 ADVANCED STAGE ORAL CANCER: T3-4; ANY N+ (STAGE III & IV) PRIMARY Surgery (Preferred) or XRT Based on tumor depth Secondary intention Primary closure Split thickness skin graft Pectoralis Flap (bulky) Free flap ADJUVANT XRT 1+ LN (Optional) ADJUVANT CHEMO/XRT ECS +/- Positive Margin (Preferred) Adverse Features: T3/4 N2/3 + LN Level IV/V Perineural Invasion Vascular Embolism SURGERY Surgery Preferred Based on tumor depth Secondary intention Primary closure Split thickness skin graft Pectoralis Flap (bulky) Free flap or MULTIMODALITY CLINICAL TRIAL 4
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: T1-2; N0 ADVANCED STAGE LIP CANCER: T3-4; ANY N+ (STAGE III & IV) PRIMARY Surgery (Preferred) NOT recommended or XRT to primary tumor Large, superficial cancer involving entire lip ADJUVANT XRT Positive margin Perineural invasion Vascular embolism Lymphatic invasion SURGERY Surgery Preferred Primary Local Flap Free flap RFFF Gracilus Adjuvant XRT or Primary Radiation +/- Chemotherapy Poor surgical candidate Unresectable disease 5
ORAL CAVITY RECON. Must prevent tethering FOM and tongue 2 separate subunits Vascularized Tissue RFFF ALT (thin pt) Tongue Recon: Primary Closure ORAL CAVITY RECON. Must prevent tethering FOM and tongue 2 separate subunits Vascularized Tissue RFFF ALT (thin pt) FOM Recon: Pectoralis Major Flap Radial Forearm Free Flap LIP RECONSTRUCTION Midline Defect < ½ lip width Bilateral advancement flaps KARAPANDZIC FLAP Near total loss of lip Full-thickness pedicled flap Nasolabial fold Neurovascular pedicle intact Microstomia 6
ORAL CAVITY SCC PEARLS LIP CANCER 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. 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??? 7