lip and oral cavity squamous cell carcinomas guy andry, m.d. dept of surgery institut jules bordet,...
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LIP AND ORAL CAVITYLIP AND ORAL CAVITYSQUAMOUS CELL SQUAMOUS CELL
CARCINOMASCARCINOMASGuy ANDRY, M.D.Guy ANDRY, M.D.
Dept of SurgeryDept of Surgery
Institut Jules Bordet, U.L.B.Institut Jules Bordet, U.L.B.
Statements 2008 on Head and Neck CancerFrankfurt, 1st & 2nd February 2008
5 Years Survival and Cause Specific 5 Years Survival and Cause Specific Survival %Survival %
LIPLIP ORAL CAVITYORAL CAVITY ∆ ∆
SS CSSCSS SS CSSCSS
St ISt I 7373 8383 6060 6868 1515
St IISt II 6464 7373 4646 5353
St IIISt III 5656 6262 3636 4141 2020
St IVSt IV 4141 4747 2323 2727
After SEER database
LIP LIP CANCERCANCER
The most common primary (~ 25 % of oral The most common primary (~ 25 % of oral cavity cancer)cavity cancer)
~ 12/100.000 habitants per year USA & ~ 12/100.000 habitants per year USA & EuropeEurope
Solar-radiation, tobacco smoking, HPV, Solar-radiation, tobacco smoking, HPV, immunosuppressionimmunosuppression
LIP CANCERLIP CANCERSURGERY IS FIRST SURGERY IS FIRST
CHOICECHOICE
< 2/3 invasion :< 2/3 invasion :–full-thickness pedicled flaps (Abbe or full-thickness pedicled flaps (Abbe or
Estlander)Estlander)
> 2/3 invasion :> 2/3 invasion :–musculo mucosalflaps (Camille Bernard…)musculo mucosalflaps (Camille Bernard…)–free flapsfree flaps–frontal flapfrontal flap
→→ irradiation in debilitated PTSirradiation in debilitated PTS
LIP CANCERLIP CANCERPROGNOSTIC FACTORSPROGNOSTIC FACTORS
Maximum tumor thickness (cf. Martinez-Maximum tumor thickness (cf. Martinez-Gimeno Scoring System)Gimeno Scoring System)
Site (upper & commissure more rapid Site (upper & commissure more rapid growth and preauricular, submandibular growth and preauricular, submandibular lymph node metastases)lymph node metastases)
LIP LIP CANCERCANCER
Scoring system Scoring system → probability of lymph node → probability of lymph node invasioninvasion
Tumor thicknessTumor thickness Martinez-Gimeno Scoring SystemMartinez-Gimeno Scoring System
T stage, T stage, Tumor thicknessTumor thickness, microvascular, perineural invasion, microvascular, perineural invasion
histologic grade of differentiation, presence of inflammatory infiltratehistologic grade of differentiation, presence of inflammatory infiltrate
Group I : Group I : 0 %0 % of of lymph node invasionlymph node invasion
Group II :Group II : 21 %21 %
Group III :Group III : 50 %50 %
Group IV :Group IV : 67 %67 %
LIP CANCERLIP CANCER
Mohs micrographic surgery has been Mohs micrographic surgery has been successfully usedsuccessfully used– No tumor related deaths or metastases at No tumor related deaths or metastases at
5 yrs5 yrs– All PTS with recurrent disease were All PTS with recurrent disease were
successfully salvagedsuccessfully salvaged
LIP CANCERLIP CANCERTT11 T T22
SurgerySurgery ifif + margins+ margins+ lymph nodes+ lymph nodes
Adjuvant radiationAdjuvant radiationRadiationRadiation if recurrence local regionalif recurrence local regional
External beamExternal beamBrachytherapyBrachytherapy Salvage surgerySalvage surgeryor bothor both
98 % local control 5 yrs98 % local control 5 yrs
LIP CANCERLIP CANCER
There are no published randomized trials There are no published randomized trials onon• the use of sequential surgery + radiation the use of sequential surgery + radiation • the use of chemotherapythe use of chemotherapy
NBNB : one preliminary study on super selective : one preliminary study on super selective intraarterial chemo (CDDP based) in six PTS with intraarterial chemo (CDDP based) in six PTS with TT11, T, T22 or local recurrence by Kishi & al, Radiology or local recurrence by Kishi & al, Radiology
213, 1999213, 1999
FLOOR OF MOUTH FLOOR OF MOUTH CANCERCANCER
High risk tumors (even in early stages)High risk tumors (even in early stages) Proximity to the mandibleProximity to the mandible
– Adhesion or invasion (by the alveolar ridge)Adhesion or invasion (by the alveolar ridge)– Risk of radiation induced bone necrosisRisk of radiation induced bone necrosis
No mechanical barrier in soft tissuesNo mechanical barrier in soft tissues– Blurred vision of margins, Even with high resolution MRIBlurred vision of margins, Even with high resolution MRI
Early lymph node metastasesEarly lymph node metastases– 20 % of occult invasion in T20 % of occult invasion in T11
– 62 % of occult invasion in T62 % of occult invasion in T22
Will develop second primary tumors (Will develop second primary tumors (~ 20 % in T~ 20 % in T11 – – TT22) ) “field cancerization” effect of carcinogens“field cancerization” effect of carcinogens
FLOOR OF MOUTH FLOOR OF MOUTH CANCERCANCER
Surgery is generally preferred for TSurgery is generally preferred for T11 T T22 (primary & necks)(primary & necks)
+ radiation+ radiation if margins are close or involvedif margins are close or involved
if lymph nodes are involved if lymph nodes are involved (CR)(CR)
if mandible is invadedif mandible is invaded
if perineural or/and vascular if perineural or/and vascular invasion invasion
(or chemo radiation)(or chemo radiation) Role of sentinel node biopsy is under studyRole of sentinel node biopsy is under study
FLOOR OF MOUTH FLOOR OF MOUTH CANCERCANCER
Surgery S 5 yrsSurgery S 5 yrs
TT11 95 %95 %
TT22 86 %86 %
Control rateControl rate
90 %90 % ← ← negative negative marginsmargins
62 %62 % ← ← positive positive marginsmargins
Primary ERTPrimary ERT
Control rateControl rate
90 %90 % TT11
77 %77 % TT22
Neck surgery when invasion depth ≥ 5 mm
level I to III unilateral for lateral tumors
bilateral for anterior/midline
ORAL TONGUE CANCERORAL TONGUE CANCERTT11 T T22
SURGERYSURGERY Partial glossectomy (negative margins Partial glossectomy (negative margins > 1 > 1
cm)cm)
→ → thickness, depth invasion, perineural spread, thickness, depth invasion, perineural spread, vascular invasionvascular invasion
Elective neck node dissectionElective neck node dissection-- TT11 TT22 T T33 T T44 N N00
NN++ 6 % 6 % 36 %36 % 50 %50 % 67 %67 %
Staging is crucial in defining the postsurgical treatment ERT + CHEMO
After Hickx WL. & al, Am J Otolaryngol 1998
ORAL TONGUE ORAL TONGUE CANCERCANCER
Role of elective neck dissection for T1 N0 ?No randomized Trial
Retrospective studies remain controversialTT1-21-2 N N00 ELNELN TNDTND
Yii (RoyalMarsden)Yii (RoyalMarsden) RECREC 7777 27 %27 % 50 % 50 % (p.025)(p.025)
19991999 S S 5yrs5yrs 75 %75 % 65 % (NS)65 % (NS)
ELNELN TNDTND
Haddadin Haddadin (Canniesburn)(Canniesburn)
19981998S S 5yrs5yrs 137137 81 %81 % 45 % 45 %
(p.001)(p.001)
But bias in the initial treatments (various types of surgery, RT or no RTto the primary and/or to the neck)
ELECTIVE VERSUS THERAPEUTIC NECK ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERSDISSECTION IN ORAL CAVITY CANCERS
Randomized trialRandomized trial
39 ELND39 ELND 36 36 observationsobservations
TT1-3 1-3 NN00 49 % N49 % N+ + 47 % N47 % N+ + : TND: TND
13 % CR13 % CR 25 % CR25 % CR
DFS DFS 5 yrs5 yrs 57 % 57 % 60 % NS60 % NS
NB : NB : 16 % of second primaries16 % of second primaries45 % of deaths met caused by the original tumor45 % of deaths met caused by the original tumorAfter Vandenbrouck & al, Cancer 46 ; 1980
ELECTIVE VERSUS THERAPEUTIC NECK ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERSDISSECTION IN ORAL CAVITY CANCERS
Randomized trialRandomized trial
30 hemiglossectomy + RND30 hemiglossectomy + RND 40 hemiglossectomy40 hemiglossectomy
10 N +10 N + 20 N-20 N- 23 N+ 23 N+
↓↓4 contralat +4 contralat +
47 % N+47 % N+ 57 % N+57 % N+
DFSDFS 63 %63 % N.SN.S 52 %52 %
(T(T11 : 70 % ; T : 70 % ; T2 2 : 60 %): 60 %) (T(T11 : 64 % ; T : 64 % ; T22 : : 46 %)46 %)
After Fakih & al, Am. J. Surg. 158; 1989
ELECTIVE VERSUS THERAPEUTIC NECK ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERSDISSECTION IN ORAL CAVITY CANCERS
Randomized trialRandomized trial : effect of tumor depth in 51 PTS : effect of tumor depth in 51 PTS
21 Hemiglossectomy + ELN21 Hemiglossectomy + ELN 30 30 hemiglossectomyhemiglossectomy
9 (≥ 4 mm)9 (≥ 4 mm) 12 ( 12 (< 4 mm)< 4 mm) ↓↓ ↓↓
6 N6 N++ (67 %) (67 %) 1 N1 N++ (8 %) (8 %)
S 43 % (p < 0.01)S 43 % (p < 0.01)S 81 %
After Fakih & al, Am. J. Surg. 158; 1989
21 (≥ 4 mm)21 (≥ 4 mm) 9 (9 (< 4 mm)< 4 mm)
↓↓ ↓↓
15 N+ (76 %)15 N+ (76 %)2 N+ (22 %)2 N+ (22 %)
LOWER ALVEOLAR RIDGE & LOWER ALVEOLAR RIDGE & RETROMOLAR TRIGONE TRETROMOLAR TRIGONE T1-21-2 cancers cancers
SURGERYSURGERY Wide local excision with marginal Wide local excision with marginal mandibulectomymandibulectomy
- close proximity to bone- close proximity to bone
- infiltration into the masticator space- infiltration into the masticator space
- nodal involvement- nodal involvement
RADIATIONRADIATION AdjuvantAdjuvant for close or positive marginsfor close or positive margins
for lymph node invasionfor lymph node invasion
OR if used as first modalityOR if used as first modality
UPPER ALVEOLAR RIDGE & HARD UPPER ALVEOLAR RIDGE & HARD PALATE CANCERSPALATE CANCERS
SURGERYSURGERYResection of part of the palatine processResection of part of the palatine process→ → maxillectomy followed by flapmaxillectomy followed by flap
reconstruction or prosthetic rehabilitationreconstruction or prosthetic rehabilitation-- St I St I (9)(9) St II St II (19)(19) St III St III (14) (14) St IVSt IV(20) *(20) *
CSSCSS 75 % 75 % 46 %46 % 36 %36 % 11 %11 %
- neck dissection in Stage III- neck dissection in Stage III RADIATIONRADIATION : alone or used for close margins, bulky & : alone or used for close margins, bulky &
infiltrating tumors, nodal spreadinfiltrating tumors, nodal spread
After Evans & Shah, Am J Surg 1981
BUCCAL MUCOSA CANCERSBUCCAL MUCOSA CANCERS SURGERYSURGERY
transoral resection transoral resection ++ check flaps check flaps++ mandibular resection mandibular resection++ maxillectomy maxillectomy- Neck : advocated for T- Neck : advocated for T22 or invasion > 5 mm, muscle or invasion > 5 mm, muscle
St I St I St II St II St IIISt III St IVSt IV
**
78 % 78 % 66 %66 % 62 %62 % 50 %50 %
NN00 necks : 70 % → rec rate if no END or RT : 25 % vs 10 % (p<.05) necks : 70 % → rec rate if no END or RT : 25 % vs 10 % (p<.05)
NN++ necks : 49 % (no CR : 69 % vs +CR : 24 %) necks : 49 % (no CR : 69 % vs +CR : 24 %)After Diaz & al, Head & Neck 2003
+ free flaps
S 5yrsS 5yrs
S 5yrsS 5yrs
BUCCAL MUCOSA CANCERS BUCCAL MUCOSA CANCERS (2)(2)
RADIATIONRADIATION : :
Used primarily for cure of T Used primarily for cure of T 1-21-2
→ → S3yrs : St I = 85 % ; St II = 63 %S3yrs : St I = 85 % ; St II = 63 % * *
Postop advocated for high riskPostop advocated for high risk
-- margins < 2 mmmargins < 2 mm- perineural invasionperineural invasion- lymph node involvementlymph node involvement
After Nair & al, Cancer, 1988
CONCLUSIONS (1)CONCLUSIONS (1)
Prognostic factors in oral cavity SCCAPrognostic factors in oral cavity SCCA T size remains an «old timer»T size remains an «old timer» Depth of invasion is more informativeDepth of invasion is more informative
– as areas are perineural spreadperineural spread
vascular invasionvascular invasion N involvement is a state of emergency N involvement is a state of emergency
from prompt an multidisciplinary from prompt an multidisciplinary aggressive treatmentaggressive treatment
CONCLUSIONS (2)CONCLUSIONS (2)
No neck should not be a cause of debate No neck should not be a cause of debate on what is to be done in a randomized trialon what is to be done in a randomized trial
Depth of invasion of the primaryDepth of invasion of the primary Status of margins (close, involved, Status of margins (close, involved,
dysplasia,… molecular markers)dysplasia,… molecular markers) Perineural spreadPerineural spread Vascular invasionVascular invasion
– ShouldShould be routinely reported andbe routinely reported and
be the basis of planned treatmentbe the basis of planned treatment