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LIP AND ORAL CAVITY SQUAMOUS CELL CARCINOMAS

LIP AND ORAL CAVITY SQUAMOUS CELL CARCINOMAS. Guy ANDRY, M.D. Dept of Surgery Institut Jules Bordet, U.L.B. Statements 2008 on Head and Neck Cancer Frankfurt, 1 st & 2 nd February 2008. 5 Years Survival and Cause Specific Survival %. After SEER database. LIP CANCER.

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LIP AND ORAL CAVITY SQUAMOUS CELL CARCINOMAS

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  1. LIP AND ORAL CAVITYSQUAMOUS CELL CARCINOMAS Guy ANDRY, M.D. Dept of Surgery Institut Jules Bordet, U.L.B. Statements 2008 on Head and Neck Cancer Frankfurt, 1st & 2nd February 2008

  2. 5 Years Survival and Cause Specific Survival % After SEER database

  3. LIP CANCER • The most common primary (~ 25 % of oral cavity cancer) • ~ 12/100.000 habitants per year USA & Europe • Solar-radiation, tobacco smoking, HPV, immunosuppression

  4. LIP CANCERSURGERY IS FIRST CHOICE • < 2/3 invasion : • full-thickness pedicled flaps (Abbe or Estlander) • > 2/3 invasion : • musculo mucosalflaps (Camille Bernard…) • free flaps • frontal flap → irradiation in debilitated PTS

  5. LIP CANCERPROGNOSTIC FACTORS • Maximum tumor thickness (cf. Martinez-Gimeno Scoring System) • Site (upper & commissure more rapid growth and preauricular, submandibular lymph node metastases)

  6. LIP CANCER Scoring system → probability of lymph node invasion Tumor thickness Martinez-Gimeno Scoring System T stage, Tumor thickness, microvascular, perineural invasion histologic grade of differentiation, presence of inflammatory infiltrate Group I : 0 % of lymph node invasion Group II : 21 % Group III : 50 % Group IV : 67 %

  7. LIP CANCER • Mohs micrographic surgery has been successfully used • No tumor related deaths or metastases at 5 yrs • All PTS with recurrent disease were successfully salvaged

  8. LIP CANCERT1 T2 Surgery if + margins + lymph nodes  Adjuvant radiation Radiation if recurrence local regional External beam Brachytherapy  Salvage surgery or both  98 % local control 5 yrs

  9. LIP CANCER • There are no published randomized trials on • the use of sequential surgery + radiation • the use of chemotherapy NB : one preliminary study on super selective intraarterial chemo (CDDP based) in six PTS with T1, T2 or local recurrence by Kishi & al, Radiology 213, 1999

  10. FLOOR OF MOUTH CANCER High risk tumors (even in early stages) • Proximity to the mandible • Adhesion or invasion (by the alveolar ridge) • Risk of radiation induced bone necrosis • No mechanical barrier in soft tissues • Blurred vision of margins, Even with high resolution MRI • Early lymph node metastases • 20 % of occult invasion in T1 • 62 % of occult invasion in T2 • Will develop second primary tumors (~ 20 % in T1 – T2) “field cancerization” effect of carcinogens

  11. FLOOR OF MOUTH CANCER • Surgery is generally preferred for T1 T2 (primary & necks)  + radiation if margins are close or involved if lymph nodes are involved (CR) if mandible is invaded if perineural or/and vascular invasion (or chemo radiation) • Role of sentinel node biopsy is under study

  12. FLOOR OF MOUTH CANCER Neck surgery when invasion depth ≥ 5 mm level I to III unilateral for lateral tumors bilateral for anterior/midline

  13. ORAL TONGUE CANCERT1 T2 SURGERY • Partial glossectomy (negative margins > 1 cm) → thickness, depth invasion, perineural spread, vascular invasion • Elective neck node dissection - T1 T2 T3 T4 N0 N+ 6 % 36 % 50 % 67 % After Hickx WL. & al, Am J Otolaryngol 1998 Staging is crucial in defining the postsurgical treatment ERT + CHEMO

  14. ORAL TONGUE CANCER Role of elective neck dissection for T1 N0 ? No randomized Trial Retrospective studies remain controversial But bias in the initial treatments (various types of surgery, RT or no RT to the primary and/or to the neck)

  15. ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERS Randomized trial 39 ELND36 observations T1-3 N0 49 % N+ 47 % N+ : TND 13 % CR 25 % CR DFS 5 yrs 57 % 60 % NS NB : 16 % of second primaries 45 % of deaths met caused by the original tumor After Vandenbrouck & al, Cancer 46 ; 1980

  16. ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERS Randomized trial 30 hemiglossectomy + RND40 hemiglossectomy 10 N + 20 N- 23 N+ ↓ 4 contralat + 47 % N+ 57 % N+ DFS 63 % N.S 52 % (T1 : 70 % ; T2 : 60 %) (T1 : 64 % ; T2 : 46 %) After Fakih & al, Am. J. Surg. 158; 1989

  17. ELECTIVE VERSUS THERAPEUTIC NECK DISSECTION IN ORAL CAVITY CANCERS Randomized trial : effect of tumor depth in 51 PTS 21 Hemiglossectomy + ELN 30 hemiglossectomy 9 (≥ 4 mm) 12 (< 4 mm) ↓ ↓ 6 N+ (67 %) 1 N+ (8 %) S 43 % (p < 0.01) 21 (≥ 4 mm) 9 (< 4 mm) ↓ ↓ 15 N+ (76 %) 2 N+ (22 %) S 81 % After Fakih & al, Am. J. Surg. 158; 1989

  18. LOWER ALVEOLAR RIDGE & RETROMOLAR TRIGONE T1-2 cancers • SURGERYWide local excision with marginal mandibulectomy - close proximity to bone - infiltration into the masticator space - nodal involvement • RADIATION Adjuvant for close or positive margins for lymph node invasion OR if used as first modality

  19. UPPER ALVEOLAR RIDGE & HARD PALATE CANCERS • SURGERY Resection of part of the palatine process → maxillectomy followed by flap reconstruction or prosthetic rehabilitation - St I (9) St II (19) St III (14)St IV(20) * CSS 75 % 46 % 36 % 11 % - neck dissection in Stage III • RADIATION : alone or used for close margins, bulky & infiltrating tumors, nodal spread After Evans & Shah, Am J Surg 1981

  20. BUCCAL MUCOSA CANCERS • SURGERY transoral resection + check flaps + mandibular resection + maxillectomy - Neck : advocated for T2 or invasion > 5 mm, muscle St I St II St IIISt IV * 78 % 66 % 62 % 50 % N0 necks : 70 % → rec rate if no END or RT : 25 % vs 10 % (p<.05) N+ necks : 49 % (no CR : 69 % vs +CR : 24 %) + free flaps S 5yrs S 5yrs After Diaz & al, Head & Neck 2003

  21. BUCCAL MUCOSA CANCERS (2) • RADIATION : Used primarily for cure of T 1-2 → S3yrs : St I = 85 % ; St II = 63 % * Postop advocated for high risk - margins < 2 mm • perineural invasion • lymph node involvement After Nair & al, Cancer, 1988

  22. CONCLUSIONS (1) Prognostic factors in oral cavity SCCA • T size remains an «old timer» • Depth of invasion is more informative • as are perineural spread vascular invasion • N involvement is a state of emergency from prompt an multidisciplinary aggressive treatment

  23. CONCLUSIONS (2) • No neck should not be a cause of debate on what is to be done in a randomized trial • Depth of invasion of the primary • Status of margins (close, involved, dysplasia,… molecular markers) • Perineural spread • Vascular invasion • Should be routinely reported and be the basis of planned treatment

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