Module 7: Treatment Options

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  • Patient survival and functional results depend upon the stage of the tumor and treatment plan selected to treat the patient.
  • Clinical stage, location and histologic type generally guide treatment options. Smaller intraoral lesions are treated with a single modality, whereas larger lesions or cases that involve lymph nodes require a combination.
  • Oropharyngeal lesions are usually treated with radiation therapy. Lip lesions are surgically excised with excellent results.
  • The oral cavity is used for a variety of functions that must be addressed prior to developing a treatment plan for the patient. Typically, a tumor board, or pretreatment conference, is convened. Multidisciplinary teams assess the patient’s condition, stage and grade of the tumor, treatment options, and effects of treatment. The planned treatment is presented to the patient for approval. Rehabilitation is addressed prior to starting treatment.
  • Quality of life issues must also be addressed. For instance, nutrition intake depends upon all of the structures mentioned in the previous slide (tongue, saliva, muscles, etc). Maintaining the ability to speak drastically affects a patient’s quality of life and ability to socialize. All of the functions performed by the mouth and associated structures must be taken into account when planning treatment for a particular patient.
  • Wide local excision involves the removal of the tumor in soft tissue with a 1-1.5-cm margin of clinically normal tissue at the periphery. Resection involves removing carcinoma that has invaded bone with a 2-cm margin of radiographically normal bone tissue at the periphery. Marginal resection involves removal of bone while leaving the inferior border of the mandible intact.
  • Segmental resection involves removal of the full height of the mandible. Composite resection involves removal of hard and soft tissue, typically the neck nodes, mandible, and soft tissues associated with the primary tumor, as in the tongue or floor of the mouth. Next, we will show some slides of the types of surgeries as we proceed.
  • Wide local excision involves the removal of the tumor in soft tissue with a 1-1.5-cm margin of clinically normal tissue at the periphery. This gentleman has a superficial squamous cell carcinoma of the right lateral surface of his tongue. The tumor measured 3 cm and had minimal induration, and no palpable lymph nodes were present. Slide on the right is the same patient five weeks after surgical excision. The area is completely healed with no pain or problems with tongue function. The patient was followed for more than five years without evidence of recurrence.
  • This patient has a deeply infiltrating squamous cell carcinoma involving the entire anterior floor of the mouth and mandible. Treatment involved complete resection followed by radiation. Reconstruction was critical to function, appearance, and quality of life. Part of the fibula was used to reconstruct the mandible. The last picture is the patient with the reconstructed mandible in place.
  • This patient has squamous cell carcinoma involving the anterior maxillary gingiva and bone. On the right is a picture of the maxillary tissues one month after surgery. A maxillary prosthesis replaced the defect, leading to good function. The patient has been cancer-free for more than 10 years.
  • Neck dissections can be comprehensive or selective. Comprehensive neck dissections include radical neck dissection and modified neck dissection. Radical neck dissection removes lymph nodes of the neck, the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.
  • Modified neck dissection preserves the sternocleidomastoid muscle or internal jugular vein, or the spinal accessory nerve. Selective neck dissections remove lymph nodes only, preserving the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve. Weakness in raising the arm above the head and weakness of the lower lip may follow neck dissection.
  • Radiation therapy may be administered as the sole treatment or in combination. It is often given following surgery if: soft tissue margin was positive one or more lymph nodes exhibited extracapsular invasion, bone invasion was present, more than one lymph node was positive in the absence of extracapsular invasion, comorbid immunosuppressive disease was present, or perineural invasion occurred. Radiation therapy may also be palliative in nature. This means it is given to a patient to alleviate symptoms of pain or obstruction if curative therapies are not an option.
  • CT and/or MRI scan, PET scanning are utilized to identify the lesion and involved structures. Dental panoramic film is used to assess dental status and mandibular involvement.
  • A Dental consult is necessary prior to radiotherapy in both dentulous and edentulous patients. Periodontally involved teeth, mobile teeth, teeth with large carious lesions, periapical pathology or impacted teeth should be extracted prior to beginning radiation therapy to avoid the threat of osteoradionecrosis. Fluoride trays with a neutral topical fluoride will be needed for the remainder of the patient’s life. Meticulous oral hygiene is required post-radiation to minimize the effects of xerostomia and osteoradionecresis of the mandible.
  • In EBRT , immobilization devices are made to minimize damage to areas other than the tumor. Damage to salivary glands is one of the radiation effects that the immobilization devices seek to minimize. Because salivary function is so important to quality of life and function, every effort is made to preserve the salivary glands when possible. IMRT , or conformal radiotherapy seeks to treat the tumor and spare more of the normal tissues. Brachytherapy or ISRT delivers high-dose, localized radiation by implanting radioactive sources into the tumor.
  • A. Squamous cell carcinoma of the lower lip. B. One month postradiotherapy.
  • Squamous cell carcinoma of the posterior buccal mucosa. Complete response following radiation therapy. Note the radiation-induced telangiectasia and fibrosis. The patient is asymptomatic.
  • This patient was diagnosed with squamous cell carcinoma (T1N0) presenting as leukoplakia of the tongue. Management was by interstitial therapy using a radium needle implant. The mucositis shown in the second slide is one week after initiation of therapy. After 1 month, in the third slide, the patient was asymptomatic and there was no evidence of the tumor or loss of function.
  • Until recently, radiation and surgery were the tools used to treat oral cancer. Chemotherapeutic agents were used prior to, during, or after radiation therapy or surgery. The terms neoadjuvant, concurrent, and adjuvant are used to indicate prior to, during, or following radiation.
  • Recently, however, several chemotherapy drugs are under investigation to increase the armamentarium available for use in treating oral cancer. Paclitaxel is one of the drugs currently being studied as a sole drug and in combination with other chemotherapy drugs and radiation therapy. Other drugs include: methotrexate, bleomycin, cisplatin and 5-Fluorouracil. New approaches to chemotherapy include intraarterial chemotherapy (injecting the drugs into the arteries feeding the cancer) and intralesional chemotherapy (injecting the drug directly into the tumor).
  • It is critical that dental care we undertaken prior to beginning cancer therapy. The health care professional should confer with the oncologist regarding the cancer diagnosis, location, stage and planned treatment (radiation fields, whether or not chemotherapy will be used, prognosis). Oral disease must be resolved and a meticulous preventive program must be instituted.
  • The goal for dental care prior to cancer therapy is to eliminate any dental disease that may cause problems later in the radiated field or during cancer treatment. High dose radiation results in PERMANENT damage to the vascularity, cellularity of soft tissue, salivary glands and bone Chemotherapy causes REVERSIBLE changes; the patient is at highest risk for side effects if the chemotherapy caused neutropenia (low neutrophil count).
  • This patient had previous radiotherapy for a carcinoma of the tongue. The tumor was controlled. You can see the residual mucosal fibrosis and telangiectasia, commonly associated with irradiated tissue.
  • The comprehensive dental care plan should assess the following: Mucosal and periodontal health Caries risk Unerupted and/or impacted teeth Presence of root tips Endodontic lesions Past dental disease: caries / restorations / endodontic treatment Dental prostheses: condition / fit / function Salivary function Temporomandibular function Oral hygiene effectiveness and patient motivation
  • Teeth that are at risk in the radiation field include those with pockets greater than 5 mm or with advanced attachment loss; those with caries or large restorations; partially erupted third molars; and endodontic lesions (abscesses) The goal is to have 1 to 2 weeks of healing before radiation is initiated. Extractions should be atraumatic with primary closure with no dressing in the socket.
  • Chemotherapy: Dental extractions of symptomatic teeth should be accomplished if sufficient time for healing is available before neutropenia occurs, otherwise prescribe antibiotics. Dental extractions may be considered between courses of chemotherapy when counts resolve.
  • A preventive program should include: Maintenance of gingival health: oral hygiene instructions, use of chlorhexidine Lower caries risk with oral hygiene instructions, dietary instructions, use of fluoride in custom-made trays, chlorhexidine and maintaining saliva levels Maintenance of muscosal health through prevention of mucositis, including the use of positioning devices, and modification of cancer therapy when needed; Cryotherapy; benzydamine; or developing therapies: cytokines/growth factors (KGF-palifermin); others Oral hygiene and dietary instructions should be provided Prevention of mucosal infections through oral hygiene instructions and the use of antifungals Maintenance of salivary levels through the use of sialogogues, mucoytics, and mouth wetting agents Use of lip lubricants Reinforcing tobacco and/or alcohol cessation
  • During cancer therapy, mucositis must be addressed, oral hygiene should be monitored, use of fluoride for caries prevention should be stressed, saliva levels must be checked and addressed, lip lubricants should be used, dental emergencies managed, oral mucosal infections should be treated, range of motion exercises should be provided for radiation patients, and tobacco and/or alcohol cessation reinforced.
  • Side effects caused by radiation therapy tend to be numerous. They are dose-dependent and some may be reversible. Temporary effects include mucositis (mucosal ulcers), pain, xerostomia (dry mouth), loss of taste (dysgeusia), candidiasis, dermatitis, erythema, and alopecia. Permanent effects include xerostomia, cervical caries, osteroradionecrosis, telangiectasias (dilation of capillaries), epithelial atrophy, focal alopecia, and focal hyperpigmentation. Radiation damages bone, and subsequent trauma may result in the loss of varying amounts of bone.
  • The first slide is the 5 th week after radiation for a base of the tongue carcinoma. Analgesics and prednisone systemically controled the signs and symptoms so radiation could be continued without interruption. The patient was then able to take in fortified liquids to maintain hydration and minimal nutrition. The second slide shows oral candidiasis in a patient with marked hyposalivation-xerostomia.
  • Managing mucositis is important during cancer therapy. Treatment includes the use of topical and systemic analgesics; and nutritional support. Developing therapies include cytokines and growth factors
  • Salivary dysfunction often includes xerostomia, or hyposalivation. Frequent intake of water, use of sugar free gum or candy can be helpful. The administration of sialogogues, including salagen, evoxac, bethanechol or sialor help some individuals. Caries prevention is critical because low salivary levels greatly increase caries. Mouth wetting agents such as Orajel can be somewhat helpful as well.
  • Pain should be treated through the use of topical analgesics or anesthetics, systemic analgesics, adjunctive medications such as tricyclic antidepressants, muscle relaxants for myogenic pain, physiotherapy for temporomandibular joint dysfunction and neck pain, and the use of oral prostheses to treat TMD.
  • Cancer patients require frequent, thorough follow-up, including A head, neck and oral exam Determination of salivary function, caries, fit and function of prostheses, diet, mucosal condition, oral hygiene, and future cancer risk Tobacco and/or alcohol cessation should be assessed Determination of the risk of osteonecrosis and immunosuppression Prognosis, change in risk factors and medical therapy should be assessed prior to developing the treatment plan
  • This patient received radiotherapy for carcinoma of the floor of the mouth. A. Nearly 2 years later, a painful osseous lesion became apparent. B. One year after that (3 years following original radiotherapy), the osteronecrosis progressed, and a resection had to be done.
  • Osteonecrosis is a very serious condition and should be prevented if at all possible. Therapy includes hyperbaric oxygen, Vitamin E and trental. Surgery may be necessary involving vascularized flaps.
  • The National Institute of Dental and Craniofacial Research (NIDCR) has a variety of excellent free materials for patients and health care providers. Check the Resources section of the Modules for ordering information.
  • Reconstruction addresses quality of life and functional issues. Various methods of reconstruction follow surgical interventions. Deltopectoral flaps and pectoralis major muocutaneous flaps are used in cases with neck dissections to replace tissue. Bone and soft tissue grafts provide good cosmetic appearance and function. Osseointegrated implants and dentures replace teeth and other facial parts. The fibula can be used to reconstruct the mandible.
  • This woman had a large midfacial defect. The first figure shows the tissue bars in position. A Hader bar retention system was used. The second picture shows the completed prosthesis. In the third photograph, the prosthesis is snapped into position.
  • This patient has a large midfacial defect. The second slide shows the oral prosthesis in place. The last slide shows the patient with the facial prosthesis in position. Various attachment features are utilized including titanium implants using bar clips, magnets and O-rings. The location of the prosthesis determines which attachment system is used. Acrylic resin substructure with the attachments fits within the contours of the silicone facial prosthesis.
  • Early detection is the key to alleviating the need for major reconstruction and a variety of side effects of treatment. These patients can be treated successfully in many cases, with the help of a multidisplinary team to restore the patient to function and improve quality of life.

Transcript

  • 1. Module 7: Treatment Options
  • 2. Surgery and/or Radiation
    • Treatment usually involves surgery or radiation or both
    • Chemotherapy primarily used as an adjunctive procedure in advanced cases
    • Advanced lesions < 30% 5-year survival rate
    • 9 - 25% of patients develop additional mouth or throat cancer
  • 3. Treatment
    • Oropharyngeal lesions: radiation therapy
    • Lip lesions: surgically excised
    • Tongue lesions: hemiglossectomy; then radiation
    • Alveolar ridge cancer: segmental resection
    • Metastasis to local lymph nodes: radical or modified radical neck dissection
  • 4. Considerations Regarding Treatment Options
    • The oral cavity is a complex structure composed of muscles, nerves, jaws, tongue and lubricated by the salivary glands.
    • Rehabilitation must be considered prior to surgical or radiographical intervention.
  • 5. Quality of Life Issues
    • Nutrition
    • Speech
    • Appearance
    • All functions must be addressed in treatment planning
  • 6. Surgery
    • Type depends upon the extent and location of cancer
    • Wide local excision: soft tissue
    • Resection: invaded bone
    • Marginal resection: inferior border of mandible intact
  • 7. Surgery
    • Segmental resection: full height of mandible removed
    • Composite resection: hard and soft tissue (nodes, mandible, and soft tissues--tongue or floor of the mouth)
  • 8. Wide Local Excision Silverman, 2003
  • 9. Silverman, 2003:98,100 Squamous Cell Carcinoma / Reconstruction
  • 10. SCC of anterior maxillary gingiva and bone One month post-surgical Silverman, 2003 Squamous Cell Carcinoma (SCC)
  • 11. Neck Dissections
    • Comprehensive neck dissections include radical neck dissection and modified neck dissection.
    • Radical neck dissection removes lymph nodes of the neck, the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.
  • 12. Neck Dissections
    • Modified neck dissection preserves the sternocleidomastoid muscle or internal jugular vein, or the spinal accessory nerve.
    • Selective neck dissections remove lymph nodes only, preserving the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.
  • 13. Radiation Therapy
    • Radiation therapy is indicated following surgery if:
      • soft tissue margin positive
      • one or more lymph nodes exhibit extracapsular invasion
      • bone invasion present
      • more than one lymph node positive in the absence of extracapsular invasion
      • comorbid immunosuppressive disease present, or
      • perineural invasion occurred
  • 14. Radiation Therapy
    • CT and/or MRI scan, PET scanning
    • Dental panoramic
  • 15. Radiation Therapy
    • Dental consult
    • Extractions prior to beginning
    • Fluoride
    • Meticulous oral hygiene
    • Osteoradionecrosis
  • 16. Types of Radiation Therapy
    • (EBRT) primary external-beam radiotherapy
    • (IMRT) intensity-modulated radiotherapy
    • (ISRT) brachytherapy or interstitial radiotherapy
  • 17. Radiation Therapy Squamous cell carcinoma One month postradiotherapy Silverman, 2003
  • 18. Radiation Therapy Silverman, 2003
  • 19. Brachytherapy Silverman, 2003:105
  • 20. Chemotherapy
    • Chemotherapy was primarily used as a palliative measure until fairly recently. It was typically administered before, during or after radiotherapy or surgery
      • neoadjuvant (before irradiation)
      • concurrent (during irradiation)
      • adjuvant (after irradiation)
  • 21. Chemotherapy
    • Several drugs currently being used include:
      • Paclitaxel (Taxol, Bristol-Myers Squibb)
      • Methotrexate
      • Bleomycin
      • Cisplatin
      • 5-Fluorouracil
    • Other research includes the use of:
      • Intraarterial chemotherapy
      • Intralesional chemotherapy
  • 22. Care Prior to Cancer Therapy
    • Comprehensive oral examination
    • Understand cancer diagnosis/location/stage/planned treatment (prognosis, chemotherapy??, radiation field)
    • Stabilize/resolve oral disease and institute preventive program
  • 23. Care Prior to Cancer Therapy
    • Goal:
    • Eliminate dental disease that cannot be maintained lifelong in radiated field or that may cause infection of become symptomatic during chemotherapy
    • High dose radiation therapy causes PERMANENT change in vascularity, cellularity of soft tissue, salivary gland and bone
    • Chemotherapy causes reversible changes, highest risk if caused neutropenia
  • 24. Telangiectasia and Mucosal Fibrosis Silverman, 2003: 115
  • 25. Care Prior to Cancer Therapy
    • Oral Disease Status
      • Mucosal and periodontal health
      • Caries risk
      • Unerupted/impacted teeth
      • Root tips
      • Endodontic lesions
      • Past dental disease: caries / restorations / endo
      • Dental prostheses: condition / fit / function
      • Salivary function
      • Temporomandibular function
      • Oral hygiene effectiveness / patient motivation
  • 26. Care Prior to Cancer Therapy
    • At risk teeth in radiation field
      • Periodontal status (pockets > 5 mm, advanced attachment loss
      • Caries / restoration status
      • Partially erupted third molars
      • Endodontic lesions
    • Goal: 1 – 2 weeks healing prior to radiation
    • Atraumatic extraction with primary closure, no dressing in socket
  • 27. Care Prior to Cancer Therapy
    • Dental extractions of symptomatic teeth due to infection, if sufficient time for healing of extraction site prior to neutropenia; if insufficient healing time, cover with antibiotics
    • Dental extractions considered if required between courses of multi-course chemotherapy, at time of count recovery
  • 28. Care Prior to Cancer Therapy
    • Preventive Program:
      • Gingival health: oral hygiene, chlorhexidine
      • Caries risk: oral hygiene, diet, fluoride carriers, chlorhexidine, saliva function
      • Mucosal health: mucositis preventive program
      • Mucosal infection: antifungal, oral hygiene
      • Saliva: sialogogue, mucolytic, mouth wetting
      • Lip lubrication
      • Reinforce tobacco / alcohol cessation
  • 29. Oral Care During Cancer Therapy
    • Mucositis: preventive program, pain management, diet instruction
    • Oral hygiene
    • Caries prevention
    • Saliva management
    • Lip lubrication
    • Manage dental emergencies
    • Manage oral mucosal infections
    • Range of motion exercises for radiation patients
    • Reinforce tobacco / alcohol cessation
  • 30. Complications from Radiation
    • Pain; neuropathy
    • Xerostomia: low flow rate, thick consistency
    • Loss of taste
    • Cervical caries
    • Epithelial atrophy
    • Fibrosis of soft tissue and muscles
    • Focal alopecia
    • Focal hyperpigmentation
    • Osteroradionecrosis
    • Telangiectasias
    • Dental prostheses fit / function
    • Esthetic, speech concerns
  • 31. Complications Acute mucositis 5 th week after radiation for base of the tongue squamous cell carcinoma Oral candidiasis in a patient with marked xerostomia Silverman, 2003: 114, 119
  • 32. Mucositis Management
    • Treatment of mucositis:
      • Symptomatic management: topical analgesics; systemic analgesics
      • Nutritional support
      • Developing therapies: cytokines/growth factors
  • 33. Management of Hyposalivation
    • Fluid intake, sugar free gum / candy
    • Sialogogues:
      • Salagen
      • Evoxac
      • Bethanechol
      • Sialor
    • Caries prevention
    • Symptomatic (mouth wetting agents)
  • 34. Oropharyngeal / Head / Neck Pain
    • Treat cause when possible
    • Topical analgesics / anesthetics
    • Systemic analgesics
    • Adjunctive medications (e.g. tricyclics)
    • Muscle relaxants (myogenic pain)
    • Physiotherapy (TMD, neck pain)
    • Oral prostheses (TMD)
  • 35. Follow-up of Cancer Patients
    • Thorough head and neck and oral exam
    • Salivary function, caries, demineralization risk, denture fit / function, oral hygiene, diet, mucosal condition, cancer risk
    • Tobacco / alcohol cessation
    • Risk of osteonecrosis with H&N RT; myelosuppression/immunosuppression
    • Know medical therapy, prognosis, change in risk factors prior to treatment planning
  • 36. Osteonecrosis Silverman, 2003:121 Two years after radiotherapy Three years after radiotherapy
  • 37. Care Following Radiation Therapy
    • Osteonecrosis:
      • Prevention:
        • Pretreatment oral care
        • Cancer therapy
        • Amputation of crown, endodontics
        • Atraumatic extraction if needed
      • Therapy:
        • Hyperbaric oxygen, trental, Vitamin E
        • Surgery – vascularized flaps
  • 38. Complications
    • National Institutes for Dental and Craniofacial Research (NIDCR) offers excellent free materials for patients
    • Ordering information included in Resources section
  • 39. Reconstruction
    • Various methods of reconstruction follow surgery
    • Deltopectoral flaps and pectoralis major muocutaneous flaps
    • Bone and soft tissue grafts
    • provide good cosmetic
    • appearance and function
    • Osseointegrated implants
    • and dentures
    • The fibula can be used to
    • reconstruct the mandible
  • 40. Silverman, 2003: 147 Reconstruction
  • 41. Silverman 2003:146 Reconstruction
  • 42. Summary
    • Early detection of lesions is critical to allow conservative treatment and protect the patient’s quality of life.
    • Many avenues are available to treat oral cancers, with improved methods constantly under investigation.
    • A multidisciplinary team can help oral cancer patients deal with the aftermath of treatment.