Oral cancer by J. Shah

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Oral cancer by J. Shah

  1. 1. The International Federation of Head and Neck Oncologic SocietiesCurrent Concepts in Head and Neck Surgery and Oncology 2012 Oral Cancer Jatin P. Shah
  2. 2. Oral Cancer 6th Most Common Cancer Worldwide2012
  3. 3. Oral Cancer International Perspective •  Geographic variance •  Incidence •  Etiologic factors •  Site prevalence •  Stage distribution •  Socio-economic factors •  Awareness – education •  Expertise/technology •  Resource allocation •  Outcomes •  Economic impact2012 •  Prevention strategies
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  8. 8. Oral Cancer Better understanding of the biology of oral cancer, particularly with relation to local progression and metastatic spread.2012
  9. 9. Oral Cancer There is increasing emphasis on preservation or restoration of form and function to improve the quality of life.2012
  10. 10. Treatment Goals for Cancer of the Oral Cavity •  Cure of cancer •  Preservation or restoration of form and function •  Avoid or minimize sequelae of treatment2012 •  Prevent second primary cancers
  11. 11. Oral Cancer Factors Affecting Choice of Therapy •  Tumor factors •  Patient factors •  Provider/Physician factors2012
  12. 12. Oral Cancer Tumor Factors •  Site •  Size (T stage) •  Location •  Multiplicity •  Proximity to bone •  Histology, grade, depth of invasion, tumor type •  Status of cervical lymph nodes •  Previous treatment2012
  13. 13. Ca. Oral Cavity - Site Distribution Tongue Floor of Mouth Cheek Gum2012 Retromolar Trigone Lip Hard Palate
  14. 14. Ca. Oral Cavity 5 yr. Survival by Stage T1 T2 T3 T4 Stage I Stage II Stage III Stage IV N0 N1 (75-95%) (65-85%) (45-65%) N2 N3 (10-35%)2012 M1
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  16. 16. Ca. Oral Cavity Histological Distribution Squamous Carcinoma 92% Minor Salivary Ca. Melanoma Lymphoma Sarcoma2012
  17. 17. Impact of Tumor Thickness 2 - 9 mm > 9 mm < 2 mm 13 3 46 17 65 35 % with Lymph Node Mets. % Dead of Disease2012
  18. 18. Oral Cancer Patient Factors•  Age •  Acceptance•  General medical •  Tolerancecondition •  Compliance•  Life style •  Socioeconomic•  Dental hygiene considerations•  Occupation •  Time constraints2012
  19. 19. Oral Cancer Physician/Provider Factors •  Expertise •  Surgery •  Rehabilitation •  Radiotherapy •  Support services •  Chemotherapy •  Resource allocation •  Dental – prosthetic •  Third party payer constraints2012
  20. 20. Oral Cancer Treatment Alternatives •  Surgery •  Radiotherapy •  Chemotherapy •  Combined modalities2012
  21. 21. Choice of Surgery vs. RadiotherapySurvival with single modality treatment 90 Choice of Treatment 80 depends upon: 70 60 50 40 • Site • Competence 30 • Location • Convenience 20 • Stage • Cost 10 • Histology • Compliance 0 • Node Status • Complications I I II I Stage I I V2012
  22. 22. Oral Cancer Choice of Treatment •  Stage I & II single modality treatment is effective and preferable •  Stage III & IV multimodal therapy is essential2012
  23. 23. Oral Cancer Surgical Approaches •  Per oral •  Pull through •  Lower cheek flap •  Upper cheek flap •  Visor flap2012 •  Mandibulotomy
  24. 24. Surgical approaches to the oral cavity2012
  25. 25. Oral Cancer Surgical approach depends on: •  Tumor size •  Tumor site •  Tumor location •  Proximity to mandible or maxilla •  Need for neck dissection •  Need for reconstructive surgery2012
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  28. 28. Management of the Mandible • Mechanism of tumor invasion • Mandible sparing approaches2012
  29. 29. Mandible Invasion by Oral Cancer Dentate Mandible Marginal mandibulectomy feasible for invasion of the alveolar process or minimal cortical erosion.2012
  30. 30. Mandible Invasion by Oral Cancer Edentulous Mandible Marginal mandibulectomy feasible for minimal erosion of the alveolar process.2012
  31. 31. Mandibulectomy Indications • Gross invasion by tumor • Proximity to tumor • Access to oral cavity?2012
  32. 32. Segmental Mandibulectomy Indications • Gross invasion by oral cancer • Primary bone tumor • Metastatic tumor • Inferior alveolar nerve invasion2012
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  49. 49. Mandible Sparing Approaches • Marginal mandibulectomy • Mandibulotomy2012
  50. 50. Mandible Sparing Indications • For margins around tumor • Approximation by tumor • Cortical erosion2012
  51. 51. Marginal Mandibulectomy Contraindications • Gross tumor invasion • Massive soft tissue disease • Radiated, edentulous mandible2012
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  60. 60. Paramedian Mandibulotomy Advantages • Wide exposure • Preserves hyomandibular complex • No denervation of skin • No devascularization • Easy fixation2012 • Out of radiation portals
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  70. 70. Trans Oral Robotic Surgery (TORS) Advantages Dis advantages•  Evolving role of the •  Robotic arms are not Robot designed for Oral•  Avoids mandibulotomy surgery•  Faster recovery •  Learning curve is•  Less bleeding steep •  Takes more time•  Less pain•  Equally good •  Expensive resection ?? •  Outcomes data not available2012
  71. 71. Oral Cancer Head and Neck Service, MSKCC •  Total no. of patients on database: 953 •  Excluded patients: 358 –  Previous treatment elsewhere: 275 –  Incomplete information: 21 –  Lip cancer: 29 –  Carcinoma in situ: 9 –  Unresectable dis. Or distant meta: 14 –  Radiotherapy alone: 102012 •  Total 595 patients treated with surgery
  72. 72. 1.0 Survival 0.9 77% 0.8 DSS 0.7 68% RFS 0.6 68% OS 0.5ProportionSurviving 0.4 0.3 0.2 DSS – OS = 9% 0.1 0.0 0 12 24 36 48 60 72 84 96 108 120 2012 Follow-up Interval in Months
  73. 73. Disease-Specific Survival – T StatusUnivariate•  Clinical T stage 1.0 94% 0.9 T1•  Clinical N stage 76% 0.8 T2•  Clinical overall stage 0.7 66% T3 0.6 58% Surviving T4•  Pathologic T stage 0.5•  Pathologic N stage 0.4 0.3•  Pathologic overall stage 0.2•  Tumor grade 0.1 P<0.0001 0.0•  Surgical margins 0 12 24 36 48 60 72 84 96 108 120•  Depth of invasion Months 2012
  74. 74. Disease-Specific Survival – N StatusUnivariate•  Clinical T stage 1.0 0.9 84% N0•  Clinical N stage 0.8•  Clinical overall stage 0.7 58% N1 0.6 Surviving•  Pathologic T stage 0.5 46% N2, 3•  Pathologic N stage 0.4 0.3•  Pathologic overall stage 0.2•  Tumor grade 0.1 P<0.0001 0.0•  Surgical margins 0 12 24 36 48 60 72 84 96 108 120•  Depth of invasion Months2012
  75. 75. Disease-Specific Survival – StageUnivariate 1.0 94%•  Clinical T stage 0.9 I 80% II•  Clinical N stage 0.8 66% 0.7 III•  Clinical overall stage 0.6 58% Surviving IV•  Pathologic T stage 0.5 0.4•  Pathologic N stage 0.3•  Pathologic overall stage 0.2 P<0.0001 0.1•  Tumor grade 0.0•  Surgical margins 0 12 24 36 48 60 72 84 96 108 120 Months•  Depth of invasion2012
  76. 76. Disease-Specific Survival - MarginsUnivariate 1.0•  Clinical T stage 0.9 82% Negative.•  Clinical N stage 0.8 0.7•  Clinical overall stage 57% Positive. 0.6 Surviving•  Pathologic T stage 0.5 0.4•  Pathologic N stage 0.3•  Pathologic overall stage 0.2 P<0.0001•  Tumor grade 0.1 0.0•  Surgical margins 0 12 24 36 48 60 72 84 96 108 120 Months•  Depth of invasion2012
  77. 77. Conclusion •  Changing distribution of primary tumor: –  Oral tongue 48% of all oral ca: The highest reported from our institute •  Improved Outcome: 5-year overall survival –  1960~1964: 48% –  1979~1983: 57% –  1986~1995: 68% •  Significant predictors: –  Disease-specific survival: surgical margins and2012 pathologic N stage
  78. 78. SummaryChanging Trends in Outcome 5-year Overall Survival 80% 68% 57% 60% 48% 40% 20% 0% 60~64 79~83 86~952012 N=494 N=398 N=595 Stage III/IV 53% 36% 37%
  79. 79. Oral Cancer Improvement in results is seen due to: •  Early identification and treatment of nodal metastases •  Employment of adjuvant therapy2012
  80. 80. Oral CancerImprovement in quality of life is seen due to •  Contemporary surgical techniques •  Preservation or reconstruction of mandible and soft tissues •  Osseointegrated implants2012
  81. 81. Age Adjusted Death Rates for Oral Cancer per 100,000 Population Country China 0.52 0.33 USA 1.5 0.69 UK 1.63 0.74 Australia 1.79 0.78 Italy 2.7 0.62 Spain 3.3 0.59 Brazil 3.4 1 France 4.1 0.73 India 7.62 4.432012 Hungary 10.27 1.4 Melanesia 21.69 13.81
  82. 82. Advanced Carcinoma of the Oral Cavity Survival Outcomes 60% 59% 47% 50% Percent Survival 40% 33% 27% 27% 30% 20% 10% 12% 10% 0% MSKCC, 2002 * India, 2000 ** Brazil, 2002 * Taiwan, 1999* (n=595) (n=1505) (n=364) (n=703) Stage III Stage IV * Represents overall survival ** Represents relative survival2012 MSKCC: Unpublished data India: Yeole BB et al. Cancer 89: 437-44, 2000 Brazil: Unpublished data Carvalho A, Kowalski L et al. Taiwan: Chen YK et al. Oral Oncol 35: 173-79, 1999.
  83. 83. Oral Cancer International Perspective The most progress in the field can be achieved by employing prevention strategies - Developed Countries Developing Countries•  Awareness/education •  Awareness/education•  Lifestyle changes •  Lifestyle changes –  Cessation of tobacco –  Cessation of tobacco in all forms and alcohol in all forms and alcohol•  Chemoprevention trials •  Mass screening strategies 2012

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