Adjuvant Therapy Of Oral Cancers               Dr Sapna Nangia           Chief Radiation Oncologist         International ...
Oral Cavity Subsites : Adjacent But Disparate5.00%        4.70%4.50%                                           4.30%4.00% ...
Factors That Determine Adjuvant Treatment Adequacy of Surgery   Margin   Lymph nodes dissected Gross & microscopic cha...
Factors That Determine Adjuvant Treatment Patterns of spread Frequency and pattern of lymph node involvement   Site   ...
Buccal Mucosa, Alveolar &Retromolar Trigone Lesions
Buccal Mucosa , Alveolar, and Retromolar Trigone                    Lesions Buccal Mucosa lesions involve the  buccinator...
Buccal Mucosa , Alveolar, and Retromolar Trigone                    Lesions Buccal Mucosa lesions involve the  buccinator...
Buccal Mucosa , Alveolar, and Retromolar Trigone                    Lesions Buccal Mucosa lesions involve the  buccinator...
Buccal Mucosa, Alveolar and Retromolar Trigone                    Lesions Buccal Mucosa lesions involve the  buccinator m...
Buccal Mucosa, Alveolar and Retromolar Trigone                   Lesions                         MDSCC Rt Gingivum        ...
Buccal Mucosa, Alveolar and Retromolar Trigone      Lesions – Lymph Node Involvement in N0 neck                  Level I  ...
Buccal Mucosa, Alveolar and Retromolar Trigone  Lesions – Lymph Node Involvement in N+ neck              Level I   Level I...
Buccal Mucosa, Alveolar and Retromolar Trigone       Lesions – The Contralateral Neck
Buccal Mucosa, Alveolar and Retromolar Trigone          Lesions – The Contralateral Neck 145 patients                    ...
Buccal Mucosa, Alveolar and RetromolarTrigone Lesions – a SummaryIndications                        DosesT3, T4, Some T2  ...
Buccal Mucosa, Alveolar and RetromolarTrigone Lesions                     Ca Left RMT, post WLE                     margin...
Oral Tongue
Oral Tongue: Indications of post operativeradiotherapy T3 T4 tumours ? T2 Positive nodes Extracapsular involvement Clo...
Oral Tongue- Lymph Node Involvement in N0 &                 N+ neck                 Level I   LevelII   Level III     Leve...
Oral Tongue : Impact of Tumour Type onLymph Node Involvement                       LN Involvement70%                      ...
Oral Tongue – When can nodal irradiationbe avoided < 8mm ( Matsuura) ,< 5 mm( O Charoenrat), < 4 cm (     Fakih) < 2 mm (...
Oral Tongue – Local Radiation Alone, In Very Select Situations.May Use Brachy therapy Instead
Oral Tongue – Dose Painting with NeckIrradiation                      Ca left lat border tongue,                      1.5c...
Oral Tongue – Dose Painting with NeckIrradiation                      Ca left lat border tongue,                      1.5c...
Oral Tongue – When to Irradiate The             Contralateral Neck Fakih et al ( 1989) Contralateral failure higher in pa...
Lip Lymph Node Involvement lower than other oral cavity  sites Avoid elective lymph node irradiation in T1 T2 lesions I...
Status of chemoradiotherapy     EORTC 22931               Both                  RTOG 9501Stage III & IV disease ECE       ...
Stauts of chemoradiotherapy                  60%                               53%                  50%              47%  ...
Mandibular health in the era of IMRT        ( & ? Improved dental prophylaxis) Ben David et al ( IJROBP 68(2) 396 176 pa...
Special Thanks to Dr Anchal Agarwal
Adjuvant Therapy Of Oral Cancers
Adjuvant Therapy Of Oral Cancers
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Adjuvant Therapy Of Oral Cancers

  1. 1. Adjuvant Therapy Of Oral Cancers Dr Sapna Nangia Chief Radiation Oncologist International Oncology Centre Fortis Hospital Noida
  2. 2. Oral Cavity Subsites : Adjacent But Disparate5.00% 4.70%4.50% 4.30%4.00% Tongue3.50% FOM3.00%2.50% LIP2.00% Gingivum1.50%1.00% 0.90% 0.70% Others ( Buccal, RMT,0.50% 0.30% palate)0.00% Relative Proportion Number of Incident Cancers by Five Year Age Group and Site Males, Chennai National Cancer Registry
  3. 3. Factors That Determine Adjuvant Treatment Adequacy of Surgery  Margin  Lymph nodes dissected Gross & microscopic characteristics of the primary lesion Gross & microscopic characteristics of dissected lymph nodes Patterns of spread Frequency and pattern of lymph node involvement
  4. 4. Factors That Determine Adjuvant Treatment Patterns of spread Frequency and pattern of lymph node involvement  Site  Size  Location, especially with relation to midline  Histomorphological features , endophytic vs exophytic, tumour thickness, differentiation
  5. 5. Buccal Mucosa, Alveolar &Retromolar Trigone Lesions
  6. 6. Buccal Mucosa , Alveolar, and Retromolar Trigone Lesions Buccal Mucosa lesions involve the buccinator muscle and buccal fat pad Alveolar and retromolar trigone lesions involve bone early; Mandibular canal and inferior alveolar nerve / maxillary antrum and floor of nose – potential routes & sites of spread, respectively. Bone Involvement : Absence of fixation to bone / small size of a mandibular lesion, does not rule our bone involvement. INTRATEMPORAL FOSSA
  7. 7. Buccal Mucosa , Alveolar, and Retromolar Trigone Lesions Buccal Mucosa lesions involve the buccinator muscle and buccal fat pad Alveolar and retromolar trigone lesions involve bone early; Mandibular canal and inferior alveolar nerve / maxillary antrum and floor of nose – potential routes & sites of spread, respectively. Bone Involvement : Absence of fixation to bone / small size of a mandibular lesion, does not rule our bone involvement. INTRATEMPORAL FOSSA
  8. 8. Buccal Mucosa , Alveolar, and Retromolar Trigone Lesions Buccal Mucosa lesions involve the buccinator muscle and buccal fat pad Alveolar and retromolar trigone lesions involve bone early; Mandibular canal and inferior alveolar nerve / maxillary antrum and floor of nose – potential routes & sites of spread, respectively. Bone Involvement : Absence of fixation to bone / small size of a mandibular lesion, does not rule our bone involvement. INTRATEMPORAL FOSSA
  9. 9. Buccal Mucosa, Alveolar and Retromolar Trigone Lesions Buccal Mucosa lesions involve the buccinator muscle and buccal fat pad Alveolar and retromolar trigone lesions involve bone early; Mandibular canal and inferior alveolar nerve / maxillary antrum and floor of nose – potential routes & sites of spread, respectively. Bone Involvement : Absence of fixation to bone / small size of a mandibular lesion, does not rule our bone involvement. Yao et al IJROBP 2007 INTRATEMPORAL FOSSA 55 pts, oral cancer alone. Mostly postoperative IMRT 2/9 locoregional failures in the infratemporal fossa
  10. 10. Buccal Mucosa, Alveolar and Retromolar Trigone Lesions MDSCC Rt Gingivum Bone Involvement Present Margins & Lymph Nodes Free
  11. 11. Buccal Mucosa, Alveolar and Retromolar Trigone Lesions – Lymph Node Involvement in N0 neck Level I Level II Level III Level IV Level V Buccal 44 11 0 0 0 Mucosa Alveolus 27 21 6 4 2 Retro Molar 19 12 6 6 0 TrigoneA minimum ?? nodes must be removed in an adequate SOND Gregoire, R O 2000, 56, 135
  12. 12. Buccal Mucosa, Alveolar and Retromolar Trigone Lesions – Lymph Node Involvement in N+ neck Level I Level II Level III Level IV Level VBuccal 82 42 65 65 0MucosaAlveolus 54 46 19 17 4Retro Molar 50 60 40 20 0Trigone Gregoire, R O 2000, 56, 135
  13. 13. Buccal Mucosa, Alveolar and Retromolar Trigone Lesions – The Contralateral Neck
  14. 14. Buccal Mucosa, Alveolar and Retromolar Trigone Lesions – The Contralateral Neck 145 patients  However 77% had Stage III – IV disease Unilateral RT Bilateral RT 120 patients ( 83%) received unilateral radiotherapy CCRT for ECS, N2 disease and N2 38 pts 15 pts positive margin 3/120 failures in contralateral neck ECE 84 pts 11 pts Author’ conclusion : Do not treat contralateral neck for buccal mucosa lesions Conclusion : Do not treat contralateral neck routinely, except in lesions close to midline . Evidence unclear for N2 neck
  15. 15. Buccal Mucosa, Alveolar and RetromolarTrigone Lesions – a SummaryIndications DosesT3, T4, Some T2 66Gy /33/fx for positive margins, ECE.Bone involvementSkin involvement 60 Gy/30 fx for primary and involvedClose or positive margins lymph node levels.Inadequate neck dissection 50Gy/ 25fx – 60 Gy/30 fx forPositive neck nodes elective nodal irradiation.Lymphovascular space involvement ChemoRT for positive margins / ECEPerineural Spread Consider for T3, 4, LVSI, PNI, N2+,Extracapsular spread Level IV, V disease
  16. 16. Buccal Mucosa, Alveolar and RetromolarTrigone Lesions Ca Left RMT, post WLE marginal mandibulectomy, Margin Positive, 2/26involved, ECE Nil, Bone free
  17. 17. Oral Tongue
  18. 18. Oral Tongue: Indications of post operativeradiotherapy T3 T4 tumours ? T2 Positive nodes Extracapsular involvement Close or positive margins Lymphovascular space involvement Perineural spread
  19. 19. Oral Tongue- Lymph Node Involvement in N0 & N+ neck Level I LevelII Level III LevelIV Level VBuccalMucosa 44 11 0 0 0 Oral Tongue 14 19 16 3 0 N0Oral Tongue N1 32 50 40 20 0 Gregoire, R O 2000, 56, 135
  20. 20. Oral Tongue : Impact of Tumour Type onLymph Node Involvement LN Involvement70% 62%60%50% 35%40% LN Involvement30% 20%20%10% 0% Exophytic Superficial Ulcerative/ /Nodular Invasive
  21. 21. Oral Tongue – When can nodal irradiationbe avoided < 8mm ( Matsuura) ,< 5 mm( O Charoenrat), < 4 cm ( Fakih) < 2 mm ( Spiro) Adequate nodal dissection that includes Level IV lymph nodes and pathologically negative60 51.2 52.3 Shrime et al cta Otolary Head50 41.4 37.9 39.9 Neck Surg 201040 Retrospectiev analysis of 1539 pts Surgery with T1,T2,N1 disease30 17.7 Surgery + RT2010 OS0 All T2N1 FOM
  22. 22. Oral Tongue – Local Radiation Alone, In Very Select Situations.May Use Brachy therapy Instead
  23. 23. Oral Tongue – Dose Painting with NeckIrradiation Ca left lat border tongue, 1.5cm, all margins free, LVSI +, PNI +, 2/26 Lymph Nodes Positive
  24. 24. Oral Tongue – Dose Painting with NeckIrradiation Ca left lat border tongue, 1.5cm, all margins free, LVSI +, PNI +, 2/26 Lymph Nodes Positive
  25. 25. Oral Tongue – When to Irradiate The Contralateral Neck Fakih et al ( 1989) Contralateral failure higher in patients who have undergone neck dissection along with surgery. Kowalski ( 1999) Tumours >4 cm in size, poorly differentiated, ipsilateral positive nodes and floor of mouth involvement have contralateral spread Bier Lanning et al( 2009) Treat the contralateral neck if thickness of primary > 3.75mm
  26. 26. Lip Lymph Node Involvement lower than other oral cavity sites Avoid elective lymph node irradiation in T1 T2 lesions Include facial and preauricular nodes for upper lip lesions Perineural spread an issue in advanced tumours
  27. 27. Status of chemoradiotherapy EORTC 22931 Both RTOG 9501Stage III & IV disease ECE Two or more positivePositive Level IV /V Surgical margins nodeslymph nodes in Oc/Op involvedprimariesVascular embolisationPerineural spread Bernier & Cooper, The Oncologist
  28. 28. Stauts of chemoradiotherapy 60% 53% 50% 47% 40% 40% 36% 31% 30% RT ChemoRT 20% 17% 10% 0% DFS OS LRFEORTC trial. ( RTOG trial : No impact on OS, differnence in no. of N2,3 and margin +ve patients )Early reactions higher, other parameters : No significant impact.
  29. 29. Mandibular health in the era of IMRT ( & ? Improved dental prophylaxis) Ben David et al ( IJROBP 68(2) 396 176 patients, 50 % receiving > 70 Gy to > 1 % of mandible Sharp dose gradient across mandible ( average 11 Gy) Strict protocol based dental prophylaxis No osteoradionecrosis at a median of 34 months
  30. 30. Special Thanks to Dr Anchal Agarwal

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