This document summarizes Day 2 of a mastercourse on oral cancer management presented by Dr. Monalisa Banerjee. It covers topics like buccal mucosa excision and marginal mandibulectomy, infrastructure maxillectomy approaches and reconstruction. Questions from attendees are addressed regarding these procedures and early oral cancers. Imaging, frozen section use, margins, and adjuvant therapy criteria are also discussed. Immunotherapy options and risk of nodal metastasis after brachytherapy are reviewed. Treatment of advanced oral cancer is debated including resectability criteria and roles of neoadjuvant therapy and adjuvant radiation/chemoradiation.

1. DAY 2
PRESENTED BY:DR.MONALISA BANERJEE
MASTERCOURSE IN ORAL
CANCER MANAGEMENT-2021

2. TOPICS COVERED

3. BUCCAL MUCOSA EXCISION+MARGINAL MANDIBULECTOMY

6. QUESTIONS DISCUSSED
 Requirement of coronoidectomy along with marginal
mandibulectomy?
 How to prevent fracture following marginal
mandibulectomy?
 How and when to preserve the lingual nerve during
marginal mandibulectomy?
 RMT lesion with no gross bone involvement clinically and
radiologically-choice of mandibulectomy?
 Post RT case-How to protect the blood supply of
mandible while raising a cheek flap?

7. Infrastructure Maxillectomy

8. Approaches

9. Reconstruction

10. QUESTIONS DISCUSSED
 How to decide which incision to take?
 How to carry out pterygomaxillary disjuntion?
 When to remove the inferior turbinate?
 Is it possible to place implants immidiately after
maxillectomy?
 How to decide the reconstruction?
 Difference in treating adenoid cystic carcinoma from
squamous cell carcinoma?

11. Early Oral Cancers:Panel Discussion
1.Importance of depth of invasion
 Can be considered in tongue lesions as usually
pre-operative MRI is done.
 More important in post-operative setting and used
as factor in pathological classification.

12. 2.Imaging in Early Oral Cancers
 Should be considered in majority of cases.
 Critical in tongue, gbs lesions.

13. 3.Chosing the modality

14. Immunotherapy for Oral Cavity and Oropharyngeal
Cancer
 Pembrolizumab (Keytruda) and nivolumab (Opdivo) are
drugs that target PD-1, a protein on T cells in the immune
system.
 PD-1 normally helps keep T cells from attacking other cells . By
blocking PD-1, these drugs boost the immune response against
cancer cells. This can shrink some tumors or slow their growth.
 Single/double dose:50%-60% success rate.

15. Risk of nodal metastasis after
primary Brachytherapy
•Single instituitional experience of 42 patients.
•Late nodal recurrence after treatment by primary brachytherapy-80%
•Tumor thickness >6mm,risk of recurrence seen to be higher

16. • Brachytherapy is suggested for oral tumors of depth<=1.5cm and at least
5mm from bone.
• Management of neck is not mentioned in these guidelines.

17. 4. FROZEN SECTION AND MARGINS
 Role of Frozen Section
 Margin revision and how beneficial is it?
 Consideration of initial / revised margin for
adjuvant radiotherapy

18. •Retrosprective analysis of 416 patients-229 with FS while 197 without FS
•Local failure was determined by age, T stage, N stage and Marginal status
•Chance of achieving clear margins not significantly improved by FS

19. •R1 TO R0 Vs RO Resection- R1 TO R0 Showed significantly worse 5-
years LRFS compared to R0
•R1 TO Negative vs R0 Resection:R1 TO Negative patient showed
significantly worse LRFS compared to R0
•R1 vs R1 TO R0 Resection-R1 showed a trend towards worse 5years
LRFS compared with R1 to R0 but did not reach any significance.

20. SPECIMEN VS DEFECT DRIVEN APPROACH

21. MARGINS
Historical cohort of 277 oral cancer patients.
5-year survival rate:
Margins>5mm-73%
3-4mm-69%
2mm or less-62%
Involved margins 39%
Advocated 3mm as adequate margin.

24. Adjuvant therapy
RISK FACTORS FOR ADJUVANT THERAPY
MAJOR FACTORS
•STAGE III/IV
•POSITIVE
MARGINS
•DEPTH OF
INVASION
•NODAL
METASTASIS
•EXTRACAPSULAR
SPREAD
MINOR FACTORS
•LVI
•PNI
•WORSE PATTERN
OF INVASION
•TUMOR BUDDING

29. ITF CLEARANCE
 Assessment of ITF Involvement
 Supra-notch vs Infra Notch disease
 Signs of unressectability
 Role of NACT in diseases involving ITF
 Role of bony reconstructions following ITF

30. Assessment of ITF involvement
Assess with CT first
Check for the widening at mandibular canal or
pterygomaxillary fissure area.
If positive go for MRI

31. Supra notch vs Infra notch disease

32. Signs of unresectability
 Lateral pterygoid muscle involvement.
 Temporalis muscle involvement above the
coronoid notch.
 Posterior extension into tonsils,lateral pharyngeal
wall.
 N3 node involving pre-vertebral fascia/encasing
the carotid artery.
 Perineural spread on CT upto/above foramen
ovale.

33. MAJOR GLOSSECTOMY

37. PATIENT EVALUATION?
 Examination under anesthesia for large lesion.
 DOI to be assessed on MRI
 BOT,FOM, mucosa between dease and mandible
to be assessed for.
 Severe trismus: Endoscopy, Imaging should be
considered.

38. PANEL DISCUSSION
 TREATMENT OF ADVANCED ORAL CANCER

39. CRITERIA OF RESSECTABILITY
 Very advanced disease: Consider PET-CT
 Evaluate the skull base: CECT and compliment
with CEMRI
 UNRESSECTABILITY of primary disease:
A>Adequate surgical clearance is not achievabable
B>Extensive ITF involvement
C>Extensive involvement of Base of Skull
D>Extensive soft tissue disease.

41. Treatment decision
 1.Criteria of resectability
 2.Role of NACT
 3.Margins in ITF.
 4.Adjuvant treatment

45. ADJUVANT RT/CTRT