This document discusses management of oral cavity cancer. It covers the incidence, risk factors, patterns of spread, staging, and treatment approaches for oral cavity cancer. The main treatment approaches are surgery, radiotherapy including external beam radiotherapy and brachytherapy, and concurrent chemoradiotherapy. Surgery involves excision of the primary tumor with margins and neck dissection. Reconstruction options after surgery include skin grafts, regional flaps, and free flaps. Brachytherapy is used as monotherapy or with external beam radiotherapy for early stage tumors. Selection criteria for brachytherapy include early stage disease localized to the organ of origin.

1. Management of oral cavity cancer
Dr Kiran Kumar
Reference: NCCN Guidelines, Perez(7th Edition)

2. INCIDENCE, EPIDEMIOLOGY, AND ETIOLOGY
• Oral cancer represents the most common noncutaneous malignancy
of the head and neck
• The incidence rate of oral cancer continues to be more than twice as
high in men than in women
• Worldwide age-standardized mortality estimates for lip and oral cavity
cancer were 2.7 per 100,000
• International Agency for Research on Cancer data indicate that the
highest rates of oral cancer are found in Melanesia, South-Central
Asia, and Eastern Europe, whereas the lowest rates are in Western
Africa and Eastern Asia

3. • Tobacco users have a 5-fold to 25-fold higher risk of oral cavity and
oropharyngeal cancer
• Smoking is identified as an independent risk factor in 80% to 90% of
patients who present with cancer of the oral cavity
• In India, the habit of chewing betel nut leaves rolled with lime and
tobacco (mixture known as “pan”), which results in prolonged
carcinogen exposure to the oral mucosa, is thought to be the leading
cause of oral cancer
• The combined use of alcohol and tobacco may have a synergistic
effect on carcinogenesis

4. • Persons with a “Scotch-Irish” complexion (red hair and blue eyes)and
exposure Ultraviolet radiation has been associated with carcinoma of the
lip
• Certain syndromes such as xeroderma pigmentosum, Li-Fraumeni, ataxia
telangiectasia, Bloom syndrome, and Fanconi anemia, because of inherent
genetic instability, have been associated with a predisposition to oral
cancer
• Individuals that have stopped smoking for 1 to 4 years have a 30% decrease
in risk of developing carcinoma of the head and neck compared to those
that continue to smoke. For those that quit smoking beyond 20 years, the
risk parallels that of never smokers; a similar effect is seen with stopping
the use of alcohol

5. Anatomy
• Anterior-skin–vermilion junction
• Superior-junction between the
hard and soft palate
• Inferior-circumvallate papillae
• Subsites-mucosal lip,buccal
mucosa,upper and lower
alveolar ridge,RMT,floor of the
mouth,hard palate,anterior two
third of the tongue

6. Lymphatic drainage
• Lips-both lips drain into the
submandibular lymph nodes,
central part of the lower lip
drains into the submental lymph
nodes
• submental nodes drain either to
the submandibular lymph nodes
or to the jugulo-omohyoid node.
• The submandibular lymph nodes
drain to the deep cervical chain
of lymph nodes
• FLOOR OF THE MOUTH-The
first-echelon nodes for the floor
of mouth are the submandibular
lymph nodes (level IB),
eventually drain to the jugulo-
omohyoid (level II) nodes
• BUCCAL MUCOSA-first-echelon
lymphatics are the
submandibular and subdigastric
lymph nodes and level II

7. • GINGIVA AND HARD PALATE
(INCLUDING RETROMOLAR
TRIGONE)-Lymphatic spread is to
the level I and level II nodes
• ORAL TONGUE-three routes of
lymphatic drainage
• tip of the tongue drains to the
submental lymph nodes;
• lateral aspects of the tongue drains
to the submandibular lymph nodes
and from there into the deep
cervical lymph nodes
• lymph from the medial tongue
drains directly to the inferior deep
cervical lymph nodes

8. NATURAL HISTORY AND PATTERNS OF SPREAD
Premalignant Lesions
• Leukoplakia
• The World Health Organization defines leukoplakia as a white patch
or plaque that cannot be rubbed off or characterized clinically or
pathologically as any other disease
• key pathologic features include hyperkeratosis and acanthosis
• may begin as a thin gray or gray/white plaque that may appear
translucent, is sometimes fissured or wrinkled, and typically soft and
flat

9. • Clinically, these lesions are nonhomogenous, nodular, speckled, or
verrucous, with central ulceration or erosion
• Low malignant potential-Homogenous
• high-risk-nonhomogenous
• between <1% and 18% of oral leukoplakias develop into oral cancer,
• Leukoplakia may regress spontaneously without therapy
• Leukoplakia with clinically or histologically aggressive features,
demonstrating dysplasia, should be excised

10. Erythroplakia
• a chronic, red, generally asymptomatic lesion or patch on the mucosal
surface that cannot be attributed to a traumatic, vascular, or
inflammatory cause.
• is a clinical diagnosis of exclusion
• Histopathologically, it has been documented that in homogenous
oral erythroplakia, 51% showed invasive carcinoma, 40% carcinoma
in situ, and 9% mild or moderate dysplasia
• The treatment of choice for erythroplakia is surgical excision.

11. Oral Submucous Fibrosis
• At early stages, these premalignant lesions are characterized by
blanching of the mucosa with a marble-like appearance
• more advanced stages, palpable fibrous bands become evident
around the buccal mucosa and the mouth opening
• Oral submucous fibrosis is associated with the use of betel quid (with
or without tobacco) or pan masala
• Advanced stages, approximately 25% of cases biopsied demonstrate
epithelial dysplasia in addition to subepithelial alterations

14. Patterns of Spread
• Local Spread
• Lip –majority- local growths
• few lip carcinomas -deeply invasive with perineural involvement, posterior
spread to involve cortical bone, extension to the inferior alveolar nerve, or
spread to the skin of the face
• floor of the mouth-involve the ventral tongue, extend along the lingual
nerve and submandibular duct, or invade the cortex of the mandible
• Anatomical gap between the mylohyoid and hyoglossus muscles through
which a carcinoma can gain access to submandibular and sublingual areas.

15. • alveolar ridge and retromolar trigone -invade bone early
• inferior alveolar ridge may access the mandibular canal and the inferior
alveolar nerve
• superior alveolar ridge may pass into the maxillary antrum or floor of the
nose.
• Infiltrating lesions of the buccal mucosa can invade the buccinator muscle,
extend to the buccal fat pad, and invade the subcutaneous tissue
• hard palate has a relatively dense mucoperiosteum that is relatively
resistant to tumor invasion
• The greater palatine foramina can allow tumors to spread posteriorly and
enter the pterygopalatine fossa and skull base

16. Lymphatic Metastases
• for patients with squamous cell carcinoma of the oral cavity, cervical
metastases occur in approximately 30% of cases
• The rate of neck metastases for carcinoma of the lip is approximately
10%
• Contralateral metastases are more common in tumors that approach
or cross the midline
• 3% of patients will have contralateral metastases

18. Distant Metastases
• Distant metastasis occurs in approximately 15% to 20% of patients
who eventually die of their disease
• The risk of distant metastases increases with the degree of lymph
node involvement.
• In general terms, with respect to head and neck cancer, 66% of
distant metastases are to the lungs, 22% to the bones, and 9.5% to
the liver

19. PATHOLOGIC CLASSIFICATION
• predominant histopathologic type of cancer in the oral cavity is
squamous cell carcinoma
• Basaloid squamous cell carcinoma-advanced disease at presentation,
distant metastases, and poorer overall survival rate
• Verrucous carcinoma-low-grade malignancy with low metastatic
potential and good overall prognosis.
• Sarcomatoid carcinomas-carries a poor prognosis with a mean
survival of approximately 2 years.

20. • Less than 10% of neoplasms of the oral cavity have nonsquamous
histology
• Adenoid cystic carcinoma accounts for approximately 30% to 40% of
minor salivary gland cancers of the oral cavity
• Other histologies that can occur in the oral cavity include
adenocarcinomas, melanoma, ameloblastoma, lymphoma, and
Kaposi sarcoma
• Approximately 50% of acquired immunodeficiency syndrome–related
cases of Kaposi sarcoma have oral cavity involvement

21. CLINICAL PRESENTATION
• oral tongue -present as small ulcers and gradually invade the musculature
of the tongue.
• Advanced lesions may be either ulcerative or exophytic and are usually
quite evident
• Most often arise along the lateral borders of the tongue
• Some cancers of the oral tongue are painful even in their early stages
• floor of the mouth-infiltrative and may invade bone, the muscles of the
floor of the mouth, and the tongue.
• The frenulum is frequently a site of involvement.
• Clinical fixation of the tumor to the mandible suggests periosteal
involvement, which may occur early.

22. • alveolar ridge -pain while chewing, loose teeth, or ill-fitting dentures in
edentulous patients
• These cancers often arise in edentulous areas or along the free margin of
the mandibular alveolus (Figs. 47.8 and 47.9).
• Anesthesia of the lower lip and teeth may indicate involvement of the
mandibular canal and inferior alveolar nerve
• retromolar trigone -exophytic growth pattern and limited involvement of
underlying bone
• may infiltrate cortical bone and spread along regional tissue planes to
involve the pterygoid complex and parapharyngeal space. These latter
lesions often induce trismus early in the clinical course

23. • buccal mucosa -rarely symptomatic, papillary or erosive and located
near the dental occlusal line, most frequently arise adjacent to the
lower molars along the occlusal line of the teeth
• hard palate-often painless, and the sole presenting symptom may be
an irregularity in the mucosa or ill-fitting dentures. Other presenting
symptoms include nonhealing ulcers of the hard palate, intermittent
bleeding, and pain.

24. DIAGNOSTIC EVALUATION
• comprehensive history and physical examination
• Detailed visual and digital examinations are particularly important for
oral cavity tumors , mirror and fibropticscopy as indicated
• Examination under anesthesia with endoscopy if indicated
• A biopsy of lesions in question should be obtained
• thorough dental assessment
• A chest x-ray should be performed to exclude lung metastases or a
second primary cancer

25. Risk assessment for caries and periodontal disease
• Existing periodontal and dental condition
• Radiographic evidence of periapical pathology
• Oral hygiene
• Past dental history
• Patient motivation and compliance

26. Treatment plan
• Eliminate potential source of infection
• Extraction atleast 2weeks before start of RT
• Treat active caries and periodontal disease
• Silicon guards to minimize radiation back scatter,if patients have
metal restorations
• Prescribe potential topical fluorides for daily use
• Evaluation of oral candidiasis and treat appropriately with antifungals

28. • CT-extent of soft tissue and bony involvement and occult disease in
the neck
• extent of invasion into the deep musculature of the tongue and
adjacent structures
• for visualizing invasion of the mandible, palate, and pterygopalatine
fossa
• If CT scanning is not available, then panoramic radiographs can be
used to demonstrate mandibular invasion

29. • MRI-contrast allergy , patient has significant dental artefact , tumor
involving the tongue and is a good modality for evaluating the
possibility of perineural spread
• Ultrasound may be used to screen for enlarged lymph nodes that are
not clinically detectable. In experienced hands, the accuracy of
ultrasound when combined with fine-needle aspiration may be
superior to CT or MRI for staging the neck

30. STAGING

32. Management
• Surgery –definitive , salvage
• Radiotherapy –adjuvant ,definitive(EBRT and /or brachytherapy
),palliative RT
• Concurrent CTRT
• Neoadjuvant CTRT followed by CTRT

33. Surgical Management of the Primary Tumor
• Excision of the primary with margins
• Surgical approach to cancer of the oral cavity may either be
transoral,transcervical(pull through) or via mandibulectomy
• It is commonly recommended to leave atleast a 1cm thick segment of
bone inferiorly following a rim mandibulectomy to reduce the risk of
pathological fracture

34. Reconstructive surgery
• Skin graft-small surgery
• Regional flap-large defect,include pectoralis major flap,trapezius flap
and lattismus dorsi flap
• Free flap-
• Radial forearm free flap ,anterolateral thigh flap ,rectus abdominis
flap and fibula flap
• Total glossectomy flap are well suited
• Reconstruction of mandible requires free flap from fibula flap ,iliac
crest and scapular flap

35. Management of neck
• Types of neck dissection
• RND
• Modified RND (type I,II and III)
• Selective neck dissection
• Supraomohyoid (level I-III/IV)
• Lateral (level II-IV)
• Posterolateral (level II-IV)
• Anterior (level VI)

38. Role of sentinel lymph node dissection
• SND usually guide by invasion of the primary oral tumour
• Depth of invasion >2mm to 4mm –require surgical intervention
• Recently, role of sentinel lymph node biopsy in patients with small volume
(T1-2) oral squamous cell carcinoma have been studied
• SLNB provides excellent sensitivity (~90% to 100%) and negative predictive
value (~95%) with no compromise of local control in the neck
• Factors that might explain the slow adaptation of SLNB in this country
include the steep learning curve, the additional preoperative workup
required, and the need for an experienced multidisciplinary team.
• There is no level I evidence yet available regarding survival equivalency
with END.

40. Brachytherapy
• Brachytherapy is used as “monotherapy” for the treatment of small
primary tumors(T1,T2,N0) or recurrent disease after external beam
radiation therapy (EBRT).
• commonly administered in conjunction with moderate doses of EBRT
• there is no unanimity regarding the sequencing of EBRT and brachytherapy,
it may be advantageous to obtain shrinkage with EBRT before applying
brachytherapy in advanced tumors
• The total duration of therapy, including EBRT and HDR, should be kept as
short as possible (within 8 weeks) to minimize tumor cell repopulation.
• The interval between EBRT and HDR should be as short as possible (within
1–2 weeks), depending on the degree of recovery from mucositis

41. • Physical examination before treatment, examination under
anesthesia, and endoscopy should be used whenever necessary
• Imaging studies such as CT, MRI, and ultrasound can be helpful at
some head-and-neck sites
• The CTV is usually based upon the original extent of disease before
delivery of EBRT
• Placement of radiopaque markers (gold seeds) before starting therapy
can be very helpful to delineate the target volume, before any
shrinkage occurs.

42. • brachytherapy catheters should be placed about 1 to 1.5 cm apart as
equidistant and parallel as possible, to encompass the CTV with a
margin determined on the basis of the clinical parameters
• HDR may be routinely employed in the treatment of soft tissues of
the oral cavity, such as the lip, buccal tissues, floor of mouth, and
tongue.
• Brachytherapy should be used selectively and with caution in lesions
that are anatomically close to the mandible
• Tumors that invade or are immediately adjacent to bone, they are
difficult to manage with radiation therapy alone, and there are
technical limitations on the placement of brachytherapy devices

43. • HDR alone is currently being tested in several centers for the
treatment of T1 and T2 N0 oral cavity lesions.
• Limited information is available on combining EBRT and HDR

44. Selection criteria
• Early accessible lesion
• Early stage disease (ideal implant <5mm)
• Well localised tumor to organ of origin
• No nodal and distant metastasis
• No local infection and inflammation
• No comorbidities:DM,HTN
• Proliferative ulcerative lesion preferred
• Favourable histology –mod differentiated scc

45. • Lip indications –T1-T2 N0 lesions
• TV:all visible and palpable lesion with 5-10mm margin
• Dose : 50 to 70Gy in 5-7 days LDR
• Technique –rigid afterloading template needles maintained in place
by template
• Classical plastic tubes
• Spacers to decrease dose to gingiva,teeth and other lip

46. • Oral tongue : indication-T1 N0,T2 NO <3cm
• TV:GTV+5mm margin
• Dose : alone-60 to 65Gy LDR
boost-20 to 25Gy after EBRT dose of 45 to 50 Gy
• Technique – guide gutter technique
• Floor of mouth : indications –T1-T2 N0 lesions ,>5mm away from
mandible
• Dose and technique same as for tongue implants
• Osteoradionecrosis -5-15%

47. Techniques of implantation
• Commonest techniques used for brachytherapy in the oral tongue are
• Hypodermic needle technique
• Guide gutter technique
• Plastic loop technique

48. Hypodermic needles
• Hollow, bevelled needles with outer diameter of 0.8mm and variable
length (4 to 8cm) open at both ends
• Cause little trauma –can be directly inserted in the tissue
• The rigid steel and template system avoids displacement of the
sources due to elasticity of the soft tissue
• Can be used in lip tumours of < 3cm in largest diameter ,not involving
the lateral commissure

49. Guide gutter technique
• Iridium implants with a fixed separation of 12mm are used
• This limits width of volume which can be treated to approximately
15mm and the technique can therefore only be used for smaller
tumors ( < 30mm in length).
• The guide gutter is first inserted and when they are in position, the
radioactive hairpins can be cut to the desired length
• The pre prepared suture is then tied over the bridge of the hairpin to
secure it within the tongue.

50. Plastic tube loop technique
• This allows a wider separation between the sources, can be used to
treat larger volumes.
• Remote after-loading that reduces the risk of exposure
• In case of local edema inducing the risk of displacement of the plastic
tubes, we can wait for an acceptable local status before loading the
iridium wire.
• Self retaining assembly , no suturing required.

53. Intraoral Cone
• The intraoral cone is another delivery tool to enable boosting of
radiation dose to sites within the oral cavity while avoiding direct
dose to the mandible
• This technique is generally best suited for anterior oral cavity lesions
in edentulous patients
• Lesions up to 3 cm are amenable to treatment with intraoral cone as
long as they are accessible
• Intraoral cone therapy requires careful daily positioning and
verification by the physician

54. • For this purpose, the device is equipped with a periscope to visualize
the lesion.
• The cone abuts the mucosa and is centered directly over the lesion.
• Intraoral cone treatment should take place prior to external beam
radiation so that the lesion can be adequately visualized
• A major advantage of cone therapy is that it is highly focal to the
tumor bed but noninvasive
• Treatment with intraoral cone involves either 100 to 250
kilovolt(peak) (kvp) x-rays or electron beams in the 6 to 12 MeV range

56. Adjuvant Radiation
• adjuvant radiation is commonly recommended to enhance the
likelihood of locoregional tumor control
• Robertson et al-phase III study in the United Kingdom of 350 patients
with T2–T4/N0–N2 oral cavity or oropharyngeal cancers comparing
surgery and postoperative radiation versus radiation alone
• Authors found that after 23 months, overall survival, cause-specific
survival, and local control were all improved in the surgery plus
radiation arm and the study was closed early

57. • RTOG 73–03 (Kramer Head Neck Surg 1987, Tupchong IJROBP 1991):
• 354 patients with locally advanced H&N SCC randomized to 2/50 Gy
pre-op vs. 2/50–60 Gy post-op.
• With median 7-year follow-up, post-op RT significantly improved LRC
(58 → 70%) but not overall survival (20 → 29%).
• Similar rates of complications

58. • Traditionally,indications for postoperative radiation therapy include
multiple cervical metastases, positive or close margins, extracapsular
extension, perineural invasion, advanced T stage, and mandibular
bone involvement
• A phase III study conducted at the University of Texas MD Anderson
Cancer Center to see prognostic significance of clusters of two or
more clinicopathologic features
• adverse clinicopathologic features in this study included (a) close or
positive margins, (b) nerve involvement, (c) ≥2 positive lymph nodes,
(d) largest node >3 cm, (e) treatment delay >6 weeks, and (f) Zubrod
performance status ≥2

59. • There has been recent interest in postoperative chemoradiation for
patients with high-risk pathologic features
• The impact of chemoradiotherapy appears to be most pronounced in
patients with ENE and/or microscopically involved surgical margins

61. • EORTC 22931 (Bernier NEJM 2004): 334 patients with operable H&N SCC
stage pT3–4, pT1-2N2-3, oral cavity/ oropharynx with levels IV–V involved,
or T1-2N0-1 with ECE, +margin, LVSI, or PNI. Randomized to post-op RT
2/60–66 Gy or chemo-RT (+ cisplatin ×3 cycles). Chemo-RT improved 5-year
DFS (36 → 47%), OS (40 → 53%), and LRC (69 → 82%). Chemo-RT increased
acute grade ≥ 3 toxicity (21 → 41%).
• RTOG 95–01 (Cooper NEJM 2004, IJROBP 2012): 459 patients with operable
H&N SCC who had ≥2 LN, ECE, or +margin randomized to post-op RT (2/60–
66 Gy) vs. chemo-RT (2/60–66 + cisplatin ×3 cycles). Chemo-RT improved 2-
year DFS (43 → 54%) and LRC (72 → 82%); only in ECE and/or +margin
subset improved 10-year DFS (12 → 18%) and LRC (21 → 33%). Trend only
for OS improvement. Chemo-RT increased acute toxicity, no significant
increase in late toxicity.

62. • Combined analysis (Bernier Head Neck 2005): In subset of ECE and/or
+margin, post-op chemo-RT improves OS (30% ARR), DFS (23% ARR),
and LRC (42% ARR) vs. RT alone. No significant benefit to concurrent
chemo without these risk factors

70. RTOG 0920,
• cetuximab in the postoperative
treatment for intermediate-risk
disease
• defines intermediate-risk disease as
perineural invasion, lymphovascular
space invasion, close margins, T3/T4a
disease, T2 disease with > 5 mm
thickness, and single lymph node >3
cm or ≥2 or lymph nodes <6 cm
without ENE
• After an R0 resection, patients are
randomized to radiation or cetuximab
plus radiation
RTOG 1216
• to explore the benefit of
cetuximab and docetaxel
compared to standard platinum-
based chemotherapy in the
setting of patients with high-risk
disease (ENE or positive
margins)
• Both studies are closed to
accrual, but results are not yet
available.

71. Lip
• Early lesions can initially invade adjacent skin and the orbicularis oris
muscle. Advanced lesions can invade the adjacent commissures of the lip
and buccal mucosa, the skin and wet mucosa of the lip, the adjacent
mandible, and eventually the mental nerve
• The incidence of perineural invasion is approximately 2%.
• Lymph node involvement at presentation occurs in approximately 5% to
10% of patients
• Hendricks and colleagues from the Mayo Clinic reported the following
incidence of positive cervical lymph nodes by T stage: T1, 2%; T2, 9%; and
T3, 30%. The overall incidence of adenopathy was 19% when the
commissure was involved

72. Clinical Manifestations and Staging
• Carcinoma of the lip usually presents as a slowly enlarging exophytic
lesion with an elevated border. Occasionally, there is minor bleeding.
Erythema of the adjacent skin may suggest dermal lymphatic
invasion. Anesthesia or paresthesia of the skin indicates perineural
invasion

73. Treatment
Early Lesions (<2 cm)
• The majority of these lesions can be surgically excised with primary
closure
• Tumors that should be treated with radiotherapy include those
involving a commissure in order to obtain better cosmesis and
improved local control
• poorly differentiated lesions are also preferably treated by irradiation
to cover a more generous treatment volume and the first-echelon
lymph nodes.

74. Moderately Advanced Lesions (2 to 4 cm)
• Excision followed by reconstruction
• if poor cosmetic and functional outcome ,in these cases, irradiation
has the advantage
Locally Advanced Lesions (> 4 cm)
• Large lesions are managed by resection and postoperative irradiation
• Management by definitive radiotherapy and concomitant
chemotherapy is generally preferred in patients who are not surgical
candidates.

75. Management of the Neck
• Regional lymphatics are not electively treated for T1 and T2 lesions
unless commissure involvement is present
• Patients with advanced (>4 cm), poorly differentiated, and/or
recurrent tumors often require elective neck treatment.

77. Immobilization, and Simulation
• Patient position is generally supine with arms at sides, shoulders relaxed
downward, and neck neutral or extended
• Immobilization involves 3-point thermoplastic head mask; 5-point head
and shoulder mask preferred for intensity-modulated radiation therapy
(IMRT).
• Tongue depressor (aka, intraoral stent) helps stabilize tongue and separate
palate from the tongue
• Contiguous 3 mm spiral computed tomography (CT) slices are acquired
from the top of the brain through the upper mediastinum.
• Intravenous (IV) contrast is preferred to delineate major blood vessels.

79. Conventional
• Generally ,the oral cavity tumour and upper echelon lymph nodes are
included within the initial lateral fields
• Upper border-positioned to provide a 1.5-2cm border on the tumour
• Inferior border-thyroid notch
• Posterior border-mid vertebral body level if level V nodal coverage is
not required
• The nodal volume should include level Ia-Ib.II and III
• Advanced neck disease or risk of positive level V lymph nodes ,the
initial field should be set behind the C1 vertebral body spinous
process

80. • The portals are then reduced at approximately 45Gy to spare high
dose to spinal cord
• If positive cervical lymph nodes metastases or high risk disease ,then
lower neck will also be treated
• In this case, a single half beam blocked anterioposterior field is
matched to the inferior border of the opposed lateral fields at the
level of the thyroid notch
• An anterior larynx block is used,protects larynx from unnecessary
dose and also protects against spinal cord overdose due to three field
overlap

81. • Anteroposterior (AP) field borders
• Superior: matched to the inferior border of lateral fields
• Inferior: 1 cm below the clavicles
• Lateral: cover medial two-thirds of the clavicle
• Posterior en-face electron field (aka “post strips”)
• Superior, posterior, inferior: same as initial lateral fields (or may add 5 to 10 mm
to account for “bowing in” of high isodose lines with electrons)
• Anterior
• Abutting posterior border of off-cord field (“hot match”)—confirm light fields
• Alternatively, may leave 2 to 3 mm gap to avoid hotspot if lymphatics are
adequately covered at depth as per plan

82. target volume design in the postoperative
setting
• There are three classes of CTVs that can be defined based on the practice
of a range of North American institutions and cooperative group guidelines
• The high-risk CTV (CTV66) is defined as the volume harboring ENE or a
positive margin. It is recommended that CTV66 receives 66Gy
• The intermediate-risk CTV (CTV60) is defined as the volume that includes
the primary tumor bed (based on preoperative imaging, physical exam, and
operative findings) plus regions of grossly involved adenopathy.
• The target volume should include the entire primary surgical bed and the
pathologically positive hemineck; this frequently requires coverage of
nodal levels I, IIa-b,III, and IV for most cases

83. • It is recommended that CTV60 receives 60 Gy in 2.0 Gy per fraction.
• The low-risk CTV (CTV54–56) usually includes the prophylactically
treated neck felt to have a low risk of harboring microscopic disease
(e.g., the uninvolved low or contralateral neck) and should receive 54
to 56 Gy as a simultaneous integrated boost in 1.8 to 1.87 Gy per
fraction

86. Definitive RT volume
• GTV = Clinical or radiographic gross disease, if present (primary and
nodes).
• CTV1 = 5–10 mm margin on primary and 3–5 mm margin on nodes
(depending on adjacent critical structures and anatomic boundaries
to microscopic spread).
• CTV2 = “High-risk” areas and nodal levels (e.g., pterygoid plates, next
drainage site from involved nodes).
• CTV3 = Elective nodal levels (same as conventional) and borders of
high-risk areas

91. Lip
• Stage T1-T2 N0
• Preferred –surgical resection of the primary
• For positive margins – re-excise if feasible ,post op RT(including nodes
if not dissected)
• For close margins,PNI,LVSI-post op RT
• Alternative – definitive EBRT+/- Brachytherapy . Salvage surgery for
residual disease

92. • T3-4a or N1-N3-
• Preferred – surgical resection of the primary and ipsilateral neck
dissection (contralateral neck dissection if tumor approach midline or
N2c).Reconstruction as indicated
• Consider post op RT for all,post op chemo RT for positive margins or
ECE
• Alternatively –concurrent chemo RT+/- brachytherapy,if primary
<CR,consider salvage surgery and neck dissection
• If residual neck involvement by imaging at 6-12weeks ,consider
salvage neck dissection

93. Oral cavity
• T1-T2 N0-
• Preferred- surgical resection of the primary with ipsilateral or bilateral
selective neck dissection (consider bilateral for midline ,oral tongue,or
floor of mouth ),for positive margins re-excise if feasible
• Post op RT for adverse features
• Post op CTRT for positive margins
• Alternatively – definitive EBRT +/- brachytherapy .salvage surgery for
residual disease

94. • T3-T4a or N1-N3-
• Preferred –surgical resection of primary with ipsilateral or bilateral
selective neck dissection (consider bilateral for tumor approaching midline
, oral tongue , floor of the mouth , N2c ).reconstruction as indicated
• Consider post op RT for all,post op CTRT for positive margins or ECE
• Unresectable –
• Preferred –concurrent CTRT with cisplatin based regimen
• Alternatively – induction chemotherapy followed by chemoRT or altered
fraction RT if unable to tolerate chemo
• If residual neck involvement by imaging at 6-12 weeks consider salvage
neck dissection

95. • Thank u