General Therapeutic Principles

For early T1 and T2 lesions, radiation therapy and surgery are equally effective in achieving local control. Superficial lesions that are < 2 cm (T1) and are away from the bone can be considered for treatment with an interstitial implant alone. Lesions > 2 cm and < 4 cm (T2) and without clinical lym-phadenopathy may be treated with external radiation therapy (5,000 cGy) which would include the adjacent regional lymph nodes (submental, submandibu-lar and jugulodigastric) and a temporary interstitiary implant (2,000 to 2,500 cGy).

For moderately advanced T2 to T3 lesions, full course external beam radiation therapy is used. However, for lesions in the floor of mouth and oral tongue, extension of disease deep into the musculature and into adjacent mandibular bone would best be treated with surgery and postoperative radiation therapy. A major concern in the primary use of radi ation therapy for T1 and T2 oral cancer regions is the potential for complications including soft tissue and bone necrosis as well as acute and long-term side effects such as mucositis and xerostomia. These concerns must be considered for early stage lesions

Figure 21-4. A patient with T2N0 squamous cell carcinoma of the lower lip prior to (A) and several months after (B) brachytherapy. He was treated with a temporary afterloaded interstitial implant technique (C).

when evaluating a patient for treatment using primary surgery or radiation therapy. At Memorial Sloan-Kettering Cancer Center, we generally would favor proceeding with surgery for T1 and T2 lesions of the oral cavity where no significant functional sequelae would result. These lesions would be technically quite accessible surgically and this modality would carry a low complication rate.

While lymph node metastasis in head and neck cancer generally occur in an orderly predictable manner by spreading consecutively from level to level, oral cavity lesions can occasionally skip the first echelon of lymph nodes down to level III or IV with an overall incidence of around 5 percent.27 Byers and colleagues28 found that 15 percent of patients with primary oral tongue cancer exhibited skip metastases down to level IV. This should be kept in mind when one is considering a patient with oral cavity cancer for possible regional nodal irradiation.

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