Treatment Goals And Alternatives Factors Affecting Choice Of Treatment

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The surgeon's goal is complete removal of all cells of the primary tumor and any cancer cells in regional lymph nodes, while preserving the integrity of uninvolved structures. Similarly, the radiotherapist endeavors to damage the abnormal cells irreparably while sparing the normal tissue. Either modality is effective in controlling early oral carcinomas, but the use of both modalities in combination is necessary to control locally advanced disease. The role of chemotherapy alone in localized disease is palliative. Currently, distantly metastatic disease is incurable but can often be effectively palliated with chemotherapy and radiation.

Treatment choices are best made after considering tumor factors, patient factors and resources factors. Tumor factors include subsite, T stage, N stage, histologic characteristics, endophytic vs. exophytic morphology, and proximity to bone. Patient factors include the patient's age, co-morbidities, convenience, rehabilitation potential, and the patient's wishes. Resource factors include the availability of a well-trained surgeon or radiotherapist with a dedicated interest in head and neck cancer, availability of advanced hardware for the planning and delivery of radiation, and the availability of funds to pay for the treatment.

The mainstay of treatment of early oral cancer is surgery. External beam radiation therapy alone can be effective for some early superficial lesions of the tongue or floor of mouth but sequelae of xerostomia

Figure 5-5. A T2N0 squamous carcinoma of the left lateral border of the tongue seen infiltrating the superficial musculature of the tongue on an MRI scan.

and mandible irradiation, and long duration and expense of treatment make radiation a poor choice. Also, bone involvement by oral cancer limits the effectiveness of external beam radiation, so lesions of the gingiva and hard palate are best treated with surgery due to the close proximity of bone and the high incidence of bone invasion. Advantages of surgery for T1 and T2 oral cancer compared to radia-

Table 5-I. UICC/AJCC STAGING SYSTEM FOR ORAL CANCER

T1 Tumor 2 cm or less in greatest dimension T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension

T3 Tumor more than 4 cm in greatest dimension T4 Tumor (lip) invades adjacent structures (eg, through cortical bone, tongue, skin of neck) Tumor (oral cavity) invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue, maxillary sinus, skin) Regional Lymph Nodes (N)

NX Regional lymph nodes cannot be assessed

NO No regional lymph node metastasis

N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3 Metastasis in a lymph node more than 6 cm in greatest dimension

Distant Metastasis (M)

MX Presence of distant metastasis cannot be assessed MO No distant metastasis M1 Distant metastasis

Stage Grouping

Stage O

Tis

NO

MO

Stage I

T1

NO

MO

Stage II

T2

NO

MO

Stage III

T3

NO

MO

T1

N1

MO

T2

N1

MO

T3

N1

MO

Stage IV

T4

NO

MO

T4

N1

MO

Any T

N2

MO

Any T

N3

MO

Any T

Any N

M1

tion include decreased cost, decreased time of treatment, the generation of a surgical specimen for examination of potential prognostic features and, in some instances, an opportunity to sample the regional clinically negative nodes for occult disease. Advantages of radiation therapy for early lesions are preservation of tissue and no need for general anesthetic.

Advanced T3 and T4 lesions are best treated with a combination of surgery and radiation therapy. Improvement in locoregional control of advanced oral cancer is attributable to the addition of postoperative radiation.1516

Brachytherapy can sometimes be employed for oral cancers (especially tumors of the tongue) utilizing after-loading catheters.17 However, resection of small lesions is usually simpler and less morbid, and surgery followed by radiation is more appropriate for treating the large volume T3 or T4 lesion. Close proximity of the tumor to the mandible, complex surface anatomy, and uncertainty of the tumor margins are tumor factors that also limit use of brachytherapy for oral cavity cancers. Tumors of the oral cavity are poorly responsive to traditional organ sparing approaches combining either sequential or concomitant chemotherapy and radiation therapy. The control rates for oral cavity cancers using these regimens are the lowest of all head and neck sites.18 Chemotherapy alone for oral cavity cancers is palliative. While some complete clinical responses can be obtained, they are not durable. Preoperative chemotherapy for oral cancers is usually not helpful because adequate resection margins do not shrink with the clinical response of the tumor. Studies show that microscopic tumor foci exist where previous gross tumor has been shrunken by chemotherapy treatment. It is therefore not ordinarily possible to reduce the extent of surgical resection and the morbidity of oral cancer surgery by tumor shrinkage with preoperative chemotherapy.19

It is important that all head and neck cancer patients and their cases be discussed in a multi-modality treatment conference setting to insure appropriate management.

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