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Palatomaxillary Cancer

Deciding on a Treatment Plan

Your doctors will typically use National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers, as well as their own professional experience, to decide on the appropriate treatment course.16Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed November 9, 2016. To view the most recent and complete version of the guideline, go online to www.NCCN.org. If these guidelines are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Pretreatment Evaluation

  • A full history and physical examination, including a complete head and neck exam (mirror and fiberoptic exam)
  • An evaluation by the members of a head and neck cancer team
  • A biopsy to confirm a diagnosis of cancer
  • Imaging of the lungs to check for spread, if needed
  • Imaging of the primary tumor and the neck with CT and/or MRI
  • Maybe a PET-CT for advanced cancers
  • A dental evaluation, with or without jaw X-rays, when necessary
  • Examination under anesthesia with endoscopy if necessary
  • Nutrition, swallowing and speech evaluation/therapy when necessary
  • Pretreatment medical clearance and optimization of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on a number of factors. Depending on whether the cancer has spread or not, there are three general therapeutic options to consider:

Surgery is the recommended treatment when possible in almost all cases of oral cancer. Also, if a positive margin (rim of tissue around the tumor that should be normal tissue but has cancer cells in it) is found after removal of the cancer, all efforts should be made to re-resect and get to negative margins (rim of normal tissue around the tumor).

The treatment recommendations for oral cancers do not really vary by subsite, though there are certain subtle differences for lip cancer. The surgery your doctor recommends does vary depending on the location of the cancer as well as the stage. You should have an extensive discussion with your care team about different surgeries that might be required for your cancer.

How to manage the maxilla and hard palate bones is an important consideration. Managing the neck in palatomaxillary cancer is also an area of discussion. Historically, the general consensus was that there was a low rate of spread of cancer to lymph nodes in the neck, so a neck dissection was not necessary. However, more recent studies have found that eventual spread to lymph nodes is more common than originally thought, and a neck dissection is probably a good idea whether it looks like there are cancerous nodes or not.17, Morris LG, Patel SG, Shah JP, Ganly I. High rates of regional failure in squamous cell carcinoma of the hard palate and maxillary alveolus. Head Neck. 2011 Jun;33(6):824-30.18Simental AA Jr, Johnson JT, Myers EN. Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate. Laryngoscope. 2006 Sep;116(9):1682-4.

The reconstruction that your doctor recommends will change depending on what is removed.

Below are the recommended treatment options for oral cancer, depending on your T and N stages.16Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed November 9, 2016. To view the most recent and complete version of the guideline, go online to www.NCCN.org.

T1-2, N0 For cancers in this category, treatment options are:

  • Surgical removal of the cancer, with or without neck dissection, depending on location of the tumor and on how thick the tumor is (preferred treatment)
  • Surgical removal of the cancer with or without a sentinel lymph node biopsy. A neck dissection may also be performed depending on the results of the biopsy

The treatments above should then be followed by either no additional treatment, radiation alone, surgery again, or chemotherapy with radiation, depending on what is found in surgery.

  • Radiation alone as primary treatment is also an option. This may be followed by either no additional treatment or surgery, depending if there is left over disease from the radiation therapy.
T3, N0 or

T1-3, N1-3 or

T4a, Any N

The initial treatment is surgical removal of the cancer with neck dissection(s). Then, either no additional treatment, radiation or chemotherapy and radiation will be recommended, depending on findings in the surgery. Certain factors that might guide what additional treatment is required will be features such as:

  • Positive margins (the presence of cancer cells at the edge of the resection that was performed)
  • Spread of cancer beyond the lymph nodes in the neck
  • T3 or T4 tumors based on pathologic evaluation
  • N2 or N3 disease in the neck lymph nodes
  • Cancerous lymph nodes in the lower part of the neck (Level IV), or towards the back portion of the side of the neck, behind the big neck muscle called the sternocleidomastoid (Level V)
  • Invasion into or around nerves
  • Tumor inside blood vessels

 

T4b, any N or

Unresectable neck disease or

Unfit for surgery

In cases that are very advanced, or in patients who are extremely sick, an extensive discussion with your doctors should be undertaken.

 

References

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8 Koch WM, Choti MA, Civelek AC, Eisele DW, Saunders JR. Gamma probe-directed biopsy of the sentinel node in oral squamous cell carcinoma. Arch Otolaryngol Head Neck Surg. 1998. 124:455-9.

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16 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed November 9, 2016. To view the most recent and complete version of the guideline, go online to www.NCCN.org.

17 Morris LG, Patel SG, Shah JP, Ganly I. High rates of regional failure in squamous cell carcinoma of the hard palate and maxillary alveolus. Head Neck. 2011 Jun;33(6):824-30.

18 Simental AA Jr, Johnson JT, Myers EN. Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate. Laryngoscope. 2006 Sep;116(9):1682-4.

19 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer.2010.

20 Lin HW, Bhattacharyya N. Survival impact of nodal disease in hard palate and maxillary alveolus cancer. Laryngoscope. 2009 Feb;119(2):312-5.

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23 Maddox WA, Urist MM. Histopathological prognostic factors of certain primary oral cavity cancers. 1990 Dec;4(12):39-42; discussion 42,45-6.

24 Piccirillo JF, Costas I, Reichman ME. Chapter 2: Cancers of the head and neck. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.