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Oromandibular Cancer

Deciding on a Treatment Plan

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 if needed)
  • 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 therapy when necessary
  • Pretreatment medical clearance and evaluation 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.

Also, 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.16

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 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 initial radiation.

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 toward 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.

 

*This table is supported by the following sources:

Adelstein, D. J., et al. (2012). “Transoral resection of pharyngeal cancer: summary of a National Cancer Institute Head and Neck Cancer Steering Committee Clinical Trials Planning Meeting, November 6-7, 2011, Arlington, Virginia.” Head Neck 34(12): 1681-1703.

Byers, R. M. (1991). “Neck dissection: concepts, controversies, and technique.” Semin Surg Oncol 7(1): 9-13.

Hinni, M. L., et al. (2013). “Margin mapping in transoral surgery for head and neck cancer.” Laryngoscope 123(5): 1190-1198.

Cracchiolo, J. R., et al. (2016). “Increase in primary surgical treatment of T1 and T2 oropharyngeal squamous cell carcinoma and rates of adverse pathologic features: National Cancer Data Base.” Cancer 122(10): 1523-1532.

Denis, F., et al. (2004). “Final results of the 94-01 French Head and Neck Oncology and Radiotherapy Group randomized trial comparing radiotherapy alone with concomitant radiochemotherapy in advanced-stage oropharynx carcinoma.” J Clin Oncol 22(1): 69-76.

Zumsteg, Z. S., et al. (2017). “Impact of concomitant chemoradiation on survival for patients with T1-2N1 head and neck cancer.” Cancer 123(9): 1555-1565.

Sher, D. J., et al. (2017). “Radiation therapy for oropharyngeal squamous cell carcinoma: Executive summary of an ASTRO Evidence-Based Clinical Practice Guideline.” Pract Radiat Oncol 7(4): 246-253.

Haughey, B. H., et al. (2011). “Transoral laser microsurgery as primary treatment for advanced-stage oropharyngeal cancer: a United States multicenter study.” Head Neck 33(12): 1683-1694.

References

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

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