treatment algorithm for oral cancer

7/29/2019 Treatment Algorithm for Oral Cancer

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1

Treatment algorithm for Oral Cancer

Commissure Involvement

Poorly differentiated

Upper lip

+ve margin

Perineural infiltration

Lip cancer

Staging evaluation CT scan for T3/T4 to assess nodal

spread/bone invasion

T1 : Early lesions(4 cm)

T4a T4b

yes no

RTSurgery: If

Cosmetic &functional outcome is

Surgery

RT: ISBT/IntraOral Cone/ExtRT

- RT- Surgery: If Cosmetic& functional out comeis favourable

- RT Salvage surgery- Surgery: If Cosmetic &functional out come isfavourable > PORT.

treat neck if lesion is

poorly differentiatedor if dermal orcommissure involvementis present

PalliativeRT

ClinicalTrial


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2

+ve marginPerineural infiltration

Floor of mouth cancerStaging evaluation

CT scan for all T3/T4 to assess nodal MRI optional Ta spread/bone invasion


T4a T4b

O erable

Inoperable

Post OperativeRadiotherapy+/_ ConcomitantChemotherapy

RT: ISBT/IntraOral Cone/ExtRT

-Close/involved margins- perineural/lymphaticspace invasion- neck involvedwith multiple nodes orextracapsular extension


PalliativeRT

ClinicalTrial

Surgery*

Surgery**Treat neck with neckdissection or radiotherapy inany patient with aprimary lesion that is morethan 1.5 mm thick

Pre OP RT +/-concomitant CT

CompleteResponse

Partial

responseNo response/

InflammatoryCa/Progressivedisease

Surgery*Radiotherapy+/-ConcomitantChemothera

PalliativeSymptomatic& supportiveTreatment.

Clinical Trial

Surgery*

Radiotherapy+/- ConcomitantChemotherapyor Palliative RT


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3

Oral tongue cancer

Staging evaluation CT scan MRI


T4a T4b

Inoperable


PO RT:ISBT/Intra OralCone/Ext RT +/-concomitant CT


PalliativeRT

ClinicalTrial

Surgery

Surgery*: > 1cms marginpreferable.*Treat neck with neckdissection or radiotherapy inany patient with aprimary lesion that is morethan 1.5 mm thick


CompleteResponse

Partial

responseNo response/InflammatoryCa/Progressivedisease

Surgery*Radiotherapy+/-ConcomitantChemotherapy

PalliativeSymptomatic &supportiveTreatment.

Clinical Trial

Surgery*

Radiotherapy+/- ConcomitantChemotherapyOr Palliative RT

RT

-Superficial-Exophyticlesion*

Close involvedmarginsmultiple positiveneck nodesvascular spaceinvasionextracapsularextension/perine

ural

Operable


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4

Buccal Mucosa cancer(Includes Lip Mucosa)

Staging evaluation CT scan X ray mandible


T4a T4b

Inoperable




PalliativeRT

ClinicalTrial

Surgery*

Surgery*: > 1cms marginpreferable.*Treat neck with neckdissection or radiotherapy inany patient with aprimary lesion Tumorthickness >6 mm, Depth ofinvasion >3 mm.*Treat neck (radiotherapy or

neck dissection) for T2 to T4tumors. Ipsilateral 1

st& 2

nd

Echelon neck


CompleteResponse

Partial



PalliativeSymptomatic &supportiveTreatment.

Clinical Trial

Surgery*

Radiotherapy+/- ConcomitantChemotherapyOr Palliative RT

RT*: ISBT.Ext+Brachy,Ext RT

Commisure Free.lesions :Ulacerative,Infilatrative

Close involvedmarginsmultiple positiveneck nodesvascular spaceinvasionextracapsularextension/peri-neural

Operable

Comissureinvoled,-Superficial-Exophyticlesion*


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GINGIVA cancer

Upper Gingiva Lower Gingiva

Staging evaluation CT scan X ray mandible MRI


T4a T4b

Inoperable




PalliativeRT

ClinicalTrial

Surgery*:Includeperiostium orBone Surgery*: > 1cms margin

preferable. Include periostiumor Bone.Upper Alveolus: Partial / TotalmaxillectomyLower Alveolus: rim resection/intro oral excision

* lower gingiva lesions :

ipsilateral , electively treatneck MND or radiotherapy inany patient


CompleteResponse

Partial



Palliation:Symptomatic &supportiveTreatment.Clinical Trial

Surgery*


RT*:Ext+IOConeRT, Ext RT

Close involvedmarginsmultiple positive

neck nodesvascular spaceinvasionextracapsularextension /peri-neural

Operable

SuperficialExtension toHard palate orsoft palateExophyticlesion*


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6

Retromolar trigone cancerStaging evaluation

CT scan MRI


T4a T4b

Inoperable


PO RT:

Intra OralCone/Ext RT


PalliativeRT

ClinicalTrial

Surgery*:Includeperiostium orBone. +vemargin,Perineuralinvasion

Surgery*: Include periostium orBone. electively treat neckMND or radiotherapy in anyatient


CompleteResponse

Partial



Symptomatic &supportiveTreatment.Clinical Trial

Surgery*



Operable

Superficial ,Exophyticlesion, Involvement ofthe tonsillar pillar, softpalate, or buccalmucosa


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7

Hard Palate cancerStaging evaluation

CT scan

MRI


T4a T4b

Inoperable

Post OperativeRadiotherapy

+/_ ConcomitantChemotherapy

PO RT:Intra OralCone/Ext RT


PalliativeRT

ClinicalTrial

Surgery*:Includeperiostium orBone. +vemargin,Perineuralinvasion

Surgery*: Include periostium orBone. electively treat neckMND or radiotherapy in anyatient


CompleteResponse

Partialresponse

No response/InflammatoryCa/Progressivedisease


Symptomatic &supportiveTreatment.Clinical Trial

Surgery*



Operable

Superficial ,Exophyticlesion, Involvement ofthe tonsillar pillar, softpalate


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Oral cancer : General Treatment principlesPreferred Primary Treatment

Modality

T1 & T2 N0 Surgery or RT

T3 & T4 A Any N Surgery + PORT

T4b Palliative

RT/CT/Clinical

Trial

Primary RT is prefered in Primary RT is prefered for early T1/T2

Cosmesis

Function

patients Profession

Patient preference

Angle of the mouth

involvement

expohytic lesions

Poorly differentiated

lesions

local facility

Local skill

Co-morbid conditons

Lip ISBT

FOM IOCRT

Tongue Ext RT + Brachy

BM Ext RT + IOCRT

Post Operative

radiotherapy is indicated

in :- N0 Clinically - N+ pathologically

positive surgical

margin

Frozen section

positivity

perineural invasion

node positivity

lymphovascular

invasion

Peri nodal spread

Bone infiltration

multiple nodes

Floor Mouth 21 - 50%

Gingiva 12 - 19%

Hard palate

Buccal Mucosa 0 - 10%

Oral Tongue 25 - 54%

Retro Molar Trigone 35%

lip 5 - 10%

treatment algorithm for oral cancer

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