Oral cancer: Prognosis & Treatment. Dr. Hani Al Sheikh Radhi

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1 Oral cancer: Prognosis & Treatment Dr. Hani Al Sheikh Radhi

2 Prognostic factors in Oral caner TNM staging T stage N stage M stage Site Histological Factors Vascular & Perineural Invasion Surgical Margins Age, sex, race

3 TNM Staging T primary lesion TX Primary tumor cannot be assessed T0 Tis T1 T2 No evidence of primary tumor Carcinoma in situ Tumor 2 cm or less in greatest dimension Tumor more than 2 cm but not more than 4 cm in greatest dimension T3 T4a* Tumor more than 4 cm in greatest dimension Tumor invades adjacent structures (e.g., through cortical bone, into deep [extrinsic] muscle of the tongue, maxillary sinus, skin of face) (resectable) T4b Tumor invades masticator space, pterygoid plates, or skull base or encases internal carotid artery (unresectable)

4 TNM Staging N Regional lymph node NX N0 N1 Regional lymph nodes cannot be assessed No regional lymph node metastasis 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 a 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 6cm 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

5 TNM staging

6 CT, MRI, FNA, USGFAN

7 TNM Staging Stage Grouping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 T1 N1 M0 T2 N1 M0 T3 N1 M0 Stage IVA T4a N0 M0 T4a N1 M0 T1 N2 M0 T2 N2 M0 T3 N2 M0 T4a N2 M0 Stage IVB Any T N3 M0 T4b Any N M0 Stage IVC Any T Any N M1

8 Site Oral better than oropharynx Anterior better than posterior Form local recurrence point of view buccal mucosa, is the worst Tongue? Recurrence or invasion

9 Histological Factors The aggressive behavior of the tumor Perineural and vascular invasion Differentiation Surgical Margins Frozen section specimen

10 Age, sex, race Younger than 40 increase Male or female? Africans

11 Ablative Surgery SCC Multidisciplinary Size and location of the tumor Normal cuff of tissue Bone resection (rim or segmental) The decision of neck management

12 Bone resection

13 Neck Management 30 40% neck involved during presentation Occult metastases Sentinel lymph node biopsy

14 Neck Management

15 Occult metastases Neck Management

16 Neck Management Sentinel lymph node biopsy (SLNB)

17 T2 tongue SCC SLNB

18 SLNB Technetium 99 & lymphoscintigraphic images

19 Gamma probe SLNB

20 Neck Management

21 NECK DISSECTION Remove and detect occult metastases elective Remove clinically evident neck therapeutic

22 Neck Dissection Radical Neck Dissection (RND) 1906 Lymph nodes (I V) Non lymphatic structures SAN SCM IJV

23 Neck Dissection Modified Radical Neck Dissection Lymph nodes (I V) Non lymphatic Type one: preserve SAN Type two: preserve SAN, SCM Type three: preserve SAN, SCM, IJV

24 Neck Dissection Selective Neck Dissection Supraomohyoid Levels I III: SND (I III) SND (I IV) with tongue

25 Neck Dissection

26 Neck Dissection

27 Neck Dissection SND (I III) OR (I IV) Intra operative Judgment Radiotherapy recommended with N2 or ECS SND contra indicated with fixation, large nodes, or ECS

28 Access Surgery Maxilla Weber Fergusson Mid face degloving Combination

29 Access Surgery Weber Fergusson

30 Access Surgery Weber Fergusson

31 Access Surgery Mid face degloving

32 Access Surgery Combination Posterior tumor can not be reached with weber fergusson WF with Lip splitting

33 Access Surgery Mandibular approaches Transoral lip splitting Mandibulotomy appraoch Pull through technique

34 Access Surgery Transoral T1&T2 tongue T1 floor of the mouth

35 Access Surgery Lip splitting Mnadibulotomy

36 Lip Splitting Access Surgery

37 Access Surgery Pull through (transcervical)

38 Radiation Radical Radiotherapy Palliative radiotherpay

39 Radiation Mucositis Xerostomia Skin Erythema Osteoradionecrosis

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42 Thank you