H&N Evaluation and Management of oral cavity cancer Flashcards
What environmental risk factors act synergistically
in the formation of oral cavity squamous cell
carcinoma and are the most common risk factors
in the Western world?
Tobacco and alcohol
In addition to tobacco and alcohol use, what risk
factors place a patient at higher risk for developing
oral cavity cancer?
● Betel nut chewing ● Chewing tobacco or other oral tobacco ● Chronic periodontal disease or irritation ● History of head and neck radiation ● History of head and neck cancer ● Immunodeficiency ● Sun exposure (lip) ● Other: Plummer-Vinson syndrome, chronic syphilis
Is HPV infection considered a major risk factor in
the development of oral cavity carcinoma?
No. Although it is a risk factor, it is not considered a major
risk factor, and its role in carcinogenesis in the oral cavity is
unclear.
What is the most common malignancy of the oral
cavity?
Squamous cell carcinoma (~95%)
Note: For the hard palate, tumors most commonly arise in
the minor salivary glands.
What are the most common squamous cell
carcinoma subtypes found within the oral cavity?
● Sarcomatoid carcinoma
● Basaloid carcinoma
● Verrucous carcinoma
What are the most common malignancies of the
oral cavity, excluding squamous cell carcinoma?
● Lymphoma
● Minor salivary gland tumors: Adenoid cystic carcinoma,
mucoepidermoid carcinoma, polymorphous low-grade
adenocarcinoma, adenocarcinoma
● Sarcoma: Osteosarcoma, chondrosarcoma, malignant
fibrous histiosarcoma, rhabdomyosarcoma, liposarcoma,
Kaposi sarcoma
● Melanoma: Malignant mucosal melanoma
What common premalignant lesions are associated with an increased risk of developing an oral
cavity squamous cell carcinoma?
● Leukoplakia: White plaque, cannot be wiped off; lower
risk of malignant conversion (< 30%)
● Erythroplakia: Red plaque, not associated with obvious
cause; higher risk of malignant conversion (< 60%)
● Lichen planus: Lacy white pattern on mucosa or atrophic
lesions (red and smooth) or erosive lesions (depressed
margins, covered with fibrinous exudate), more common
in women (40s), < 1% 10-year conversion rate
● Submucosal fibrosis: Thickened and fibrotic buccal
mucosa and deeper structures; associated with betel quid
chewing, poor oral hygiene
What premalignant lesion can be mistaken for
verrucous carcinoma but is differentiated on
pathology because it does not invade the lamina
propria?
Verrucous hyperplasia. Most commonly occurs on the
buccal mucosa of men in their fourth decade of life.
What benign lesion manifests as a butterfly-
shaped ulceration commonly found at the hard–
soft palate junction and is associated with pressure
injuries?
Necrotizing sialometaplasia
What benign lesion is commonly found in mucosal
or salivary tissue and may resemble squamous cell
carcinoma?
Pseudoepitheliomatous hyperplasia
What are common benign exostoses that appear
as firm submucosal masses on the anterior lingual
mandible and midline hard palate?
Torus mandibularis and torus palatini, respectively
What are the most common initial signs and
symptoms associated with oral cavity cancer?
Bleeding, pain, halitosis, dysphagia, and dysarthria
What is the most common site of oral verrucous
carcinoma?
Buccal mucosa
What is the most common location of oral tongue
squamous cell carcinoma?
Posterolateral oral tongue
What is the most common location of buccal
mucosa squamous cell carcinoma?
Adjacent to the thirrd mandibular molar
When does the NCCN (2013) recommend PET/CT
scan in the workup of patients with oral cavity
cancer?
Consider for stage III–IV disease
Name four common features of patients with early
stage (stage I or II) oral cavity cancer.
● Primary tumor < 4 cm (T1–2)
● No evidence of invasion into adjacent structures
● No evidence of cervical metastases (N0)
● No distant metastases (M0)
How is a T4a oral cavity tumor defined?
Moderately advanced local disease:
● Lip: It invades through the cortical bone, inferior alveolar
nerve, floor of mouth, or skin of face.
● Oral cavity: Tumor invades adjacent structures (e.g.,
through cortical bone, extrinsic (deep) tongue muscu-
lature, maxillary sinus, skin of face).
True or False. Superficial erosion bone or tooth
socket alone meets the criteria for staging a tumor
as T4a.
False
How are T4b oral cavity tumors defined?
● Very advanced local disease
● Tumor invades masticator space, pterygoid plates, or
skull base, and/or encases the internal carotid artery.
What pathologic factors directly relate to prog-
nosis in oral cavity cancer?
● Tumor thickness (> 5 mm = increased risk of occult nodal
disease, decreased recurrence free and overall survival
rates)
● Differentiation
● Angiolymphatic invasion
Which has a worse prognosis: upper or lower lip
cancer?
Upper lip cancer tends to be more aggressive and to have
early metastatic potential.
What are the adverse risk features considered by
the NCCN (2011) in their algorithm for oral cavity
cancer management?
● Extracapsular nodal spread ● Positive margins ● pT3 or pT4 primary ● N2 or N3 nodal disease ● Nodal disease in levels IV or V ● Perineural invasion ● Vascular embolism
What treatment strategy recommended by the
NCCN (2013) for early stage (stage I and II) oral
cavity cancer?
● Surgical resection ± neck dissection as indicated by tumor
thickness and location (preferred):
○ No adverse risk factors→ Surveillance
○ One positive node without adverse risk features→
Optional adjuvant radiation
○ Extracapsular spread and/or positive margin→ Che-
moradiation (preferred) versus reexcision versus radia-
tion therapy
○ Other adverse risk features→ Radiation therapy versus
chemoradiation therapy.
● Radiation therapy ± brachytherapy
For patients with advanced stage disease (T1–
3N1–3; T3N0; T4a, any N), excluding T4b or
unresectable nodal disease, what is the primary
treatment strategy recommended by the NCCN
(2013)?
● Surgical resection with ipsilateral or bilateral neck
dissection (N2c or high risk to contralateral neck)
● No adverse features: Radiation therapy (optional)
● Extracapsular spread and/or positive margin: Chemo-
radiation therapy (preferred) vs reexcision versus radiation therapy
● Other risk features: Radiation therapy versus chemo-
radiation therapy
● Multimodality clinical trials
How can the mandible be managed if an oral
cavity cancer appears to invade the periosteum,
cortex, or medullary space, either intraoperatively
or on preoperative workup?
● Marginal or rim mandibulectomy: Periosteum or super-
ficial cortical invasion
● Segmental mandibulectomy: More than superficial cort-
ical invasion, medullary invasion, invasion from perineural spread via the mandibular or mental foramen, hypoplastic/atrophic/edentulous mandible making rim mandibulectomy unsafe, invasion of periodontal ligament or tooth socket
When performing osteotomy for mandibulotomy, which is preferable: straight or stepwise osteot-
omy? Median or paramedian placement?
● Stepwise mandibulotomy: Provides better alignment and
stability
● Paramedian: Minimizes trauma to the genioglossus,
geniohyoid, and digastric muscles
Describe the extent of neck dissection recommended by the NCCN (2013) for oral cavity cancer
based on clinical nodal staging.
● No neck dissection: It can be considered for T1N0 lower-
lip cancer, T1–T2N0 oral tongue with < 2 mm of invasion,
T1–T2N0 upper alveolar ridge and hard palate tumors.
For lesions 2- to 4-mm thick, elective neck dissection is
used when appropriate (patient reliability, other risk
factors, and so forth).
● N0: Select neck dissection. Supraomohyoid (levels I–III)
recommended for oral cavity tumors > 4 mm; level IIB
dissection is controversial; can consider preserving for
early stage disease. Consider suprahyoid dissection (levels
IA and IB) for T2 lower-lip tumors.
● N1–N2c: Select or comprehensive neck dissection as
indicated
● N3: Comprehensive neck dissection
What is regimen is recommended by the NCCN
(2013) for definitive radiation therapy for oral
cavity cancer with gross lymphadenopathy?
● Conventional fractionation: 66–74 Gy, Monday through
Friday for 7 weeks
● Altered fractionation:
○ Six fractions/week accelerated: 66 to 74 Gy (gross
disease), 44 to 64 Gy (subclinical disease)
○ Concomitant boost accelerated: 72 Gy for 6 weeks
(boost given during a second daily fraction for the last
12 days of treatment)
○ Hyperfractionation: 81.6 Gy x 7 weeks given twice daily
Monday through Friday.
What radiation dose is typically given to uninvolved nodal levels at risk for occult disease in oral cavity cancer undergoing definitive radiation?
44 to 64 Gy
When should adjuvant radiation or chemoradia-
tion begin after surgical resection for oral cavity
cancer?
Six weeks or less (often around 3 to 4 weeks). Ideally all
treatment will be completed within 12 weeks from
diagnosis. Given 6 weeks of typical adjuvant therapy, this
gives 6 weeks from diagnosis to initiation of adjuvant
therapy.
What is the recommended adjuvant radiation
recommended for oral cavity cancer?
● Primary site: 60 to 66 Gy, daily Monday through Friday for
6 weeks
● N(+) levels: 60 to 66 Gy
● N(-) levels: 44 to 64 Gy
What chemotherapeutic regimen is recommended when adjuvant chemoradiation therapy is planned for oral cavity cancer?
Concurrent cisplatin (100 mg/m2 every 3 weeks)
What is the reconstruction of choice for lower-lip
defects smaller than one-third the length of the
lip, between one-third and two-thirds, greater
than two-thirds?
● Less than one-third: Primary closure
● One-third to two-thirds: Abbe-Estlander flap
● More than two-thirds: Karapandzic flap, Webster-Bernard
flap, or radial forearm free flap with palmaris longus
tendon
What local flap using the facial artery can be used
to close intraoral defects?
Facial artery musculomucosal (FAMM) flap
In a patient with a floor of mouth or oral tongue
tumor, resection followed by primary closure of a
large defect can result in what long-term compli-
cation?
Tethered tongue
What reconstructive options are best used to avoid
trismus in defects of the buccal mucosa larger
than 3 cm in diameter?
Skin graft or free tissue transfer
What is the reconstruction of choice for patients
with segmental resection of the anterior mandi-
ble?
Free tissue transfer with vascularized bone (i.e., fibula free
flap)
What is the reconstruction of choice for patients who
have greater than 50% of the oral tongue resected?
Fasciocutaneous free flap, radial forearm free flap
What reconstruction options are best in patients
with segmental mandibulectomy who are not
candidates for free tissue transfer?
Soft tissue pedicled flap with or without a reconstruction
bar. Reconstruction bars should be used with caution
without underlying bone. They are prone to fracture,
exposure, and infection.
What is an adequate nonsurgical method for
rehabilitation of speech and swallow function after
resection of a hard palate or maxillary alveolar ridge
tumor with resultant oronasal or oroantral fistula?
Prosthetic obturator
