Treatment algorithm for Oral Cancer

Lip cancer
Staging evaluation CT scan for T3/T4 to assess nodal spread/bone invasion

T1 : Early lesions (<2.0 cm)

T2: Moderately advanced lesions (2-4 cm)

T3 Locally advanced lesions (>4 cm)

T4a

T4b

Commissure Involvement Poorly differentiated Upper lip

yes no - RT - Surgery: If Cosmetic & functional out come is favourable - RT Salvage surgery - Surgery: If Cosmetic & functional out come is favourable > PORT. treat neck if lesion is poorly differentiated or if dermal or commissure involvement is present Palliative RT Clinical Trial

RT Surgery: If Cosmetic & functional out come is favourable

Surgery

+ve margin Perineural infiltration

RT: ISBT/Intra Oral Cone/Ext RT

Floor of mouth cancer

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

T1 : Early lesions (<2.0 cm) (T1 and superficial T2)

T2: Moderately advanced Lesions (large T2 and endophytic T3)

T3 Locally advanced lesions (>4 cm)

T4a

T4b

Surgery*

+ve margin Perineural infiltration

Surgery* *Treat neck with neck dissection or radiotherapy in any patient with a primary lesion that is more than 1.5 mm thick

Palliative RT Operable Clinical Trial

RT: ISBT/Intra Oral Cone/Ext RT -Close/involved margins - perineural/lymphatic space invasion - neck involved with multiple nodes or extracapsular extension

Surgery* Inoperable

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Post Operative Radiotherapy +/_ Concomitant Chemotherapy Complete Response

Pre OP RT +/concomitant CT

Radiotherapy +/- Concomitant Chemotherapy or Palliative RT

Partial response

No response/ Inflammatory Ca/Progressive disease

Radiotherap y +/Concomitant Chemothera py Surgery* Palliative Symptomatic & supportive Treatment. Clinical Trial

Oral tongue cancer

Staging evaluation CT scan MRI

T1 : Early lesions (<2.0 cm) (T1 and superficial T2)

T2: Moderately advanced Lesions

T3 Locally advanced lesions (>4 cm)

T4a

T4b

-Superficial -Exophytic lesion* Surgery * Close involved margins multiple positive neck nodes vascular space invasion extracapsular extension/perine ural invasion RT * Surgery*: > 1cms margin preferable. *Treat neck with neck dissection or radiotherapy in any patient with a primary lesion that is more than 1.5 mm thick Palliative RT Operable Clinical Trial

Surgery* Inoperable

PO RT: ISBT/Intra Oral Cone/Ext RT +/concomitant CT

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Pre OP RT +/concomitant CT

Radiotherapy +/- Concomitant Chemotherapy Or Palliative RT

Complete Response

Partial response

No response/ Inflammatory Ca/Progressive disease

Radiotherapy +/Concomitant Chemotherapy Surgery* Palliative Symptomatic & supportive Treatment. Clinical Trial Clinical Trial

Buccal Mucosa cancer

(Includes Lip Mucosa)
Staging evaluation CT scan X ray mandible

T1 : Early lesions (<2.0 cm) (T1 and superficial T2)

T2: Moderately advanced Lesions

T3 Locally advanced lesions (>4 cm)

T4a

T4b

Commisure Free. lesions : Ulacerative, Infilatrative

Comissure involed,Superficial -Exophytic lesion*

Surgery* RT*: ISBT. Ext+Brachy, Ext RT Close involved margins multiple positive neck nodes vascular space invasion extracapsular extension/perineural invasion

Surgery*: > 1cms margin preferable. *Treat neck with neck dissection or radiotherapy in any patient with a primary lesion Tumor thickness >6 mm, Depth of invasion >3 mm. *Treat neck (radiotherapy or neck dissection) for T2 to T4 tumors. Ipsilateral 1st & 2nd Echelon neck

Palliative RT Operable Clinical Trial

Surgery* Inoperable

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

PO RT: ISBT/Intra Oral Cone/Ext RT +/concomitant CT Complete Response

Pre OP RT +/concomitant CT

Radiotherapy +/- Concomitant Chemotherapy Or Palliative RT

Partial response

No response/ Inflammatory Ca/Progressive disease

Radiotherapy +/Concomitant Chemotherapy Surgery* Palliative Symptomatic & supportive Treatment. Clinical Trial Clinical Trial

GINGIVA cancer Upper Gingiva Lower Gingiva

Staging evaluation CT scan X ray mandible MRI

T1 : Early lesions (<2.0 cm) (T1 and superficial T2)

T2: Moderately advanced Lesions

T3 Locally advanced lesions (>4 cm)

T4a

T4b

Surgery*: Include periostium or Bone

Superficial Extension to Hard palate or soft palate Exophytic lesion*

Close involved margins multiple positive neck nodes vascular space invasion extracapsular extension /perineural invasion

RT*: Ext+IOCone RT, Ext RT

Surgery*: > 1cms margin preferable. Include periostium or Bone. Upper Alveolus: Partial / Total maxillectomy Lower Alveolus: rim resection/ intro oral excision * lower gingiva lesions : ipsilateral , electively treat neck MND or radiotherapy in any patient

Palliative RT Operable Clinical Trial

Surgery* Inoperable

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

PO RT: ISBT/Intra Oral Cone/Ext RT +/concomitant CT

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Pre OP RT +/concomitant CT

Radiotherapy +/- Concomitant Chemotherapy or Palliative RT

Complete Response

Partial response

No response/ Inflammatory Ca/Progressive disease

Radiotherapy +/Concomitant Chemotherapy Surgery* Palliation: Symptomati c& supportive Treatment. Clinical Trial

Retromolar trigone cancer

Staging evaluation CT scan MRI

T1 : Early lesions (<2.0 cm) (T1 and superficial T2)

T2: Moderately advanced Lesions

T3 Locally advanced lesions (>4 cm)

T4a

T4b

Surgery*: Include periostium or Bone. +ve margin, Perineural invasion

Superficial ,Exophytic lesion, Involvement of the tonsillar pillar, soft palate, or buccal mucosa

Surgery*: Include periostium or Bone. electively treat neck MND or radiotherapy in any patient

Palliative RT Operable Clinical Trial

Surgery* PO RT: Intra Oral Cone/Ext RT RT*: Ext+IOCone RT, Ext RT Post Operative Radiotherapy +/_ Concomitant Chemotherapy Inoperable

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Pre OP RT +/concomitant CT

Radiotherapy +/- Concomitant Chemotherapy or Palliative RT

Complete Response

Partial response

No response/ Inflammatory Ca/Progressive disease

Radiotherapy +/Concomitant Chemotherapy Surgery* Symptomatic & supportive Treatment. Clinical Trial

Hard Palate cancer

Staging evaluation CT scan MRI

T1 : Early lesions (<2.0 cm) (T1 and superficial T2)

T2: Moderately advanced Lesions

T3 Locally advanced lesions (>4 cm)

T4a

T4b

Surgery*: Include periostium or Bone. +ve margin, Perineural invasion

Superficial ,Exophytic lesion, Involvement of the tonsillar pillar, soft palate

Surgery*: Include periostium or Bone. electively treat neck MND or radiotherapy in any patient

Palliative RT Operable Clinical Trial

Surgery* Inoperable PO RT: Intra Oral Cone/Ext RT

RT*: Ext+IOCone RT, Ext RT

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Post Operative Radiotherapy +/_ Concomitant Chemotherapy

Pre OP RT +/concomitant CT

Radiotherapy +/- Concomitant Chemotherapy or Palliative RT

Complete Response

Partial response

No response/ Inflammatory Ca/Progressive disease

Radiotherapy +/Concomitant Chemotherapy Surgery* Symptomatic & supportive Treatment. Clinical Trial

Oral cancer : General Treatment principles

T1 & T2 N0 T3 & T4 A Any N Preferred Primary Treatment Modality Surgery or RT Surgery + PORT

RT/CT/Clinical T4b Palliative Trial Primary RT is prefered in Primary RT is prefered for early T1/T2 Lip ISBT FOM IOCRT Cosmesis Tongue Ext RT + Brachy Function BM Ext RT + IOCRT patients Profession Patient preference Angle of the mouth involvement expohytic lesions Poorly differentiated lesions local facility Local skill Co-morbid conditons Post Operative radiotherapy is indicated in :N0 Clinically - N+ pathologically positive surgical Floor Mouth 21 - 50% margin Gingiva 12 - 19% Frozen section positivity Hard palate perineural invasion Buccal Mucosa 0 - 10% node positivity Oral Tongue 25 - 54% lymphovascular Retro Molar Trigone 35% invasion Peri nodal spread Bone infiltration multiple nodes lip 5 - 10%