CURRENT CONCEPTS IN CANCER MANAGEMENT
From the Hospital of San Raphael’s Father McGivney Cancer Center Symposium on Diagnosis and Treatment of
Oral Cavity and Head and Neck Tumors
| ORAL CAVITY CANCER —Eugene N. Myers, MD, Professor and Chair Emeritus, Department of Otolaryngology, University
of Pittsburgh School of Medicine
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| Oral cavity cancer: occurs most often in men; cancer of—tongue and floor of mouth rare among people who are not
heavy consumers of alcohol and tobacco, ie, alcohol seems to exacerbate adverse effects of tobacco on tissue; buccal mucosa
related to use of smokeless tobacco and pan masala (in Asia; consists of areca nut, slaked lime, and condiments
packaged in betel leaf); squamous cell carcinoma—seen most often; premalignant lesions leading to development of
oral cancer include leukoplakia, lichen planus, erythroplakia, and dysplasia; careful biopsy evaluation and excision necessary
to prevent cancer from developing
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| Second primary disease in upper and lower respiratory tract: not uncommon; keys to identifying second primary
lesion—temporal separation (ie, disease occurring 5 yr after initial cancer most likely second primary tumor and not recurrent
disease); geographic separation (second primary tumors can develop away from site of initial primary disease);
field cancerization—explains phenomenon; combination of tobacco and alcohol damages all mucosa in oral cavity and
renders any site susceptible to development of second primary disease; second primary tumors—can develop in head,
neck, lung, or esophagus (risk mandates thorough examination of head and neck; endoscopic examination of esophagus
usually performed; lungs can be scanned to detect synchronous lesion); potentially lethal (once aggressive primary lesion
treated with radiation and surgery, no effective options remain for managing second primary tumor)
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| Identification of oral cavity cancer: perform thorough physical examination; lesion can—be exophytic, infiltrative, or
ulcerative; be small in diameter and have major infiltrative component; be associated with pain and trismus when pterygoid
muscles involved; arise from alveolar ridge and infiltrate muscle and skin (try to palpate lymph nodes); caveat—
failure to maintain high index of suspicion may lead to missed diagnosis; keys to evaluation—inspection; palpation;
mirror examination of base of tongue and oropharynx; imaging; panendoscopy to stage and evaluate primary disease and
rule out second primary tumor
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| Treatment of oral cavity cancer: prevention strategies—next horizon in managing primarily lifestyle-associated disease
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 | Factors influencing selection of treatment approach: anatomic location of tumor (eg, surgery limited to tongue can, in some
cases, produce satisfactory swallowing, speaking, and cure rate; history—patient’s occupation; disease characteristics;
previous treatment; patient age—oral cavity cancer usually occurs in 60- to 70-yr age group; cohort of women in
their 20s have developed tongue disease (these patients claim to have never used tobacco; problem may be viral-induced,
eg, human papillomavirus [HPV]; to facilitate survival, young people must be treated as aggressively as older
patients); comorbidities—common in 60- to 70-yr age group; include chronic obstructive pulmonary disease
(COPD), heart disease, and liver disease; risk for complications mandates thorough work-up; point—despite comorbidities,
patients seem to do well with surgery; motivation—key concern; patient must feel determined before initiating
treatment; socioeconomic level—cancer of head and neck primarily disease of people in low socioeconomic
environment; factors of concern include at-risk lifestyle (eg, heavy consumption of alcohol and tobacco), and low expectations
and motivation; management team—surgical staff dedicated to treating head and neck cancer and not discouraged
by ≈30% survival rate; radiation and medical oncologists; dental specialist; maxillofacial prosthodontist;
speech and swallowing experts; social workers; plastic surgeons
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| Surgery: patients who undergo surgery alone generally do better than patients who undergo radiation; outcome depends
on—site, location, stage, and histology of tumor; complications; convenience and cost; physician competence; treatment
goals—eliminate cancer; facilitate reconstruction and rehabilitation of speech and swallowing function; achieve acceptable
level of cosmesis, ie, minimize scarring and other physical disfigurement; approaches to primary cancer in oral
cavity—transoral; transmandibular; transmaxillary; transpharyngeal
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| Observations on surgery: primary closure rarely possible, since oral cavity contains minimal extra tissue; transmandibular
approach used in selected cases
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| Deeply invasive cancer of tongue (case example): surface area small; managed with hemiglossectomy; systematic frozen
section analysis performed to ensure lesion completely excised; defect closed with skin graft; patients with—clear
surgical margins do better; positive margins on permanent section require reoperation (radiation therapy does not usually
cure positive disease margins)
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| Neck disease (elective neck dissection vs watchful waiting): among patients with carcinoma of tongue, elective neck dissection
performed as part of initial therapy should be carried out over levels I to IV; among patients with T1 and T2
tongue disease who underwent elective neck dissection—20% of individuals believed to have N0 necks had cancer;
patients who underwent watchful waiting had 17% incidence of disease conversion and recurrence in neck; survival
rate at 5 yr—55% for elective neck dissection; 33% for watchful waiting; rate of local regional control—91% for
elective neck dissection; 50% for watchful waiting (many patients on watchful waiting do not return for follow-up
evaluation until serious problem develops)
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| Cancer of: palate—appliance facilitates speech and swallowing after removal of all or part of palate; hard palate and
alveolar ridge—high rate of metastasis; patients can develop adenocarcinoma; selective neck dissection mandatory
(disease associated with 25% to 50% rate of neck metastasis)
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| Cancer of floor of mouth: may involve soft tissues or mandible; patients who are dentate must have teeth removed along
with alveolar process; typical patient—marginal mandibulectomy not necessary because cancer sticks to periosteum
with no evidence of bone destruction; after surgery, skin graft can be spliced into defect; complete dentures can be applied;
patients who have their own teeth may require special types of dental prostheses
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| Myocutaneous flaps: case example (patient with high-grade mucoepidermoid lesion that destroyed tongue)—total
glossectomy performed and larynx preserved; approach limited to patients who are well motivated, have good pulmonary
reserve, and belong to younger age group; myocutaneous flap closed defect
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| Osteocutaneous flaps: used to reconstruct bone and skin; mandibular defects—lateral defect does not interfere with function
(question as to whether reconstruction necessary); anterior defect must be repaired to avoid oral incompetence,
drooling, and impaired swallowing (lateral aspect of thigh popular site for obtaining osteocutaneous flap material)
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| Radial forearm osteocutaneous flap: speaker uses for almost all oral cavity reconstruction; advantages—thin, pliable
skin; long pedicle; provides sufficient bone to repair larger excisions; good cosmesis with view toward function;
caveat—bone invasion portends poor prognosis
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| Scapular flap: not widely used; bivalved flap; good option for patients requiring extensive oral reconstruction and bone
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| Multiple flaps: necessary in desperate cases; patient who underwent total glossectomy and dissection of cervical
esophagus, larynx, and neck received—jejunal free flap sewn into place in oral cavity and cervical esophagus; myocutaneous
flaps without skin; skin grafts
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| Pointers: generally treat early-stage disease with surgery alone
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| Late-stage disease: generally requires combination of surgery and radiation; surgical therapy alone adequate when—
tumor small; tumor-free margins obtained; maximum elective neck dissection shows patient has ≤2 involved lymph
nodes and no extracapsular spread (radiation unnecessary); no perineural involvement in primary lesion; treatment
scheme—ensures local control in >90% of patients; avoids radiation therapy in 77% of patients and resulting reduction
in quality of life (radiating oral cavity can cause permanent severe xerostomia and loss of taste); caveat—expect high recurrence
rates if elective neck dissection not performed; additional aspects—clinical stage of disease helps predict
treatment outcome in patients with squamous cell carcinoma of oral cavity (cure and survival rates vary inversely with
disease stage); local regional control difficult to achieve in patient with deeply infiltrative tumor (outcome poor when
compared to superficial disease); palpable lymph node metastases exert negative effect on disease-free survival
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| LARYNGEAL CANCER —K. Tom Robbins, MD, Professor of Otolaryngology—Head and Neck Surgery, Southern Illinois
University School of Medicine, Springfield
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| Laryngeal cancer: subglottic disease rare; glottic cancer—most common form; typically occurs on free membranous
fold in middle or anterior third of vocal cord; hoarseness develops early in disease and facilitates early diagnosis; early-
stage disease associated with better survival rates; untreated tumors eventually extend into underlying thyroarytenoid
muscle and thyroid cartilage and become more difficult to treat; supraglottic cancer—does not cause hoarseness; may
go undetected until patient develops large mass with airway obstruction or regional lymph node disease; can extend into
pre-epiglottic or paraglottic spaces and outside larynx; has high propensity to involve regional lymph nodes; paraglottic
space provides “highway” joining supraglottic larynx and glottic/ subglottic region; point—treatment of supraglottic
cancer must control regional lymph nodes
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| Early glottic cancer: current staging (as of 2002)—involves degree of invasion into thyroid cartilage, eg, T3 disease
includes involvement of inner cortex; distinguishes between resectable and unresectable disease; radiation therapy—
uses relatively small radiation field because regional lymphatics not at risk; administers ≥66 Gy to patients with T1
disease (dose increases with disease volume); achieves good outcome, ie, local control with laryngeal preservation in
patients with early-stage disease (T1, T2, T2a, or T2b lesions)
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| Surgery: endoscopic CO2 laser resection of glottic and supraglottic cancers—favored over traditional open laryngofissure
approach; removes pieces of tumor until disease-free margins achieved; avoids performing technically demand
ing en bloc approach in small laryngeal space; provides effective alternative to irradiation; laryngofissure (open)
approach—technically reasonable option for removing vocal cord; less attractive option from patient’s point of view
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| Hemilaryngectomy: removes portion of thyroid cartilage; produces larger defect and poorer voice quality than laser; achieves
good results in selected cases; can be carried out after disease recurrence in patients who underwent radiation therapy
and have—tumor limited to vocal cord; arytenoid free of tumor; minimal subglottic extension; mobile vocal cord; no
cartilage invasion; recurrence correlating with initial tumor; point—external conservation approach viable alternative for
patients with low-volume disease who fail radiation therapy
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| Early supraglottic carcinoma: involves different biologic factors; current staging classifies—tumor involving medial
wall of piriform sinus as T2 disease; extension into pre-epiglottic space as T3 disease; minor invasion of mucosa at
base of tongue—was classified as T4 disease; should, as low-volume cancer, be classified as T2 disease
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| Radiation therapy: must address regional lymph nodes; systematic approach—starts with large field that encompasses
posterior nodes located over cord; gradually shrinks field until final field receives 70 Gy; University of Florida data
show—radiation most effective for managing T1 and T2 disease (efficacy falls off for T3 and T4 disease); 45% of
cases with local recurrence salvaged; people who fail radiation therapy at increased risk of dying from cancer; tumor
volume as means of selecting radiation approach—once-daily and hyperfractionation schemes equally effective for
T1 disease; bid treatment more effective for T2 and T3 disease; tumor volume as means of stratifying disease—
tumors <6 mL respond well to radiation therapy; irradiation less effective for tumors >6 mL (in these patients, radiation
therapy must be combined with chemotherapy)
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| Neck dissection: appropriate management includes—definitive radiation therapy with surgery for salvage of primary
lesion; planned neck dissection in patients with bulky neck disease; points—lateral neck dissection recommended for
managing highest-risk areas, ie, levels II, III, and IV; level VI at risk for disease extending below level of glottis and
into subglottic region
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| Options for resectable late disease: radiation therapy alone inadequate for achieving local control in patients with advanced
glottic and supraglottic disease; supraglottic laryngectomy—remains option in selected patients with supraglottic
disease; removes everything from level of vocal cords up to and including pre-epiglottic space and hyoid bone;
results depend on T classification, ie, results good for T1 and T2 disease, variable for T3 and T4
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| Supracricoid laryngectomy: performed as long as patient has 1 tumor-free arytenoid; removes everything above level of
cricoid and arytenoid cartilages; sacrifices vocal cords, ie, approach ensures disease located in supraglottic larynx and
paraglottic space will be excised; hyoid bone left behind; epiglottis—removed when managing supraglottic cancer;
left behind as part of closure when managing glottic cancer (during closure, bring cricoid up to base of tongue);
patients—can achieve reasonable functional results postoperatively; with clean resections and tumor-free margins,
can experience recurrence rate of 6.1%; with supraglottic cancer, can die of distant metastases, not local regional disease
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| Additional options: when compared to other therapeutic options, chemoradiation achieved highest degree of laryngeal preservation
without adversely affecting survival; total laryngectomy indicated for patients who have significantly advanced disease
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Educational Objectives
| The goal of this program is to educate the listener about some current concepts in management of head and neck cancer. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Describe current concepts concerning the evaluation and management of oral cavity cancer.
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| 2. List key factors that can influence the selection of appropriate treatment for patients presenting with cancer of the
oral cavity.
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| 3. Repair structural damage incurred during the surgical excision of cancerous lesions of the oral cavity.
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| 4. Evaluate current options for treating early glottic and supraglottic carcinoma.
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| 5. Review the role of surgery and chemoradiation in the treatment of advanced laryngeal cancer.
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Suggested Reading
Accortt NA et al: Cancer incidence among a cohort of smokeless tobacco users (United States). Cancer Causes Control
16:1107, 2005; Duflo S et al: Microvascular radial forearm fasciocutaneous free flap in hard palate reconstruction. Eur J
Surg Oncol 31:784, 2005; Lin K et al: Second primary malignancy of the aerodigestive tract in patients treated for cancer
of the oral cavity and larynx. Head Neck 27:1024, 2005; Nair U et al: Alert for an epidemic of oral cancer due to use of
the betel quid substitutes gutkha and pan masala: a review of agents and causative mechanisms. Mutagenesis 19:251, 2004;
Petruzzelli GJ, Myers EN: Malignant neoplasms of the hard palate and upper alveolar ridge. Oncology 8:43, 1994;
Procter E et al: Postoperative complications after chemoradiation for advanced head and neck cancer. Head Neck 26:272,
2004; Robbins KT: Selecting from the menu of treatment options for locally advanced laryngeal cancer. Arch Otolaryngol
Head Neck Surg 131:819, 2005; Robbins KT et al: Effectiveness of superselective and selective neck dissection for
advanced nodal metastases after chemoradiation. Arch Otolaryngol Head Neck Surg 131:965, 2005; Takushima A et
al: Choice of osseous and osteocutaneous flaps for mandibular reconstruction. Int J Clin Oncol 10:234, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty
reported nothing to disclose.
Drs. Myers and Robbins gave their scientific presentations at the Father McGivney Cancer Center, Hospital of San Raphael,
symposium on Diagnosis and Treatment of Oral Cavity and Head and Neck Tumors, presented October 21 to 22, 2005,
in New Haven, Connecticut. The Audio-Digest Foundation thanks the speakers, the Hospital of San Raphael’s Father McGivney
Cancer Center, and the Smith/Strothers Lecture Series for their cooperation in the production of this program.
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