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Module 7:. Treatment Options. Surgery and/or Radiation. Treatment usually involves surgery or radiation or both Chemotherapy primarily used as an adjunctive procedure in advanced cases Advanced lesions < 30% 5-year survival rate 9 - 25% of patients develop additional mouth or throat cancer.

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Module 7 l.jpg

Module 7:

Treatment Options


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Surgery and/or Radiation

  • Treatment usually involves surgery or radiation or both

  • Chemotherapy primarily used as an adjunctive procedure in advanced cases

  • Advanced lesions < 30% 5-year survival rate

  • 9 - 25% of patients develop additional mouth or throat cancer


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Treatment

  • Oropharyngeal lesions: radiation therapy

  • Lip lesions: surgically excised

  • Tongue lesions: hemiglossectomy; then radiation

  • Alveolar ridge cancer: segmental resection

  • Metastasis to local lymph nodes: radical or modified radical neck dissection


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Considerations Regarding Treatment Options

  • The oral cavity is a complex structure composed of muscles, nerves, jaws, tongue and lubricated by the salivary glands.

  • Rehabilitation must be considered prior to surgical or radiographical intervention.


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Quality of Life Issues

  • Nutrition

  • Speech

  • Appearance

  • All functions must be addressed in treatment planning


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Surgery

  • Type depends upon the extent and location of cancer

  • Wide local excision: soft tissue

  • Resection: invaded bone

  • Marginal resection: inferior border of mandible intact


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Surgery

  • Segmental resection: full height of mandible removed

  • Composite resection: hard and soft tissue (nodes, mandible, and soft tissues--tongue or floor of the mouth)


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Wide Local Excision

Silverman, 2003



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Squamous Cell Carcinoma (SCC)

SCC of anterior maxillary gingiva and bone

One month post-surgical

Silverman, 2003


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Neck Dissections

  • Comprehensive neck dissections include radical neck dissection and modified neck dissection.

  • Radical neck dissection removes lymph nodes of the neck, the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.


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Neck Dissections

  • Modified neck dissection preserves the sternocleidomastoid muscle or internal jugular vein, or the spinal accessory nerve.

  • Selective neck dissections remove lymph nodes only, preserving the sternocleidomastoid muscle, the internal jugular vein, and the spinal accessory nerve.


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Radiation Therapy

  • Radiation therapy is indicated following surgery if:

    • soft tissue margin positive

    • one or more lymph nodes exhibit extracapsular invasion

    • bone invasion present

    • more than one lymph node positive in the absence of extracapsular invasion

    • comorbid immunosuppressive disease present, or

    • perineural invasion occurred


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Radiation Therapy

  • CT and/or MRI scan, PET scanning

  • Dental panoramic


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Radiation Therapy

  • Dental consult

  • Extractions prior to beginning

  • Fluoride

  • Meticulous oral hygiene

  • Osteoradionecrosis


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Types of Radiation Therapy

  • (EBRT) primary external-beam radiotherapy

  • (IMRT) intensity-modulated radiotherapy

  • (ISRT) brachytherapy or interstitial radiotherapy


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Radiation Therapy

Squamous cell carcinoma

One month postradiotherapy

Silverman, 2003


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Radiation Therapy

Silverman, 2003


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Brachytherapy

Silverman, 2003:105


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Chemotherapy

  • Chemotherapy was primarily used as a palliative measure until fairly recently. It was typically administered before, during or after radiotherapy or surgery

    • neoadjuvant (before irradiation)

    • concurrent (during irradiation)

    • adjuvant (after irradiation)


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Chemotherapy

  • Several drugs currently being used include:

    • Paclitaxel (Taxol, Bristol-Myers Squibb)

    • Methotrexate

    • Bleomycin

    • Cisplatin

    • 5-Fluorouracil

  • Other research includes the use of:

    • Intraarterial chemotherapy

    • Intralesional chemotherapy


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Care Prior to Cancer Therapy

  • Comprehensive oral examination

  • Understand cancer diagnosis/location/stage/planned treatment (prognosis, chemotherapy??, radiation field)

  • Stabilize/resolve oral disease and institute preventive program


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Care Prior to Cancer Therapy

Goal:

  • Eliminate dental disease that cannot be maintained lifelong in radiated field or that may cause infection of become symptomatic during chemotherapy

  • High dose radiation therapy causes PERMANENT change in vascularity, cellularity of soft tissue, salivary gland and bone

  • Chemotherapy causes reversible changes, highest risk if caused neutropenia


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Telangiectasia and

Mucosal Fibrosis

Silverman, 2003: 115


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Care Prior to Cancer Therapy

  • Oral Disease Status

    • Mucosal and periodontal health

    • Caries risk

    • Unerupted/impacted teeth

    • Root tips

    • Endodontic lesions

    • Past dental disease: caries / restorations / endo

    • Dental prostheses: condition / fit / function

    • Salivary function

    • Temporomandibular function

    • Oral hygiene effectiveness / patient motivation


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Care Prior to Cancer Therapy

  • At risk teeth in radiation field

    • Periodontal status (pockets > 5 mm, advanced attachment loss

    • Caries / restoration status

    • Partially erupted third molars

    • Endodontic lesions

      Goal: 1 – 2 weeks healing prior to radiation

      Atraumatic extraction with primary closure, no dressing in socket


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Care Prior to Cancer Therapy

  • Dental extractions of symptomatic teeth due to infection, if sufficient time for healing of extraction site prior to neutropenia; if insufficient healing time, cover with antibiotics

  • Dental extractions considered if required between courses of multi-course chemotherapy, at time of count recovery


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Care Prior to Cancer Therapy

  • Preventive Program:

    • Gingival health: oral hygiene, chlorhexidine

    • Caries risk: oral hygiene, diet, fluoride carriers, chlorhexidine, saliva function

    • Mucosal health: mucositis preventive program

    • Mucosal infection: antifungal, oral hygiene

    • Saliva: sialogogue, mucolytic, mouth wetting

    • Lip lubrication

    • Reinforce tobacco / alcohol cessation


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Oral Care During Cancer Therapy

  • Mucositis: preventive program, pain management, diet instruction

  • Oral hygiene

  • Caries prevention

  • Saliva management

  • Lip lubrication

  • Manage dental emergencies

  • Manage oral mucosal infections

  • Range of motion exercises for radiation patients

  • Reinforce tobacco / alcohol cessation


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Complications from Radiation

  • Pain; neuropathy

  • Xerostomia: low flow rate, thick consistency

  • Loss of taste

  • Cervical caries

  • Epithelial atrophy

  • Fibrosis of soft tissue and muscles

  • Focal alopecia

  • Focal hyperpigmentation

  • Osteroradionecrosis

  • Telangiectasias

  • Dental prostheses fit / function

  • Esthetic, speech concerns


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Complications

Acute mucositis 5th week after radiation for base of the tongue squamous cell carcinoma

Oral candidiasis in a patient with marked xerostomia

Silverman, 2003: 114, 119


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Mucositis Management

  • Treatment of mucositis:

    • Symptomatic management: topical analgesics; systemic analgesics

    • Nutritional support

    • Developing therapies: cytokines/growth factors


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Management of Hyposalivation

  • Fluid intake, sugar free gum / candy

  • Sialogogues:

    • Salagen

    • Evoxac

    • Bethanechol

    • Sialor

  • Caries prevention

  • Symptomatic (mouth wetting agents)


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Oropharyngeal / Head / Neck Pain

  • Treat cause when possible

  • Topical analgesics / anesthetics

  • Systemic analgesics

  • Adjunctive medications (e.g. tricyclics)

  • Muscle relaxants (myogenic pain)

  • Physiotherapy (TMD, neck pain)

  • Oral prostheses (TMD)


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Follow-up of Cancer Patients

  • Thorough head and neck and oral exam

  • Salivary function, caries, demineralization risk, denture fit / function, oral hygiene, diet, mucosal condition, cancer risk

  • Tobacco / alcohol cessation

  • Risk of osteonecrosis with H&N RT; myelosuppression/immunosuppression

  • Know medical therapy, prognosis, change in risk factors prior to treatment planning


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Osteonecrosis

Two years after radiotherapy

Three years after radiotherapy

Silverman, 2003:121


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Care Following Radiation Therapy

  • Osteonecrosis:

    • Prevention:

      • Pretreatment oral care

      • Cancer therapy

      • Amputation of crown, endodontics

      • Atraumatic extraction if needed

    • Therapy:

      • Hyperbaric oxygen, trental, Vitamin E

      • Surgery – vascularized flaps


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Complications

  • National Institutes for Dental and Craniofacial Research (NIDCR) offers excellent free materials for patients

  • Ordering information included in Resources section


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Reconstruction

  • Various methods of reconstruction follow surgery

  • Deltopectoral flaps and pectoralis major muocutaneous flaps

  • Bone and soft tissue grafts

    provide good cosmetic

    appearance and function

  • Osseointegrated implants

    and dentures

  • The fibula can be used to

    reconstruct the mandible


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Reconstruction

Silverman, 2003: 147


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Reconstruction

Silverman 2003:146


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Summary

  • Early detection of lesions is critical to allow conservative treatment and protect the patient’s quality of life.

  • Many avenues are available to treat oral cancers, with improved methods constantly under investigation.

  • A multidisciplinary team can help oral cancer patients deal with the aftermath of treatment.


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