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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

Module 7:

Treatment Options

surgery and or radiation
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
treatment
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
considerations regarding treatment options
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.
quality of life issues
Quality of Life Issues
  • Nutrition
  • Speech
  • Appearance
  • All functions must be addressed in treatment planning
surgery
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
surgery7
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)
wide local excision
Wide Local Excision

Silverman, 2003

slide10

Squamous Cell Carcinoma (SCC)

SCC of anterior maxillary gingiva and bone

One month post-surgical

Silverman, 2003

neck dissections
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.
neck dissections12
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.
radiation therapy
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
radiation therapy14
Radiation Therapy
  • CT and/or MRI scan, PET scanning
  • Dental panoramic
radiation therapy15
Radiation Therapy
  • Dental consult
  • Extractions prior to beginning
  • Fluoride
  • Meticulous oral hygiene
  • Osteoradionecrosis
types of radiation therapy
Types of Radiation Therapy
  • (EBRT) primary external-beam radiotherapy
  • (IMRT) intensity-modulated radiotherapy
  • (ISRT) brachytherapy or interstitial radiotherapy
radiation therapy17
Radiation Therapy

Squamous cell carcinoma

One month postradiotherapy

Silverman, 2003

radiation therapy18
Radiation Therapy

Silverman, 2003

brachytherapy
Brachytherapy

Silverman, 2003:105

chemotherapy
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)
chemotherapy21
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
care prior to cancer therapy
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
care prior to cancer therapy23
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
slide24

Telangiectasia and

Mucosal Fibrosis

Silverman, 2003: 115

care prior to cancer therapy25
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
care prior to cancer therapy26
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

care prior to cancer therapy27
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
care prior to cancer therapy28
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
oral care during cancer therapy
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
complications from radiation
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
complications
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

mucositis management
Mucositis Management
  • Treatment of mucositis:
    • Symptomatic management: topical analgesics; systemic analgesics
    • Nutritional support
    • Developing therapies: cytokines/growth factors
management of hyposalivation
Management of Hyposalivation
  • Fluid intake, sugar free gum / candy
  • Sialogogues:
    • Salagen
    • Evoxac
    • Bethanechol
    • Sialor
  • Caries prevention
  • Symptomatic (mouth wetting agents)
oropharyngeal head neck pain
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)
follow up of cancer patients
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
osteonecrosis
Osteonecrosis

Two years after radiotherapy

Three years after radiotherapy

Silverman, 2003:121

care following radiation therapy
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
complications38
Complications
  • National Institutes for Dental and Craniofacial Research (NIDCR) offers excellent free materials for patients
  • Ordering information included in Resources section
reconstruction
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

slide40

Reconstruction

Silverman, 2003: 147

slide41

Reconstruction

Silverman 2003:146

summary
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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