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An Update on Oral Cancers

An Update on Oral Cancers. Leo Pang BSc (Med), MB BS, FRACS (OHNS) Royal North Shore Hospital. Overview. Oral Cavity and Oropharyngeal Cancers Squamous Cell Carcinoma most common (90%) Anatomy DIAGNOSIS Investigations Treatment Options Surgery, Chemotherapy, Radiotherapy

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An Update on Oral Cancers

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  1. An Update on Oral Cancers Leo Pang BSc (Med), MB BS, FRACS (OHNS) Royal North Shore Hospital

  2. Overview • Oral Cavity and Oropharyngeal Cancers • Squamous Cell Carcinoma most common (90%) • Anatomy • DIAGNOSIS • Investigations • Treatment Options • Surgery, Chemotherapy, Radiotherapy • PREVENTATIVE STRATEGIES

  3. Oral Cavity Cancer Overview • 30% of all Head and Neck cancers • Most present late (68% Stage 3 and 4) • Surgery remains primary treatment modality • HPV status is of prognostic significance • Early detection improves survival • Overall survival for oral cancers improving

  4. Anatomy • Oral Cavity (7 subsites) • Lip (30%) • Tongue (20-50%) • Floor of mouth (30%) • Alveolar Ridge (<10%) • Buccal Mucosa (<5%) • RetromolarTrigone (<5%) • Hard Palate (<1%)

  5. Diagnosis • History • Local Symptoms • Changes in fit of denture • Oral/ dental pain • Bleeding • Regional Symptoms • Halitosis • Trismus • Dysphagia, odynophagia, dysarthria • Otalgia • Facial paraesthesia • Neck mass and pain • Systemic Symptoms • Weight loss • General medical history • Tobacco and alcohol usage

  6. Diagnosis • Histology

  7. Investigations • CT Head, Neck, Chest with IV contrast • Fluoro-deoxy-D-glucose (FDG) Positron Emission Tomography • Sensitivity 90% • Specificity 95% • US Guided FNA Neck nodes • MRI • Histology • HPV + p16

  8. Still primary treatment modality • Resection and Reconstruction • Extent of Resection • N0 Necks • Sentinel Nodes? • Adjuvant treatment modality • Margins, differentiation, size, depth, invasion • Neck nodes: no, size, extracapsular spread Surgery Radiotherapy Chemotherapy • Adjuvant treatment modality • Presence of extracapsular spread

  9. Novel Treatment Options? • Targeted therapy • Immunotherapy • Phototherapy

  10. Oropharyngeal Cancer Overview • Little is known about the disease-specific cumulative survival rate and factors affecting it among patients with oropharyngeal cancer • 81.9% present Stage 3 and 4 • Historically treated with radical surgery • Current treatment is concurrent ChemoRT • No Level 1 evidence to compare surgery vs CRT • Changing demographics • Slow paradigm shift towards surgical treatment • Laser, Da Vinci Robot

  11. Anatomy • 5 subsites • Soft palate • Tonsillar fossae • Base of tongue • Oropharyngeal walls • Vallecula (Cummings 2010)

  12. AnatomyBoundaries • Superior – Hard Palate (Netter 2003)

  13. AnatomyBoundaries • Anterior – Palatoglossal Arch, Hard/Soft Palate Border

  14. AnatomyBoundaries • Lateral – Tonsillar fossa, lateral pharyngeal wall

  15. AnatomyBoundaries • Posterior – Posterior pharyngeal wall

  16. AnatomyBoundaries • Inferior – Level of Hyoid Bone

  17. AnatomyBase of Tongue • Circumvallate papillae (anteriorly) • Pharyngoepiglottic fold (posteriorly) • Glossoepiglottic fold (posteriorly) • Lingual tonsils are lateral

  18. Epidemiology • Relatively uncommon • Fewer than 1% of all new cancers • Comprises 10-12% of head and neck malignancies • Squamous cell carcinoma (SCCA) accounts for 90% of oropharyngeal malignancies • Peak incidence in 6th or 7th decades of life • Tobacco and alcohol are synergistic risk factors • Increasing incidence in 4th and 5th decades of life • Changing demographics • Younger adults, equal gender distribution • Good performance status • Nonsmokers, but possible association with marijuana use • Orogenital sexual practices

  19. Human Papilloma Virus (HPV) • High-risk HPV, type 16 • Types 16 and 18 involved with cancer of genital tract • Associated with 45-70% of oropharyngeal SCCA (Cohen 2011) • Integration of genome into host cell nucleus • Express E6 and E7 oncoproteins • Inactivate tumor-suppressant p53 and retinoblastoma protein • Associated with p16-positivity • Histology • Predominantly poorly differentiated SCCA • Basaloid background • Correlated with HPV- and p16-positivity (Mendelsohn 2010) • No increase in lymphovascular or perineural invasion • Highly predictive of lymph node metastasis (http://www.pubcan.org)

  20. Human Papilloma Virus (HPV) • Retrospective review of oropharyngeal SCCA (Ang 2010) • HPV-positive in 206 out of 323 with stage III or IV disease (63.8%) • Improved 3-year overall survival (82.4% vs. 57.1%) • Improved 3-year progression-free survival (73.7% vs. 43.4%) • HPV-positive conveys 58% reduction in death • HPV-positivity is favorable prognostic factor (Ihloff 2010) • Meta-analysis of 8 studies between 2000 and 2010 • HPV-positive tumors generally respond well to treatment • Advanced primary associated with recurrence and death (Sedaghat 2009) • Studies needed to investigate impact of HPV vaccinations

  21. Oropharyngeal CancerLymphatic Drainage (http://imaging.consult.com) (AJR 2008; 191:W299-306) (http://emedicine.medscape.com)

  22. Diagnosis • Local • Pain • Bleeding • Foreign Body Sensation • Regional • Halitosis • Trismus • Dysphagia/odynophagia • Otalgia • Neck mass • Voice changes • Paraesthesia • Neck Mass • Systemic • Weight loss • Loss of appetite • General • Smoking/ETOH

  23. Staging • T tumor • N node • M metastasis • Tx: primary site cannot be evaluated • T0: no evidence of carcinoma • Tis: carcinoma in-situ • T1: tumor < 2cm in greatest dimension • T2: tumor 2-4cm in greatest dimension • T3: tumor > 4cm in greatest dimension • T4 • T4a: invades larynx, deep/extrinsic tongue muscles, medial pterygoid, hard palate, or mandible • T4b: invades lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, or carotid

  24. Oropharyngeal CancerStaging • T, tumor • N, node • M, metastasis • Nx: lymph nodes cannot be evaluated • N0: no evidence of nodal metastasis • N1: single node involved, < 3cm • N2 • N2a: single node involved, 3-6cm • N2b: multiple nodes involved unilaterally, < 6cm • N2c: bilateral nodal involvement, < 6cm • N3: nodal involvement > 6cm

  25. Oropharyngeal CancerStaging • T, tumor • N, node • M, metastasis • Mx: distant metastasis cannot be evaluated • M0: no distant metastasis • M1: distant metastasis present

  26. Investigations • CT Head, Neck, Chest with IV contrast • Fluoro-deoxy-D-glucose (FDG) Positron Emission Tomography • US Guided FNA Neck nodes • MRI • Histology • HPV + p16

  27. CT Scan (Radiograhics 2011; 31:339-54) Invasion of pre-epiglottic fat (i.e. laryngeal involvement) Invasion of medial pterygoid muscle

  28. CT Scan (Radiograhics 2011; 31:339-54) Encasement of carotid artery Involvement of foramen ovale

  29. Early Cancers in selected patients • Transoral Laser • Transoral Robotic Surgery (TORS) • ?Emerging role Surgery Radiotherapy • Concurrent chemotherapy and radiotherapy (CRT) considered mainstays of treatment • Organ Preservation Chemotherapy

  30. Treatment • Concurrent chemotherapy and radiotherapy (CRT) considered mainstays of treatment • Organ preservation strategies • Good local and regional control rates • Meta-analysis (Blanchard 2011) • 87 randomized trials between 1965 and 2000 • Improved overall and disease-free survival with CTX • Concomitant CTX more favorable than adjuvant or neoadjuvant CTX • Applies to all head and neck SCCA, but statistical significance in oropharynx and larynx • Note: Not level evidence comparing Surgery +/- RT vs CRT • Unlikely to be proven

  31. Preventative Strategies • 81.9% Stage 3 or 4at presentation • 90.9% Tonsil or Tongue Base • Significant drop in survival from Stage 1/2 (95%) to Stage 3/4 (70%) • Secondary Prevention is key to early detection and improved survival • Planned Free Oral Cancer Screening Day

  32. References Ang KK, et al. Human papillomavirus and survival of patients with oropharyngeal cancer. NEJM 2010; 363:24-35. Bailey BJ, Johnson, JT, Newlands SD, eds. Head and Neck Surgery – Otolaryngology, 4th Ed. Philadelphia: Lippincott, 2006. pp 12-3, 1673-88. Bernier J, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. NEJM2004; 350:1945-52. Blanchard P, et al. Meta-analysis of chemotherapy in head and neck cancer (MACH-NC): a comprehensive analysis by tumour site. Radiother Oncol 2011; 100:33-40. Cano ER, et al. Management of squamous cell carcinoma of the base of tongue with chemoradiation and brachytherapy. Head Neck 2009; 31:1431-8. Cohen MA, et al. Transoral robotic surgery and human papillomavirus status: oncologic results. Head Neck 2011; 33:573-80. Cooper JS, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. NEJM 2004; 350:1937-44. Greene FL, et al, eds. AJCC Cancer Staging Atlas, 6th Ed. Chicago: Springer, 2006. pp 27-34. Fein D, et al. Oropharyngeal carcinoma treated with radiotherapy: a 30 year experience. Int J Radiat Oncol Biol Phys 1996; 34:289-96. Flint PW, et al, eds. Cummings Otolaryngology: Head and Neck Surgery, 5th Ed. Philadelphia: Mosby Elsevier, 2010. ch 8, 100. Furness S, et al. Interventions for the treatment of oral cavity and oropharyngeal cancer: chemotherapy. Cochrane Database Syst Rev 2010; 9:CD006386. Grant DG, et al. Oropharyngeal cancer: a case for single modality treatment with transoral laser microsurgery. Arch Otolaryngol Head Neck Surg 2009; 135:1225-30. Henstrom DK, et al. Transoral resection for squamous cell carcinoma of the base of the tongue. Arch Otolaryngol Head Neck Surg 2009; 135:1231-8.

  33. Thank you

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