Treatment Option Overview
Depending on the site and extent of the primary tumor and the status of the
lymph nodes, the treatment of lip and oral cavity cancer may be by surgery
alone, radiation therapy alone, or a combination of these. Some general
considerations are as follows.[1-5]
For lesions of the oral cavity, surgery must adequately encompass all of the
gross as well as the presumed microscopic extent of the disease. If regional
nodes are positive, cervical node dissection is usually done in continuity.
With modern approaches, the surgeon can successfully ablate large posterior
oral cavity tumors and with reconstructive methods can achieve satisfactory
functional results. Prosthodontic rehabilitation is important, particularly in
early-stage cancers, to assure the best quality of life.
Radiation therapy for lip and oral cavity cancers can be by external-beam
radiation therapy (EBRT) or interstitial implantation alone, but for many sites the use of both
modalities produces better control and functional results. Small superficial
cancers can be very successfully treated by local implantation using any one of
several radioactive sources, by intraoral cone radiation therapy, or by
electrons. Larger lesions are frequently managed using EBRT to include the primary site and regional lymph nodes even if they are
not clinically involved. Supplementation with interstitial radiation sources
may be necessary to achieve adequate doses to large primary tumors and/or bulky
nodal metastases. A review of published clinical results of radical radiation
therapy for head and neck cancer suggests a significant loss of local control
when the administration of radiation therapy was prolonged; therefore,
lengthening of standard treatment schedules should be avoided whenever
possible.[6,7]
Early cancers (stage I and stage II) of the lip, floor of mouth, and retromolar
trigone are highly curable by surgery or radiation therapy. The choice of
treatment is dictated by the anticipated functional and cosmetic results and by
the availability of the particular expertise required of the surgeon or
radiation oncologist for the individual patient. Advanced cancers (stage III
and stage IV) of the lip, floor of mouth, and retromolar trigone represent a wide
spectrum of challenges for the surgeon and radiation oncologists. Except for
patients with small T3 lesions and no regional lymph node and no distant
metastases or who have no lymph nodes larger than 2 cm, for whom
treatment by radiation therapy alone or surgery alone might be appropriate,
most patients with stage III or stage IV tumors are candidates for treatment by a
combination of surgery and radiation therapy. Furthermore, because local
recurrence and/or distant metastases are common in this group of patients, they
should be considered for clinical trials evaluating the following: the
potential role of radiation modifiers to improve local control or decrease
morbidity; or, the role of combinations of chemotherapy with surgery and/or radiation
therapy both to improve local control and to decrease the frequency of distant
metastases.
Early cancers of the buccal mucosa are equally curable by radiation therapy or
by adequate excision. Patient factors and local expertise influence the choice
of treatment. Larger cancers require composite resection with reconstruction
of the defect by pedicle flaps.
Early lesions (T1 and T2) of the anterior tongue may be managed by surgery or
by radiation therapy alone. Both modalities produce 70% to 85% cure rates in
early lesions. Moderate excisions of tongue, even hemiglossectomy, can often
result in surprisingly little speech disability provided the wound closure is
such that the tongue is not bound down. If, however, the resection is more
extensive, problems may include aspiration of liquids and solids and difficulty
in swallowing in addition to speech difficulties. Occasionally, patients with
tumor of the tongue require almost total glossectomy. Large lesions generally
require combined surgical and radiation treatment. The control rates for
larger lesions are about 30% to 40%. According to clinical and radiological
evidence of involvement, cancers of the lower gingiva that are exophytic and
amenable to adequate local excision may be excised to include portions of bone.
More advanced lesions require segmental bone resection, hemimandibulectomy, or
maxillectomy, depending on the extent of the lesion and its location.
Early lesions of the upper gingiva or hard palate without bone involvement can
be treated with equal effectiveness by surgery or by radiation therapy alone.
Advanced infiltrative and ulcerating lesions should be treated by a combination
of radiation therapy and surgery. Most primary cancers of the hard palate are
of minor salivary gland origin. Primary squamous cell carcinoma of the hard
palate is uncommon, and these tumors generally represent invasion of squamous
cell carcinoma arising on the upper gingiva, which is much more common. Thus,
management of squamous cell carcinoma of the upper gingiva and hard palate are
usually considered together. Surgical treatment of cancer of the hard palate
usually requires excision of underlying bone producing an opening into the
antrum. This defect can be filled and covered with a dental prosthesis, a
maneuver that restores satisfactory swallowing and speech.
Patients who smoke while on radiation therapy appear to have lower response
rates and shorter survival durations than those who do not;[8] therefore,
patients should be counseled to stop smoking before beginning radiation
therapy. Dental status evaluation should be performed prior to therapy to
prevent late sequelae.
References
-
Harrison LB, Sessions RB, Hong WK, eds.: Head and Neck Cancer: A Multidisciplinary Approach. Philadelphia, Pa: Lippincott-Raven, 1999.
-
Wang CC, ed.: Radiation Therapy for Head and Neck Neoplasms. 3rd ed. New York: Wiley-Liss, 1997.
-
Myers EN, Suen JY, eds.: Cancer of the Head and Neck. 3rd ed. Philadelphia, Pa: Saunders, 1996.
-
Freund HR: Principles of Head and Neck Surgery. 2nd ed. New York, NY: Appleton-Century-Crofts, 1979.
-
Lore JM: An Atlas of Head and Neck Surgery. 3rd ed. Philadelphia, Pa: Saunders, 1988.
-
Fowler JF, Lindstrom MJ: Loss of local control with prolongation in radiotherapy. Int J Radiat Oncol Biol Phys 23 (2): 457-67, 1992.
[PUBMED Abstract]
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Langendijk JA, de Jong MA, Leemans ChR, et al.: Postoperative radiotherapy in squamous cell carcinoma of the oral cavity: the importance of the overall treatment time. Int J Radiat Oncol Biol Phys 57 (3): 693-700, 2003.
[PUBMED Abstract]
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Browman GP, Wong G, Hodson I, et al.: Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer. N Engl J Med 328 (3): 159-63, 1993.
[PUBMED Abstract]
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