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Module 7:

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:

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  1. Module 7: Treatment Options

  2. 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

  3. 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

  4. 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.

  5. Quality of Life Issues • Nutrition • Speech • Appearance • All functions must be addressed in treatment planning

  6. 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

  7. 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)

  8. Wide Local Excision Silverman, 2003

  9. Squamous Cell Carcinoma / Reconstruction Silverman, 2003:98,100

  10. Squamous Cell Carcinoma (SCC) SCC of anterior maxillary gingiva and bone One month post-surgical Silverman, 2003

  11. 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.

  12. 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.

  13. 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

  14. Radiation Therapy • CT and/or MRI scan, PET scanning • Dental panoramic

  15. Radiation Therapy • Dental consult • Extractions prior to beginning • Fluoride • Meticulous oral hygiene • Osteoradionecrosis

  16. Types of Radiation Therapy • (EBRT) primary external-beam radiotherapy • (IMRT) intensity-modulated radiotherapy • (ISRT) brachytherapy or interstitial radiotherapy

  17. Radiation Therapy Squamous cell carcinoma One month postradiotherapy Silverman, 2003

  18. Radiation Therapy Silverman, 2003

  19. Brachytherapy Silverman, 2003:105

  20. 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)

  21. 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

  22. 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

  23. 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

  24. Telangiectasia and Mucosal Fibrosis Silverman, 2003: 115

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. 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

  31. 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

  32. Mucositis Management • Treatment of mucositis: • Symptomatic management: topical analgesics; systemic analgesics • Nutritional support • Developing therapies: cytokines/growth factors

  33. Management of Hyposalivation • Fluid intake, sugar free gum / candy • Sialogogues: • Salagen • Evoxac • Bethanechol • Sialor • Caries prevention • Symptomatic (mouth wetting agents)

  34. 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)

  35. 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

  36. Osteonecrosis Two years after radiotherapy Three years after radiotherapy Silverman, 2003:121

  37. 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

  38. Complications • National Institutes for Dental and Craniofacial Research (NIDCR) offers excellent free materials for patients • Ordering information included in Resources section

  39. 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

  40. Reconstruction Silverman, 2003: 147

  41. Reconstruction Silverman 2003:146

  42. 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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