Transcript TRAITEMENTS MULTINODAUX EN CANCEROLOGIE

LIP AND ORAL CAVITY
SQUAMOUS CELL
CARCINOMAS
Guy ANDRY, M.D.
Dept of Surgery
Institut Jules Bordet, U.L.B.
Statements 2008 on Head and Neck Cancer
Frankfurt, 1st & 2nd February 2008
5 Years Survival and Cause Specific Survival %
LIP
ORAL CAVITY
S
CSS
S
CSS
St I
73
83
60
68
St II
64
73
46
53
St III
56
62
36
41
St IV
41
47
23
27
∆
 15
 20
After SEER database
LIP CANCER

The most common primary (~ 25 % of oral cavity
cancer)

~ 12/100.000 habitants per year USA & Europe

Solar-radiation, tobacco smoking, HPV,
immunosuppression
LIP CANCER
SURGERY IS FIRST CHOICE

< 2/3 invasion :
– full-thickness pedicled flaps (Abbe or Estlander)

> 2/3 invasion :
– musculo mucosalflaps (Camille Bernard…)
– free flaps
– frontal flap
→ irradiation in debilitated PTS
LIP CANCER
PROGNOSTIC FACTORS

Maximum tumor thickness (cf. MartinezGimeno Scoring System)

Site (upper & commissure more rapid
growth and preauricular, submandibular
lymph node metastases)
LIP CANCER
Scoring system → probability of lymph node invasion
Tumor thickness Martinez-Gimeno Scoring System
T stage, Tumor thickness, microvascular, perineural invasion
histologic grade of differentiation, presence of inflammatory infiltrate
Group I :
Group II :
Group III :
Group IV :
0 % of lymph node invasion
21 %
50 %
67 %
LIP CANCER

Mohs micrographic surgery has been
successfully used
– No tumor related deaths or metastases at 5 yrs
– All PTS with recurrent disease were successfully
salvaged
LIP CANCER
T1 T2
Surgery
if + margins
+ lymph nodes
 Adjuvant radiation
if recurrence local regional
Radiation
External beam
Brachytherapy  Salvage surgery
or both

98 % local control 5 yrs
LIP CANCER

There are no published randomized trials on
• the use of sequential surgery + radiation
• the use of chemotherapy
NB : one preliminary study on super selective
intraarterial chemo (CDDP based) in six PTS with
T1, T2 or local recurrence by Kishi & al, Radiology
213, 1999
FLOOR OF MOUTH CANCER
High risk tumors (even in early stages)
 Proximity to the mandible
– Adhesion or invasion (by the alveolar ridge)
– Risk of radiation induced bone necrosis

No mechanical barrier in soft tissues
– Blurred vision of margins, Even with high resolution MRI

Early lymph node metastases
– 20 % of occult invasion in T1
– 62 % of occult invasion in T2

Will develop second primary tumors (~ 20 % in T1 – T2)
“field cancerization” effect of carcinogens
FLOOR OF MOUTH CANCER
Surgery is generally preferred for T1 T2 (primary &
necks)
 + radiation if margins are close or involved
if lymph nodes are involved (CR)
if mandible is invaded
if perineural or/and vascular invasion
(or chemo radiation)
 Role of sentinel node biopsy is under study

FLOOR OF MOUTH CANCER
Primary ERT
Surgery S 5 yrs
Control rate
T1
95 %
90 %
← negative
margins
T2
86 %
62 %
← positive
margins
Control rate
90 %
T1
77 %
T2
Neck surgery when invasion depth ≥ 5 mm
level I to III
unilateral for lateral tumors
bilateral for anterior/midline
ORAL TONGUE CANCER
T1 T2
SURGERY
 Partial glossectomy (negative margins > 1 cm)
→ thickness, depth invasion, perineural spread,
vascular invasion
 Elective neck node dissection
- T1
N+ 6 %
T2
T3
T4
36 % 50 % 67 %
N0
After Hickx WL. & al, Am J Otolaryngol 1998
Staging is crucial in defining the postsurgical treatment ERT + CHEMO
ORAL TONGUE CANCER
Role of elective neck dissection for T1 N0 ?
No randomized Trial
Retrospective studies remain controversial
Yii (RoyalMarsden)
REC
1999
S
Haddadin (Canniesburn)
1998
S
T1-2 N0
ELN
TND
77
27 %
50 % (p.025)
75 %
65 % (NS)
ELN
TND
81 %
45 % (p.001)
5yrs
5yrs
137
But bias in the initial treatments (various types of surgery, RT or no RT
to the primary and/or to the neck)
ELECTIVE VERSUS THERAPEUTIC NECK
DISSECTION IN ORAL CAVITY CANCERS
Randomized trial
T1-3 N0
DFS 5 yrs
39 ELND
36 observations
49 % N+
47 % N+ : TND
13 % CR
25 % CR
57 %
60 % NS
NB : 16 % of second primaries
45 % of deaths met caused by the original tumor
After Vandenbrouck & al, Cancer 46 ; 1980
ELECTIVE VERSUS THERAPEUTIC NECK
DISSECTION IN ORAL CAVITY CANCERS
Randomized trial
30 hemiglossectomy + RND
10 N +
20 N-
40 hemiglossectomy
23 N+
↓
4 contralat +
47 % N+
DFS
57 % N+
63 %
N.S
52 %
(T1 : 70 % ; T2 : 60 %)
(T1 : 64 % ; T2 : 46 %)
After Fakih & al, Am. J. Surg. 158; 1989
ELECTIVE VERSUS THERAPEUTIC NECK
DISSECTION IN ORAL CAVITY CANCERS
Randomized trial : effect of tumor depth in 51 PTS
21 Hemiglossectomy + ELN
9 (≥ 4 mm) 12 (< 4 mm)
30 hemiglossectomy
21 (≥ 4 mm)
↓
9 (< 4 mm)
↓
↓
↓
6 N+ (67 %) 1 N+ (8 %) 15 N+ (76 %) 2 N+ (22 %)
S 43 % (p < 0.01)
S 81 %
After Fakih & al, Am. J. Surg. 158; 1989
LOWER ALVEOLAR RIDGE &
RETROMOLAR TRIGONE T1-2 cancers

SURGERY
Wide local excision with marginal mandibulectomy
- close proximity to bone
- infiltration into the masticator space
- nodal involvement

RADIATION
Adjuvant for close or positive margins
for lymph node invasion
OR if used as first modality
UPPER ALVEOLAR RIDGE & HARD PALATE
CANCERS

SURGERY
Resection of part of the palatine process
→ maxillectomy followed by flap
reconstruction or prosthetic rehabilitation
- St I (9)
CSS 75 %
St II (19)
46 %
St III (14)
36 %
St IV(20)
11 %
*
- neck dissection in Stage III
 RADIATION : alone or used for close margins, bulky &
infiltrating tumors, nodal spread
After Evans & Shah, Am J Surg 1981
BUCCAL MUCOSA CANCERS

SURGERY
transoral resection + check flaps
+ mandibular resection
+ free flaps
+ maxillectomy
- Neck : advocated for T2 or invasion > 5 mm, muscle
S 5yrs
St I
78 %
St II
66 %
S 5yrs
St III
62 %
St IV
50 %
*
N0 necks : 70 % → rec rate if no END or RT : 25 % vs 10 % (p<.05)
N+ necks : 49 % (no CR : 69 %
vs +CR : 24 %)
After Diaz & al, Head & Neck 2003
BUCCAL MUCOSA CANCERS (2)

RADIATION :
Used primarily for cure of T 1-2
→ S3yrs : St I = 85 % ; St II = 63 % *
Postop advocated for high risk
- margins < 2 mm
- perineural invasion
- lymph node involvement
After Nair & al, Cancer, 1988
CONCLUSIONS (1)
Prognostic factors in oral cavity SCCA
 T size remains an «old timer»
 Depth of invasion is more informative
– as are perineural spread
vascular invasion

N involvement is a state of emergency
from prompt an multidisciplinary
aggressive treatment
CONCLUSIONS (2)





No neck should not be a cause of debate on
what is to be done in a randomized trial
Depth of invasion of the primary
Status of margins (close, involved, dysplasia,…
molecular markers)
Perineural spread
Vascular invasion
– Should be routinely reported and
be the basis of planned treatment