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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4518_Библиотеки_им_академика_М_И_Перельмана
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• T1: Tumor ≤2 cm in greatest dimension and with <5 mm depth of invasion (DOI)
• T2: Tumor ≤2cm and with DOI between 5mm and 10mm
• or tumor is >2cm but ≤4cm and DOI is ≤10mm
• T3: Tumor >4cm or
• or any tumor with DOI>10mm but ≤20mm
• T4a: Tumor involves adjacent structures such as cortical bone, deep musculature
of tongue (genioglossus, hyoglossus, palatoglossus, styloglossus, maxillary
sinus, and skin of face), and/or DOI>20mm
• T4b: Tumor involves masticator space, pterygoid plates, skull base, or internal
carotid artery encasement
A. A. Jategaonkar and M. Khan
Nodal Disease (Clinical N Stage, cN)
• Nx: Regional nodes cannot be assessed
• N0: No regional nodal metastasis
• N1: Metastasis in a single ipsilateral node ≤3 cm with no extranodal extension, ENE (−)
• N2a: Metastasis in a single ipsilateral node >3 cm but not more than 6 cm
and ENE (−)
• N2b: Metastasis in multiple ipsilateral nodes, none >6cm in greatest dimension
and ENE (−)
• N2c: Metastasis in bilateral or contralateral nodes, none >6cm and ENE (−)
• N3a: Metastasis in a single node >6cm and ENE (−)
• N3b: Any nodal metastasis with clinically overt ENE (+)
Nodal Disease (Pathological N Stage, pN)
• Nx: Regional nodes cannot be assessed
• N0: No regional nodal metastasis
• N1: Metastasis in a single ipsilateral node ≤3 cm with no extranodal extension, ENE (−)
• N2a: Metastasis in a single impsilateral node ≤3cm and is ENE (+) or metastasis
in a single ipsilateral node >3cm but ≤6cm and ENE (−)
• N2b: Metastasis in multiple ipsilateral nodes, none >6cm in greatest dimension
and ENE (−)
• N2c: Metastasis in bilateral or contralateral nodes, none >6cm and ENE (−)
• N3a: Metastasis in a single node >6cm and ENE (−)
• N3b: Metastasis in a single node >3cm and ENE (+) or multiple nodes of any
size with ENE (+) in any node
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Distant Metastasis (M Stage)
• M0: No distant metastases
• cM1: Clinically evident distant metastases
• pM1: Pathologically conrmed distant metastases
Management
The primary treatment modality for oral cavity malignancies is primary surgical
excision. In general, early-stage disease is treated with single-modality therapy.
Patients who are otherwise not surgical candidates may be treated with radiation or
chemotherapy. Patients treated surgically may also need adjuvant therapy.
• Management of Nodal Disease:
– Oral cavity cancers metastasize to levels I, II, and III in the neck.
– In clinically N0 necks, the role of elective neck dissections can be debated.
– There is however level I evidence to support elective neck dissection in
patients with an N0 neck.
– Elective neck dissections should be performed in patients who have primary
oral tongue tumors with depth of invasion >4mm.
– Contralateral neck dissection should be considered in patients with large
tumors (T3 or T4) or tumors that approach/cross midline
– Contralateral neck dissection should also be considered if there are metastatic
nodes in the ipsilateral neck or there is evidence of extranodal extension of
disease.
• Radiation Therapy:
– Radiation therapy should be added in patients with large tumors (T3/T4),
those with multiple positive nodes, or perineural invasion. Chemotherapy
should also be considered in patients with positive margins that cannot be reresected or those with extranodal extension.
– Radiation therapy should occur 4–6weeks after surgery to allow for wound
healing. Delays in administering RT are associated with poorer oncologic
outcomes.
– Pretreatment considerations include airway management (consider elective
tracheostomy), dysphagia assessment, and dental extractions. Extractions
should take place 2weeks prior to beginning radiation.
There are several types of radiation therapy.
• Brachytherapy: radioisotopes are applied directly to the tumor, e.g., implants or
catheters. This is commonly used in lip cancers or for recurrence of certain oropharyngeal and nasopharyngeal cancers.
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• Conventional external beam radiation therapy
• Intensity-modulated radiation therapy (IMRT)
• Stereotactic body radiation therapy (SBRT), e.g., cyberknife
• Complications of radiation include mucositis, xerostomia, and osteoradionecrosis (late complication).
• Chemotherapy
– Chemotherapy can be given concurrently or as induction chemotherapy.
Chemotherapy sensitizes the tumor to radiation. Chemotherapy is not curative as a single-modality treatment. Chemotherapy should be added to
adjuvant radiation in cases with positive margins and with extranodal
extension.
Cisplatin and carboplatin are the primary platinum-based chemotherapeutic agents.
Cisplatin is more toxic and associated with alopecia, nephrotoxicity, ototoxicity, nausea, and neutropenia. Carboplatin is generally better tolerated
and less ototoxic.
Taxanes are primarily used together with other agents in induction chemotherapy protocols.
5-Fluorouracil (5-FU) is associated with severe mucositis and is less commonly used
Biologics such as cetuximab and other immune check point inhibitors will
likely become increasingly common as data regarding oncologic outcomes
with these agents become available.
A. A. Jategaonkar and M. Khan
• Surgical Management (by subsite)
Lip
• Extends up to skin–vermillion border
• Lip represents the most common site for oral cavity SCCA (up to 25% of all oral
cavity SCCA)
• Risk factors are fair skin, tobacco, alcohol, and sun exposure
• Treatment is single modality, generally primary surgery
• Advanced stage often will need addition of multimodality therapy with adjuvant
radiation and/or chemotherapy
• Reconstruction of lip defects is important for oral competence and facial
aesthetics
– Various local aps are employed for reconstruction including Abbe/Estlander
aps, Karapandzic aps, etc.
– Free tissue transfer may be necessary for large lip defects
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Buccal Mucosa
• Risk factors include tobacco/alcohol, betel nut use in south Asian population
• Represents 5–10% of oral cancers in the United States
• Buccal cancers can be particularly aggressive given the relative lack of anatomy
boundaries
• Small T1 lesions are rarely identied and may be mistaken for oral/dental trauma.
• Cervical metastases are common. Up to half of all T2 and T3 tumors will have
nodal disease. In addition to level I, peri-facial nodes should also be assessed.
• Reconstruction often is indicated given the late stage of presentation and the
tendency for signicant scar contracture, leading to trismus.
• Adjuvant therapy is often needed
Oral Tongue
• This represents the anterior two-third of the tongue
• Nodal metastasis typically occurs in levels I–III
• NO neck should under elective supra-omohyoid neck dissection especially if
DOI on primary oral tongue tumor >4mm.
• Reconstruction dependent on extent of defect. If 50% or more of the tongue is
resected, free tissue transfer is often necessary
• Speech and swallow function can be compromised by treatment and speech language pathologist evaluation and assistance is needed
• Adjuvant therapy is needed in patients with advanced disease
Alveolar Ridge (Mandibular or Maxillary)
• Primary treatment is surgery
• Nodal metastasis are common in levels I, II, and III.Retropharyngeal nodes may
also be involved
• In patients without cortical invasion of the bone, marginal mandibulectomy may
be considered
• Patients with cortical invasion (or invasion into tooth roots) should undergo segmental mandibulectomy
• Edentulous patients with atrophic mandibles may not be able to tolerate marginal
mandibulectomy (risk of pathologic fracture)
• Mandibular defects can be reconstructed with bone-containing free aps, e.g.,
bula, scapula, or osseo-cutaneous radial forearm free aps
• Adjuvant therapy is often needed
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A. A. Jategaonkar and M. Khan
Retromolar Trigone
• Triangular mucosal space bounded by the last mandibular molar and the maxillary tuberosity.
• Nodal metastasis typically occurs in levels I–III
• Given close proximity to maxilla, mandible, buccal mucosa invasion into other
subsites is common and mandibulectomy (marginal or segmental) may be
necessary
• Lip splits and/or mandibulotomies may be necessary given the difculty of
obtaining exposure
Hard Palate
• The hard palate is formed by the bone of the palatine process of the maxilla and
the palatine bone.
• The overlying mucosa is tightly adherent to the periosteum which in turn is
tightly held to the bone by the brous pegs of Sharpey
• Nodal metastasis typically occurs in levels I or II (or retropharyngeal nodes)
• Treatment is primarily surgical with palatectomies or maxillectomies needed
depending on extent of tumor invasion.
• Reconstruction is necessary to close any communication between oral and nasal
cavities.
• Reconstruction can be achieved with obturation, local aps (e.g., palatal island),
or free tissue transfer.
• Adjuvant therapy is needed in patients with advanced disease
Floor ofMouth
• This represents the anterior two-third of the tongue
• Nodal metastasis typically occurs in levels I–III
• NO neck should under elective supra-omohyoid neck dissection especially if
DOI on primary tumor >4mm.
• Reconstruction dependent on extent of defect. If 50% or more of the tongue is
resected, free tissue transfer is often necessary
• Speech and swallow function can be compromised by treatment and so careful
monitoring and assessment is needed
• Adjuvant therapy is needed in patients with advanced disease
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Oropharyngeal Squamous Cell Carcinoma (OP SCCA)
• Anatomy
• The oropharynx is bound superiorly by the soft palate. The anterior borders lie at
the hard/soft palate junction and the circumvallate papillae (separating oral
tongue from oropharyngeal tongue). The hyoid is the lower limit of the oropharynx. Posterior pharyngeal wall is the posterior limit of the oropharynx. The oropharynx functions to maintain oronasal separation, enable phonation, and prevent
aspiration.
– The subsites of the oropharynx are as follows:
Palatine tonsils: Most common site of OP SCCA
Tonsillar pillars
Base of tongue (lingual tonsils)
Soft palate and uvula
Posterior pharyngeal wall
• Epidemiology/Pathogenesis
• SCCA represents the vast majority of OP cancers. OP SCCA can be thought of
as two distinct diseases, HPV/P16 positive, and HPV/P16 negative (or traditional SCCA).
– HPV-mediated SCCA (P16 positive)
HPV 16, 18. 31, and 33 are oncogenic strains of HPV
E6 and E7 are the viral proteins associated with oncogenesis.
E6 and E7 counteract/suppress the tumor suppressor genes p53 and RB,
respectively
Not associated with tobacco/alcohol consumption
Often with small primary tumors
Early presentation with large nodal/cystic nodal metastases
Favorable prognosis when compared with conventional (HPV negative) OP SCCA
– Traditional SCCA (P16/HPV negative)
Associated with tobacco and alcohol use
Several subtypes have been described including spindle/sarcomatoid
(aggressive), basaloid, and verrucous.
Often with large primary tumors compared to nodal disease
Poor prognosis when compared to HPV-mediated cancers
– Other malignancies seen in the oropharynx that are not discussed here include
lymphoma (recall the lymphoid tissues of Waldeyer’s ring), minor salivary
gland cancers, and sarcomas.
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• Clinical Presentation
– Most common presenting symptom in the era of HPV-related OP SCCA is
often a painless neck mass.
– Others include otalgia, odynophagia, dysphagia, voice changes, dyspnea, glo-
bus sensation, and unintentional weight loss.
• Work-Up
A. A. Jategaonkar and M. Khan
Physical Exam
• All patients should undergo beroptic exam
• Palpation may also be helpful in identifying smaller primary tumors
• Neck exam should be done to evaluate for clinical lymphadenopathy
• Evaluate the airway and access to the oropharynx (think of the Ts of access to the
oropharynx for transoral surgery, e.g., teeth, trismus, tethering, and tumor)
• FNA should be obtained of any neck masses
– Send for HPV/EBV (EBV to assess for nasopharyngeal cancer if unknown
primary)
• Given small primary tumors, HPV-positive patients may need direct laryngoscopy to identify the primary tumor
Imaging
• Computed tomography (CT) with contrast is the preferred imaging modality to
assess local/regional disease.
• MRI can be useful in assessing the soft tissues
• PET/CT can be used to evaluate for distant metastasis and to help identify an
unknown primary (in patients presenting with a metastatic nodal disease)
Staging
AJCC eighth edition has divided the staging of OP SCCA into separate groups for
HPV+and HPV– disease
Primary Tumor Stage: HPV+ Oropharyngeal SCCA
• T0: No primary tumor identied
• T1: Tumor is ≤2cm in greatest dimension
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• T2: Tumor is >2cm but ≤4cm
• T3: Tumor >4 cm or any tumor that extends to the lingual surface of the
epiglottis
• T4: Tumor invades the larynx, extrinsic muscles of the tongue, medial pterygoid,
hard palate, mandible, or beyond.
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Clinical Nodal Disease Stage (cN) forHPV+Cancers
• Nx: Regional nodes cannot be assessed
• N0: No regional nodal metastasis
• N1: One or more ipsilateral nodes, none >6cm
• N2: Contralateral or bilateral nodes, none >6cm
• N3: Any nodal metastasis >6cm
Pathological Nodal Disease Stage (pN) forHPV+Cancers
• Nx: Regional nodes cannot be assessed
• N0: No regional nodal metastasis
• N1: Metastasis in 4 or fewer lymph nodes
• N2: Metastasis more than 4 lymph nodes
Primary Tumor Stage forHPV (−) OP SCCA
• Tx: Primary tumor cannot be assessed
• Tis: Carcinoma in situ
• T1: Tumor ≤2cm in greatest dimension
• T2: Tumor is >2cm but ≤4cm
• T3: Tumor >4cm or with extension to lingual aspect of epiglottis
• T4a: Tumor involves larynx, extrinsic tongue muscles, medial pterygoid, hard
palate, or mandible
• T4b: Tumor invades lateral pterygoid muscle or plates lateral nasopharynx, skull
base, or with carotid encasement
Clinical Nodal Disease Stage (cN) forHPV (−))
• Nx: Regional nodes cannot be assessed
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• N0: No regional nodal metastasis
• N1: Metastasis in a single ipsilateral node ≤3 cm with no extranodal extension, ENE (−)
• N2a: Metastasis in a single ipsilateral node >3cm but ≤6cm and ENE (−)
• N2b: Metastasis in multiple ipsilateral nodes, none >6cm in greatest dimension
and ENE (−)
• N2c: Metastasis in bilateral or contralateral nodes, none >6cm and ENE (−)
• N3a: Metastasis in a single node >6cm and ENE (−)
• N3b: Any nodal metastasis with clinically overt ENE (+)
A. A. Jategaonkar and M. Khan
Pathological Nodal Disease Stage (pN) forHPV (−)
• Nx: Regional nodes cannot be assessed
• N0: No regional nodal metastasis
• N1: Metastasis in a single ipsilateral node ≤3 cm with no extranodal extension, ENE (−)
• N2a: Metastasis in a single ipsilateral node ≤3cm and is ENE (+)
• or metastasis in a single ipsilateral node >3cm but ≤6cm and ENE (−)
• N2b: Metastasis in multiple ipsilateral nodes, none >6cm in greatest dimension
and ENE (−)
• N2c: Metastasis in bilateral or contralateral nodes, none >6cm and ENE (−)
• N3a: Metastasis in a single node >6cm and ENE (−)
• N3b: Metastasis in a single node >3cm and ENE (+) or multiple nodes of any
size with ENE (+) in any node or single contralateral node of any size that
is ENE (+)
Distant Metastasis (M Stage)
• M0: No distant metastases
• cM1: Clinically evident distant metastases
• pM1: Pathologically conrmed distant metastases
• Management
• Early-stage disease can be treated with single-modality therapy (surgery or radiation). Advanced-stage disease can be treated with surgery and adjuvant radiation (if resectable) or concurrent chemoradiation.
– Management of Nodal Disease:
Oropharyngeal cancers tend to metastasize to levels II, III, and IV of
the neck.
Consider elective ipsilateral elective neck dissections in patients that are
clinically N0
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Base of tongue cancers is more likely to have contralateral nodal
metastasis
– Radiation Therapy:
Principles, types, and complications of radiation therapy are similar to
those described above under oral cavity cancer.
– Chemotherapy
Just as in oral cavity cancers, chemotherapy can be given concurrently or
as induction chemotherapy. Adjuvant chemotherapy reserved for positive
margin resection or extranodal extension. Generally, the goal is to avoid
triple modality treatment in patients with early-stage HPV+ disease.
– Surgical Management
Conventional/open techniques:
• These techniques are not commonly employed for primary treatment
given the associated morbidity. However, it may still be needed in cases
of surgical salvage
• Lip split/mandibulotomy can provide great exposure; however, facial
scarring and mandibular non-union or resultant malocclusion are potential complications.
• Transhyoid pharyngotomy utilizes a cervical incision to approach the
vallecular space and make a pharyngotomy.
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– Pharyngotomy is generally made laterally away from tumor.
– Can provide decent access to lateral lesions of the inferior orophar-
ynx (lateral base of tongue, inferior tonsillar pole)
• Glossectomy approaches such as lingual release can also be used to
access the oropharynx but can be associated with signicant morbidity
given the release of mandibular and lingual attachments.
Transoral approaches:
• These approaches do not require any morbid procedures for exposure
such as mandibulotomies/lip splits.
• They are associated with excellent oncologic outcomes, shorter hospitalization, and increased speed in return to normalcy of diet.
• Close margins are accepted with these procedures and are supported by
the literature
• Transoral Robotic Surgery (TORS) typically utilizes a DaVinci Robot
and is approved by the FDA for T1 and T2 OP SCCA.
– High-denition 3D visualization allows for excellent tumor and sur-
gical visualization
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