Role of radiotherapy and chemotherapy in oral cavity cancer

1. ROLE OF
RADIOTHERAPY AND
CHEMOTHERAPY IN
ORAL CAVITY CANCER
Presented by- Dr. Rashmi
Moderated by- Dr. Pavan

2. INTRODUCTION
• Oral cavity cancers are approximately 30% of head and
neck cancers.
• Occurs after the 5th decade of life
• 80% cases are tobacco related
• Oral leukoplakia (4–18%) and erythroplakia (30%) can
proceed to cancer
• 1.5%will have synchronous cancers
• 10-40% will develop second primaries

3. ORAL CAVITY CANCERS :
SUBSITES
1. Lip
2. Buccal mucosa
3. Floor of mouth
4. GB sulcus
5. Alveolar Ridge
6. RMT
7. Hard Palate

5. RELATIVE INVOLVEMENT OF
LYMPH NODE REGIONS
Submandibular Submental Upper
Jugular
Midjugular
ORAL
TONGUE
18 9 73 18
FLOOR OF
MOUTH
64 7 43 0
RMT 25 0 63 12.5
• Percentage Involved

6. PATHOLOGICAL CLASSIFICATION
• Normally, Oral cavity is lined by non-keratinized stratified squamous
epithelium except dorsum of the tongue, hard palate and attached
gingiva lined by keratinized squamous epithelium.
• Squamous cell carcinoma >95%
• Basaloid – worse prognosis
• Verrucous
• Sarcomatoid
• Minor salivary gland tumors – adenoid cystic carcinoma, muco-epidermoid
carcinoma, and adenocarcinoma
• Soft tissue tumors
• Lymphoepithelial carcinoma
• Haematolymphoid tumors
• Secondary tumors

7. CLINICAL PRESENTATION
• Non-healing painful ulcer
• Neck lymphadenopathy – 30-40% (frequency of neck metastases can
range from 15% to 75%, depending on the size of the primary lesion)
• Dysphagia (difficulty in swallowing)/ Odynophagia (pain while swallowing)
• Speech alteration or hoarseness
• Trismus (extension into pterygoid muscles)
• Otalgia (CNV)
• Facial Numbness(CNV)
• Hypoesthesia of the face, lips, or mandible (perineural spread along
inferior alveolar nerve after penetration of the mandible)
• Hyper salivation
• Limited tongue movements

8. DIAGNOSTIC STUDY
• Proper history and complete clinical examination.
• Routine blood investigations-CBC, LFT, KFT
• Dental examination and orthopantogram
• Chest X-Ray – to see pulmonary metastasis.
• Biopsy- incisional biopsy of most suspicious part with normal adjoining mucosa is
mandatory before planning treatment. Biopsy can be taken under LA.
• FNAC – from neck nodes if any.

9.  CT SCAN - for cervical metastasis infiltration of mandible.
Sensitivity 74% And Specificity-85%
 MRI – investigation of choice for imaging soft tissue infiltration.
Can detect peri-neural invasion.
Sensitivity-82% Specificity-66.7%
 PET-CT- not routinely recommended
 optional use in detection of distant metastasis in advance case
sensitivity 83%, specificity 88%

10. AJCC 8TH. T-STAGE

11. CLINICAL N-STAGE

12. PATHOLOGICAL N-STAGE

13. N1 N2 N3
<=3cm >3-6cm
>6cm
N1-Ipsilateral single LN ≤3cm N2A – Ipsilateral LN > 3cm. - 6 cm.
N2b – Ipsilateral multiple LN ≤ 6 cm.
N2c – Bilateral / contralateral LN ≤ 6 cm
N3a-Any node > 6 cm.
N3b- any node, ENE+

14. •DISTANT METASTASIS
Mx – Can not be assessed.
M0 – No detectable distant metastasis.
M1 – Distant metastasis present.

15. STAGE GROUPING
STAGE T N M
I T1 N0 M0
II T2 N0 M0
III T1 N1 M0
T2 N1 M0
T3 N0/N1 M0
IV A T4 N0 M0
T4 N1 M0
ANY T N2 M0
IV B ANY T N3 M0
IV C ANY T ANY N M1

16. PROGNOSTIC FACTORS
• Location/thickness/depth of primary tumor
• Staging
• Type of histology
• Grading
• Presence of perineural spread
• Mandibular invasion
• LN extension (Level, size, extracapsular)

17. TREATMENT
AIM :
• Highest loco-regional control (anatomical) with functional preservation and
minimize sequelae of treatment
Choice depends on:
• Tumor factors - Site, Size, Type
• Patient factors
• Facilities available
• Stage I / II disease - Single modality ( Surgery or RT )
• Stage III / IV disease – Combined modality

18. TREATMENT
Multimodality approach
•Surgery
•Radiotherapy
•Chemotherapy

19. COMBINED MODALITY
1. RT (Pre-op RT) Surgery
2. Surgery + RT (Intra-operative RT)
3. Surgery RT (Post-op RT) – standard of care
4. Radical RT Salvage Surgery

20. CHOICE OF TREATMENT DEPENDS UPON
VARIOUS FACTORS
Site of disease
Stage of disease:
•Early – Surgery
•Intermediate – Both (surgery & RT)
•Advance – BOTH (surgery & RT+/-CT)
Previous irradiation
Patients physical / social & personal status

21. SURGICAL TREATMENT
AIMs OF SURGERY
• Complete excision of primary, three dimensionally with Ro
(microscopically clear) margins.
• Treatment of LN.
• Reconstruction of tissue loss to provide rapid healing, restoration of
function & appearance to improve quality of life.

22. NECK DISSECTION
• Depend on nodal status.
• MRND give better cosmetic & functional result.
• Classic RND : 5 level LN with SAN, IJV, SCM.
• MRND : 5 level LN with preservation of the structure.
• Type-1 preserve SAN.
• Type-2 preserves SAN & IJV.
• Type-3 preserves SAN , SCM & IJV.

23. ROLE OF RADIOTHERAPY

24. Selective neck dissection Modified RND type 1,2,3.

25. RADIOTHERAPY
1. EBRT (External Beam Radiotherapy)
 Conventional
 3DCRT
 IMRT
2. Brachytherapy
3. Combination therapy

26. INDICATION OF RADIOTHERAPY
•Pre-operative RT:
o Inoperable
o Unfit for surgery
o Down staging
•Post-operative RT
oT3/T4 primary
oPositive surgical margins
oPerineural , peri-lymphatic vascular invasion
oMicroscopic gross residual tumor
oExtra capsular spread
oPathologically positive LN after SOHND

27. Role Of Radiotherapy
For T1- T2 lesion
Single-modality treatment (i.e., surgery or radiation) for early-
stage.
Transoral surgical resection - Small, well define lesion
involving the tip and anterolateral border of tongue.
RT (60 TO 65 Gy in 6 to 7 week) – Small, posteriorly situated,
ill define, inaccessible for surgical excision.
RT (70Gy in 7 week) - Superficial exophytic T1,T2 with
muscle invasion.

28. T3-T4 lesion
Multi modality approach is recommended
Best managed by radiotherapy with surgery.
Post-operative irradiation is recommended for larger lesions.
Adjuvant radiation proceed as soon as surgical wounds are well
healed, optimally 4 to 6 weeks after completion of surgery.

29. Pre op vs. Post op RT
Pre op RT Post op RT
• Decreases viability of tumor, • Pathologic information to modify
wound implantation dose or treatment portals
• Improves resectibility • Allows proper wound healing
• Allows delivery of dose of
radiation
• Post op RT superior to pre op RT in H&N Cancer
• Timing of post op RT critical-Within 4-6 weeks of surgery.

30. Steps of Radiotherapy
•Position – Supine position with a bite block
• Neck- support by head rest
•Immobilization in supine position with custom thermoplastic mold.

31. EBRT
2D Conventional radiotherapy
•A two phase technique is used with large lateral fields
for phase I. 44Gy / 22#
•Smaller lateral fields matched to posterior electron
fields for phase II. 26Gy / 13#
• A matched anterior neck field treats lower neck nodes with midline
shielding to reduce dose to the larynx, pharynx and spinal cord.

32. Total dose 50-70Gy/25-35 fractions by conventional radiotherapy
LN
Phase I: 44Gy/22#
LN
Primary
Phase I : 44Gy / 22#
Phase II : 26Gy / 13#
Ant. Neck : 50Gy/25#
CONVENTIONAL RADIOTHERAPY

33. 3D CRT
Computed tomography imaging for three dimensional
planning.
 Target and critical structure delineation, Contouring of the
target volume including gross tumour volume , clinical target
volume, planning target volume /OAR.

35. IMRT
• More conformal dose distribution
• Better sparing of organs at risk
o Allow for dose escalation
o Limit dose to organs at risk (OAR)
o Less toxicity, improved QOL

37. DEFINITIVE:
RT Alone
High risk: Primary tumor and involved lymph nodes [this includes possible local subclinical
infiltration at the primary site and at the high- risk level lymph node(s)
◊ Fractionation:
• 66 Gy (2.2 Gy/fraction) to 70 Gy (2.0 Gy/fraction); daily Monday–Friday in 6–7 weeks
• 72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during
last 12 treatment days)
Low to intermediate risk:
Sites of suspected subclinical spread
◊ 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)

38. POSTOPERATIVE
RT or Concurrent Systemic Therapy
High risk:
• Adverse features such as positive margins
• 60–66 Gy (2.0 Gy/fraction)
• Monday–Friday in 6–6.5 weeks
Low to intermediate risk:
• Sites of suspected subclinical spread
• 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)

39. PALLIATIVE RADIOTHERAPY
Some recommended RT regimens include:
◊ 50 Gy in 20 fractions
◊ 37.5 Gy in 15 fractions
◊ 30 Gy in 10 fractions
◊ 30 Gy in 5 fractions
◊ 44.4 Gy in 12 fractions

40. CHEMOTHERAPY
CURATIVE
• Neo-adjuvant
• Adjuvant
• Concurrent
PALLIATIVE
• Recurrance
• Metastatic

42. CHEMOTHERAPY
1. TPF Induction Chemotherapy Carboplatin + Radiation
Therapy
• Docetaxel: 70 mg/m2 IV on day 1
• Cisplatin: 75–100 mg/m2 IV on day 1
• 5-Fluorouracil: 1000 mg/m2/day IV continuous infusion on days
1–4
• Repeat cycle every 3 weeks for 3 cycles followed by:
• Carboplatin: AUC of 1.5, IV weekly for 7 weeks during radiation therapy
• Radiation therapy: 200 cGy/day to a total dose of 7000 cGy
• At the completion of chemo-radiotherapy, surgical resection as
indicated

43. CONCURRENT CHEMOTHERAPY
• Inj CISPLATIN 40mg/m2 weekly along with Radiotherapy

46. BRACHYTHERAPY
Interstitial brachytherapy is
considered for selected cases.
1. As sole treatment
2. As boost
INDICATION
T1 or T2

47. • Brachytherapy – brachy Greek for “short distance.”
• Radiation sources placed close to the tumor so large doses can hit the
cancer cells.
• Allows minimal radiation exposure to normal tissue.
• Radioactive sources used are thin wires, ribbons, capsules or seeds.
• These can be either permanently or temporarily placed in the body.
LDR brachytherapy (0.4–0.5 Gy per hour):
– Consider LDR boost 20–35 Gy if combined with 50 Gy EBRT or 60–70
Gy over several days if using LDR as sole therapy.
HDR brachytherapy:
– Consider HDR boost 21 Gy at 3 Gy/fraction if combined with 40–50 Gy
EBRT or 45–60 Gy at 3–6 Gy/fraction if using HDR as sole therapy.

48. squamous-cell carcinoma involving the left lateral oral tongue. B: Submental
view of interstitial implantation catheters housing 192Ir seeds for delivery of 25-Gy tumor
boost following external beam radiation of 50 Gy. C: Implantation bed mucositis
conforming to the tumor distribution seven days following 25-Gy implant boost.

51. FOLLOW-UP
•Clinical examination of head and neck mucosa (including
fiberoptic ) and neck palpation / performance status /
nutritional assessment
every 2 months (first 2 years),
every 6 months (years 3-5),
once a year (> 5 year)
•Dental examination and orthopantomogram every 6 months
•Chest X-ray every year
•Chest spiral CT every year
•Laboratory tests: TSH every year (if Radiotherapy delivered)
•Evolution of late toxicity.

53. THANK YOU