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MASTERCOURSE IN ORAL CANCER MANAGEMENT-2021.pptx

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MASTERCOURSE IN ORAL CANCER MANAGEMENT-2021.pptx

  1. 1. DAY 2 PRESENTED BY:DR.MONALISA BANERJEE MASTERCOURSE IN ORAL CANCER MANAGEMENT-2021
  2. 2. TOPICS COVERED
  3. 3. BUCCAL MUCOSA EXCISION+MARGINAL MANDIBULECTOMY
  4. 4. QUESTIONS DISCUSSED  Requirement of coronoidectomy along with marginal mandibulectomy?  How to prevent fracture following marginal mandibulectomy?  How and when to preserve the lingual nerve during marginal mandibulectomy?  RMT lesion with no gross bone involvement clinically and radiologically-choice of mandibulectomy?  Post RT case-How to protect the blood supply of mandible while raising a cheek flap?
  5. 5. Infrastructure Maxillectomy
  6. 6. Approaches
  7. 7. Reconstruction
  8. 8. QUESTIONS DISCUSSED  How to decide which incision to take?  How to carry out pterygomaxillary disjuntion?  When to remove the inferior turbinate?  Is it possible to place implants immidiately after maxillectomy?  How to decide the reconstruction?  Difference in treating adenoid cystic carcinoma from squamous cell carcinoma?
  9. 9. Early Oral Cancers:Panel Discussion 1.Importance of depth of invasion  Can be considered in tongue lesions as usually pre-operative MRI is done.  More important in post-operative setting and used as factor in pathological classification.
  10. 10. 2.Imaging in Early Oral Cancers  Should be considered in majority of cases.  Critical in tongue, gbs lesions.
  11. 11. 3.Chosing the modality
  12. 12. Immunotherapy for Oral Cavity and Oropharyngeal Cancer  Pembrolizumab (Keytruda) and nivolumab (Opdivo) are drugs that target PD-1, a protein on T cells in the immune system.  PD-1 normally helps keep T cells from attacking other cells . By blocking PD-1, these drugs boost the immune response against cancer cells. This can shrink some tumors or slow their growth.  Single/double dose:50%-60% success rate.
  13. 13. Risk of nodal metastasis after primary Brachytherapy •Single instituitional experience of 42 patients. •Late nodal recurrence after treatment by primary brachytherapy-80% •Tumor thickness >6mm,risk of recurrence seen to be higher
  14. 14. • Brachytherapy is suggested for oral tumors of depth<=1.5cm and at least 5mm from bone. • Management of neck is not mentioned in these guidelines.
  15. 15. 4. FROZEN SECTION AND MARGINS  Role of Frozen Section  Margin revision and how beneficial is it?  Consideration of initial / revised margin for adjuvant radiotherapy
  16. 16. •Retrosprective analysis of 416 patients-229 with FS while 197 without FS •Local failure was determined by age, T stage, N stage and Marginal status •Chance of achieving clear margins not significantly improved by FS
  17. 17. •R1 TO R0 Vs RO Resection- R1 TO R0 Showed significantly worse 5- years LRFS compared to R0 •R1 TO Negative vs R0 Resection:R1 TO Negative patient showed significantly worse LRFS compared to R0 •R1 vs R1 TO R0 Resection-R1 showed a trend towards worse 5years LRFS compared with R1 to R0 but did not reach any significance.
  18. 18. SPECIMEN VS DEFECT DRIVEN APPROACH
  19. 19. MARGINS Historical cohort of 277 oral cancer patients. 5-year survival rate: Margins>5mm-73% 3-4mm-69% 2mm or less-62% Involved margins 39% Advocated 3mm as adequate margin.
  20. 20. Adjuvant therapy RISK FACTORS FOR ADJUVANT THERAPY MAJOR FACTORS •STAGE III/IV •POSITIVE MARGINS •DEPTH OF INVASION •NODAL METASTASIS •EXTRACAPSULAR SPREAD MINOR FACTORS •LVI •PNI •WORSE PATTERN OF INVASION •TUMOR BUDDING
  21. 21. ITF CLEARANCE  Assessment of ITF Involvement  Supra-notch vs Infra Notch disease  Signs of unressectability  Role of NACT in diseases involving ITF  Role of bony reconstructions following ITF
  22. 22. Assessment of ITF involvement Assess with CT first Check for the widening at mandibular canal or pterygomaxillary fissure area. If positive go for MRI
  23. 23. Supra notch vs Infra notch disease
  24. 24. Signs of unresectability  Lateral pterygoid muscle involvement.  Temporalis muscle involvement above the coronoid notch.  Posterior extension into tonsils,lateral pharyngeal wall.  N3 node involving pre-vertebral fascia/encasing the carotid artery.  Perineural spread on CT upto/above foramen ovale.
  25. 25. MAJOR GLOSSECTOMY
  26. 26. PATIENT EVALUATION?  Examination under anesthesia for large lesion.  DOI to be assessed on MRI  BOT,FOM, mucosa between dease and mandible to be assessed for.  Severe trismus: Endoscopy, Imaging should be considered.
  27. 27. PANEL DISCUSSION  TREATMENT OF ADVANCED ORAL CANCER
  28. 28. CRITERIA OF RESSECTABILITY  Very advanced disease: Consider PET-CT  Evaluate the skull base: CECT and compliment with CEMRI  UNRESSECTABILITY of primary disease: A>Adequate surgical clearance is not achievabable B>Extensive ITF involvement C>Extensive involvement of Base of Skull D>Extensive soft tissue disease.
  29. 29. Treatment decision  1.Criteria of resectability  2.Role of NACT  3.Margins in ITF.  4.Adjuvant treatment
  30. 30. ADJUVANT RT/CTRT

Hinweis der Redaktion

  • Europian society of radiotherapy and oncology

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