Oral cancer medical therapy: Difference between revisions

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{{Oral cancer}}
{{Oral cancer}}
{{CMG}};{{AE}}{{Simrat}}
{{CMG}}; {{AE}} {{SSW}}, {{Simrat}}; {{GRR}} {{Nat}}
==Overview==
==Overview==
The predominant therapy for oral cancer is [[surgical]] resection, [[radiation]] therapy or a combination of both. Adjunctive [[chemotherapy]], [[radiation]],
The predominant therapy for oral cancer is [[surgical]] resection, [[radiation]] therapy or a combination of both. Adjunctive [[chemotherapy]], [[radiation]], [[chemotherapy]] may be required. Radiation in the form of external-beam [[radiation]] therapy (EBRT) or interstitial implantation is used. Advantages of radiotherapy are that normal anatomy or function are maintained and general anesthesia is not needed. Disadvantages of radiotherapy are that it is inefficient to treat large tumors, subsequent surgery is more difficult, oral mucositis, dry mouth (xerostomia), osteoradionecrosis (ORN), etc.
chemoradiation may be required.


==Medical Therapy==
==Medical Therapy==
Depending on the site and extent of the primary tumor and the status of the [[lymph nodes]], some general considerations for the treatment of lip and oral cavity cancer include the following:
* Depending on the site and extent of the primary tumor and the status of the [[lymph nodes]], some general considerations for the treatment of lip and oral cavity cancer include the following:
*Surgery alone
**Surgery alone
*Radiation therapy alone
**Radiation therapy alone
*A combination of the above
**A combination of the above
===Surgery===
 
For [[lesions]] of the oral cavity, surgery must adequately encompass all of the gross as well as the presumed microscopic extent of the disease. If regional nodes are positive, [[cervical]] node dissection is usually done in continuity. With modern approaches, the surgeon can successfully ablate large posterior oral cavity tumors and with reconstructive methods can achieve satisfactory functional results. Prosthodontic rehabilitation is important, particularly in early-stage cancers, to assure the best quality of life.
===Radiation===
===Radiation===
Radiation therapy for lip and oral cavity cancers can be administered by external-beam [[radiation]] therapy (EBRT) or interstitial implantation alone, but for many sites the use of both modalities produces better control and functional results. Small superficial cancers can be very successfully treated by local implantation using any one of several radioactive sources, by intraoral cone radiation therapy, or by electrons. Larger lesions are frequently managed using EBRT to include the primary site and regional [[lymph nodes]], even if they are not clinically involved. Supplementation with [[interstitial]] radiation sources may be necessary to achieve adequate doses to large primary tumors and/or bulky nodal [[metastases]]. A review of published clinical results of radical radiation therapy for head and neck cancer suggests a significant loss of local control when the administration of [[radiation]] therapy was prolonged; therefore, lengthening of standard treatment schedules should be avoided whenever possible.
* External-beam [[radiation]] therapy (EBRT) or interstitial implantation can be administered to give radiation therapy for lip and oral cavity cancers.
===Treatment of early cancers{stage I and stageII}===
** These can be used alone; whereas, combined use of both modalities produce better control and functional results at some sites.  
Early cancers (stage I and stage II) of the lip, floor of the mouth, and retromolar trigone are highly curable by surgery or radiation therapy. The choice of treatment is dictated by the anticipated functional and cosmetic results. Availability of the particular expertise required of the surgeon or radiation oncologist for the individual patient is also a factor in treatment choice.
** Implants of iridium Ir 192 are often used.
Early cancers of the [[buccal]] mucosa are equally curable by radiation therapy or by adequate [[excision]]. Patient factors and local expertise influence the choice of treatment. Larger cancers require composite resection with reconstruction of the defect by pedicle flaps.
* Small, superficial cancers are treated by local implantation using intra-oral cone radiation therapy or by radiation using electrons.
* Larger lesions are managed using EBRT to include the primary site and regional [[lymph nodes]], even if they are not clinically involved.  
* [[interstitial]] radiation is used to supplement therapy to achieve adequate doses to treat large primary tumors and/or bulky nodal [[metastases]].<ref name="pmid2466229">{{cite journal |vauthors=Bansberg SF, Olsen KD, Gaffey TA |title=High-grade carcinoma of the oral cavity |journal=Otolaryngol Head Neck Surg |volume=100 |issue=1 |pages=41–8 |year=1989 |pmid=2466229 |doi=10.1177/019459988910000107 |url=}}</ref>
* A review of published clinical results of radical radiation therapy for head and neck cancer suggests a significant loss of local control when the administration of [[radiation]] therapy was prolonged; therefore, lengthening of standard treatment schedules should be avoided whenever possible.<ref name="pmid19403886">{{cite journal |vauthors=Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA |title=Future of cancer incidence in the United States: burdens upon an aging, changing nation |journal=J. Clin. Oncol. |volume=27 |issue=17 |pages=2758–65 |year=2009 |pmid=19403886 |doi=10.1200/JCO.2008.20.8983 |url=}}</ref>
 
==== Advantages of radiotherapy ====
* Normal anatomy and function are maintained
* General anesthesia is not needed
 
==== Disadvantages of radiotherapy ====
* More adverse effects 
* Not efficient to treat large tumors
* Subsequent surgery is more difficult and hazardous and survival is reduced further
* [[dry mouth]]
*Difficulty [[swallowing]]
*[[weight loss]]


Early [[lesions]] (T1 and T2) of the anterior [[tongue]] may be managed by surgery or by radiation therapy alone. Both modalities produce 70% to 85% cure rates in early lesions. Moderate excisions of tongue, even hemiglossectomy, can often result in little speech disability provided the wound closure is such that the tongue is not bound down. If, however, the resection is more extensive, problems may include aspiration of liquids and solids and difficulty in swallowing in addition to speech difficulties. Occasionally, patients with tumor of the tongue require almost total glossectomy. Large lesions generally require combined surgical and radiation treatment. The control rates for larger lesions are about 30% to 40%. According to clinical and radiological evidence of involvement, cancers of the lower [[gingiva]] that are exophytic and amenable to adequate local excision may be excised to include portions of bone. More advanced lesions require segmental bone resection, hemimandibulectomy, or maxillectomy, depending on the extent of the lesion and its location.
* Short-term complications
** Oral mucositis
*** 40% of patients are affected
*** Can be so severe that treatment has to be stopped sometimes
* Long-term complications
** Dry mouth (xerostomia)
** Loss of taste
** Osteoradionecrosis (ORN)
 
===Treatment of early cancers {stage I and stage II}===
* Stage I and II cancer of the lip, floor of the mouth, and retromolar trigone can be treated by surgery or radiation therapy.<ref name="pmid8417381">{{cite journal |vauthors=Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, Skingley P, Levine MN |title=Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer |journal=N. Engl. J. Med. |volume=328 |issue=3 |pages=159–63 |year=1993 |pmid=8417381 |doi=10.1056/NEJM199301213280302 |url=}}</ref>
* The choice of treatment is decided based on functional and cosmetic results.
* [[buccal]] mucosa carcinoma can be treated by radiation therapy.
* T1 and T2 stage cancer of the anterior [[tongue]] may be treated radiation therapy alone.
* Radiation therapy has 85% cure rates in early lesions.
* Benefits of using radiation therapy over surgical resection are:
** Lesser chances of speech disabilities
** Less chance of aspiration of liquids and solid.
* Cancer involving upper-gingiva or hard palate without bone involvement can be treated by radiation therapy alone.  
* Patients who smoke while on radiation therapy appear to have lower response rates and a shorter survival duration than those who do not; therefore, patients should be counseled to stop smoking before beginning radiation therapy.<ref name="pmid22135122">{{cite journal |vauthors=Peppone LJ, Mustian KM, Morrow GR, Dozier AM, Ossip DJ, Janelsins MC, Sprod LK, McIntosh S |title=The effect of cigarette smoking on cancer treatment-related side effects |journal=Oncologist |volume=16 |issue=12 |pages=1784–92 |year=2011 |pmid=22135122 |pmc=3248778 |doi=10.1634/theoncologist.2011-0169 |url=}}</ref>


Early lesions of the upper gingiva or hard palate without bone involvement can be treated with equal effectiveness by surgery or by radiation therapy alone. Advanced infiltrative and ulcerating lesions should be treated by a combination of radiation therapy and surgery. Most primary cancers of the [[hard palate]] are of minor salivary gland origin. Primary squamous cell carcinoma of the hard palate is uncommon, and these [[tumors]] generally represent invasion of [[squamous cell carcinoma]] arising on the upper [[gingiva]], which is much more common. Management of squamous cell carcinoma of the upper [[gingiva]] and hard [[palate]] are usually considered together. Surgical treatment of cancer of the hard [[palate]] usually requires [[excision]] of underlying bone producing an opening into the antrum. This defect can be filled and covered with a dental prosthesis, which is a maneuver that restores satisfactory swallowing and speech.
Patients who smoke while on radiation therapy appear to have lower response rates and shorter survival durations than those who do not; therefore, patients should be counseled to stop smoking before beginning radiation therapy. Dental status evaluation should be performed prior to therapy to prevent late sequelae.<ref>{{Cite web | title =NIH Oral cancer treatment| url =http://www.cancer.gov/types/head-and-neck/hp/lip-mouth-treatment-pdq#section/_53 }}</ref>
===Treatment of advanced cancers{stage III and stage IV}===
===Treatment of advanced cancers{stage III and stage IV}===
Advanced cancers (stage III and stage IV) of the [[lip]], floor of the [[mouth]], and retromolar trigone represent a wide spectrum of challenges for the surgeon and radiation oncologists. Most patients with stage III or stage IV tumors are candidates for treatment by a combination of surgery and radiation therapy. Patients with small T3 lesions and no regional lymph nodes, and no distant [[metastases]] or patients who have no [[lymph nodes]] larger than 2 cm in diameter, for whom treatment by radiation therapy alone or surgery alone might be appropriate, are the exceptions. Because local recurrence and/or distant metastases are common in this group of patients, they should be considered for clinical trials that are evaluating the following:
* Most patients with stage III or stage IV tumors are candidates for treatment by a combination of surgery and radiation therapy.
*The potential role of radiation modifiers to improve local control or decrease [[morbidity]].
* Patients with small T3 lesions,no regional lymph nodes, and no distant [[metastases]] (or patients who have no [[lymph nodes]] larger than 2 cm in diameter) can be treated by radiation therapy alone.
*The role of combinations of chemotherapy with surgery and/or radiation therapy both to improve local control and to decrease the frequency of distant metastases.
* Because local recurrence and/or distant metastases are common in this group of patients, they should be considered for clinical trials that are evaluating the following:
**The potential role of radiation modifiers are to improve local control or decrease [[morbidity]].
**The role of combinations of chemotherapy with surgery and/or radiation therapy are to both to improve local control and decrease the frequency of distant metastases.


===Complications of treatment===
===Surgery===
*Postoperative disfigurement of the face, [[head]] and [[neck]]
* For [[lesions]] of the oral cavity, surgery must adequately encompass all of the gross, as well as the presumed microscopic extent of the disease.<ref name="pmid12139232">{{cite journal |vauthors=Neville BW, Day TA |title=Oral cancer and precancerous lesions |journal=CA Cancer J Clin |volume=52 |issue=4 |pages=195–215 |year=2002 |pmid=12139232 |doi= |url=}}</ref>
*Complications of radiation therapy include [[dry mouth]] and difficulty [[swallowing]]
** If regional nodes are positive, [[cervical]] node dissection is usually done in continuity.
*Other [[metastasis]] (spread) of the cancer
** Surgeons ablate large posterior oral cavity tumors using reconstructive methods so that satisfactory functional results can be achieved.
*Significant [[weight loss]]<ref>{{Cite web | title =Wikipedia complications of oral cancer treatment| url =https://en.wikipedia.org/wiki/Oral_cancer }}</ref>
** Prosthodontic rehabilitation is important, particularly in early-stage cancers, to assure the best quality of life.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 12:53, 11 April 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sargun Singh Walia M.B.B.S.[2], Simrat Sarai, M.D. [3]; Grammar Reviewer: Natalie Harpenau, B.S.[4]

Overview

The predominant therapy for oral cancer is surgical resection, radiation therapy or a combination of both. Adjunctive chemotherapy, radiation, chemotherapy may be required. Radiation in the form of external-beam radiation therapy (EBRT) or interstitial implantation is used. Advantages of radiotherapy are that normal anatomy or function are maintained and general anesthesia is not needed. Disadvantages of radiotherapy are that it is inefficient to treat large tumors, subsequent surgery is more difficult, oral mucositis, dry mouth (xerostomia), osteoradionecrosis (ORN), etc.

Medical Therapy

  • Depending on the site and extent of the primary tumor and the status of the lymph nodes, some general considerations for the treatment of lip and oral cavity cancer include the following:
    • Surgery alone
    • Radiation therapy alone
    • A combination of the above

Radiation

  • External-beam radiation therapy (EBRT) or interstitial implantation can be administered to give radiation therapy for lip and oral cavity cancers.
    • These can be used alone; whereas, combined use of both modalities produce better control and functional results at some sites.
    • Implants of iridium Ir 192 are often used.
  • Small, superficial cancers are treated by local implantation using intra-oral cone radiation therapy or by radiation using electrons.
  • Larger lesions are managed using EBRT to include the primary site and regional lymph nodes, even if they are not clinically involved.
  • interstitial radiation is used to supplement therapy to achieve adequate doses to treat large primary tumors and/or bulky nodal metastases.[1]
  • A review of published clinical results of radical radiation therapy for head and neck cancer suggests a significant loss of local control when the administration of radiation therapy was prolonged; therefore, lengthening of standard treatment schedules should be avoided whenever possible.[2]

Advantages of radiotherapy

  • Normal anatomy and function are maintained
  • General anesthesia is not needed

Disadvantages of radiotherapy

  • More adverse effects
  • Not efficient to treat large tumors
  • Subsequent surgery is more difficult and hazardous and survival is reduced further
  • dry mouth
  • Difficulty swallowing
  • weight loss
  • Short-term complications
    • Oral mucositis
      • 40% of patients are affected
      • Can be so severe that treatment has to be stopped sometimes
  • Long-term complications
    • Dry mouth (xerostomia)
    • Loss of taste
    • Osteoradionecrosis (ORN)

Treatment of early cancers {stage I and stage II}

  • Stage I and II cancer of the lip, floor of the mouth, and retromolar trigone can be treated by surgery or radiation therapy.[3]
  • The choice of treatment is decided based on functional and cosmetic results.
  • buccal mucosa carcinoma can be treated by radiation therapy.
  • T1 and T2 stage cancer of the anterior tongue may be treated radiation therapy alone.
  • Radiation therapy has 85% cure rates in early lesions.
  • Benefits of using radiation therapy over surgical resection are:
    • Lesser chances of speech disabilities
    • Less chance of aspiration of liquids and solid.
  • Cancer involving upper-gingiva or hard palate without bone involvement can be treated by radiation therapy alone.
  • Patients who smoke while on radiation therapy appear to have lower response rates and a shorter survival duration than those who do not; therefore, patients should be counseled to stop smoking before beginning radiation therapy.[4]

Treatment of advanced cancers{stage III and stage IV}

  • Most patients with stage III or stage IV tumors are candidates for treatment by a combination of surgery and radiation therapy.
  • Patients with small T3 lesions,no regional lymph nodes, and no distant metastases (or patients who have no lymph nodes larger than 2 cm in diameter) can be treated by radiation therapy alone.
  • Because local recurrence and/or distant metastases are common in this group of patients, they should be considered for clinical trials that are evaluating the following:
    • The potential role of radiation modifiers are to improve local control or decrease morbidity.
    • The role of combinations of chemotherapy with surgery and/or radiation therapy are to both to improve local control and decrease the frequency of distant metastases.

Surgery

  • For lesions of the oral cavity, surgery must adequately encompass all of the gross, as well as the presumed microscopic extent of the disease.[5]
    • If regional nodes are positive, cervical node dissection is usually done in continuity.
    • Surgeons ablate large posterior oral cavity tumors using reconstructive methods so that satisfactory functional results can be achieved.
    • Prosthodontic rehabilitation is important, particularly in early-stage cancers, to assure the best quality of life.

References

  1. ↑ Bansberg SF, Olsen KD, Gaffey TA (1989). "High-grade carcinoma of the oral cavity". Otolaryngol Head Neck Surg. 100 (1): 41–8. doi:10.1177/019459988910000107. PMID 2466229.
  2. ↑ Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA (2009). "Future of cancer incidence in the United States: burdens upon an aging, changing nation". J. Clin. Oncol. 27 (17): 2758–65. doi:10.1200/JCO.2008.20.8983. PMID 19403886.
  3. ↑ Browman GP, Wong G, Hodson I, Sathya J, Russell R, McAlpine L, Skingley P, Levine MN (1993). "Influence of cigarette smoking on the efficacy of radiation therapy in head and neck cancer". N. Engl. J. Med. 328 (3): 159–63. doi:10.1056/NEJM199301213280302. PMID 8417381.
  4. ↑ Peppone LJ, Mustian KM, Morrow GR, Dozier AM, Ossip DJ, Janelsins MC, Sprod LK, McIntosh S (2011). "The effect of cigarette smoking on cancer treatment-related side effects". Oncologist. 16 (12): 1784–92. doi:10.1634/theoncologist.2011-0169. PMC 3248778. PMID 22135122.
  5. ↑ Neville BW, Day TA (2002). "Oral cancer and precancerous lesions". CA Cancer J Clin. 52 (4): 195–215. PMID 12139232.


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