Oropharyngeal and Oral Cavity Cancer Surgical Practice Guidelines

Scope and Format of Guidelines

The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative evaluation for extent of disease, androle of the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim ofthe Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.

Following each guideline is a brief narrative highlighting and expandingon selected sections of the guideline document, with a few relevant references.The current staging system for the site and approximate 5-year survivaldata are also included.

The Society does not suggest that these guidelines replace good medicaljudgment. That always comes first. We do believe that the family physician,as well as the health maintenance organization director, will appreciatethe provision of these guidelines as a reference for better patient care.

Societyof Surgical Oncology Practice Guidelines: Oropharyngeal and Oral CavityCancer

Symptoms and SignsEarly-stage disease

• Persistent sore in the oral cavity
• Swallowing difficulty
• Lesion discovered as an incidental finding on routine oral examination
• Pain and ulceration in the mouth

Advanced-stage disease

• Pain, especially referred to the ear
• Slurred speech
• Difficulty in swallowing
• Neck mass
• Trismus

Evaluation of the Symptomatic Patient Work-up

• Examination of the head and neck, oropharynx
• Flexible laryngoscopy
• Punch biopsy in the office
• Biopsy, followed by examination under anesthesia to determine the stageand extent of the disease, if office evaluation is unsatisfactory

Appropriate timeliness of surgical referral

• Follow evaluation as described above (in patients having symptoms orsigns of early or advanced disease as soon as possible)

Preoperative Evaluation for Extent of Disease

• Physical examination
• Laryngoscopy
• Chest x-ray
• Panoramic x-ray of the mandible
• CT scan of head and neck

Surgical Considerations Early stages

• T1 and T2 lesions of the oropharynx (base of the tongue, tonsillarfossa, soft palate, pharyngeal wall) should be treated with radiotherapyor surgery
• Most T1 and T2 tumors of the oral cavity should be treated with surgery.

Advanced stages (III and IV)

• Multimodality therapy indicated. Most T3 and T4 lesions should be treatedwith planned surgery and radiation, with emphasis on primary reconstruction.T3 exophytic tumors may be treated with radiotherapy alone.
• Surgical approach and exposure may be difficult.
• External radiation therapy coupled with interstitial implant (brachy-therapy)to the base of tongue has shown control rates equal to those of surgery.Appropriate selection is very important.
  

These guidelines are copyrighted by the Society of Surgical Oncology(SSO). All rights reserved. These guidelines may not be reproduced in anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 West Algonquin Road, Arlington Heights, IL 60005.

Approximately 39,750 new patients with tumors of the oral cavity (encompassingthe lip, buccal
mucosa, alveolar ridge and retromolar trigone, anterior two thirds of thetongue, hard palate, and floor of the mouth) or oropharynx (including thebase of the tongue, tonsillar pillar and fossa, and soft palate) are seenevery year, and 8,440 patients die from these cancers. However, tumorsof the oral cavity alone are diagnosed in approximately 19,000 individualsand account for 4,200 deaths. The tongue is the most frequent site of tumorin the oral cavity, with an incidence of 5,550 patients per year

The most common etiologic agents are smoking and alcohol. Consumptionof betel nuts, which is very common in Southeast Asia, especially India,has also been implicated. Other possible etiologic agents include chronicirritation, ill-fitting dentures, and a history of syphilis.

The most common symptom related to cancer of the oral cavity is persistentsoreness. In other cases, such a lesion is found incidentally on routineoral examination. Pain referred to the ear, slurred speech, difficultyin swallowing, a neck mass, or occasionally in advanced cases, trismus,are also clues to the diagnosis.

Evaluation

The work-up of a patient with a suspected oropharyngeal or oral cancerincludes a complete head and neck examination. Biopsy of a suspicious lesioncan be performed under local anesthesia

Preoperative evaluation should include indirect laryngoscopy and a chestx-ray. A CT scan is indicated only for evaluation of an extensive cancer.

Staging

The TNM staging system is routinely utilized for cancers of the oralcavity and oropharynx (Table 1). TheT-stage describes the greatest dimension of the tumor, with T1 being lessthan 2 cm; T2, between 2 and 4 cm; and T3, greater than 4 cm. The T4 designationdenotes tumor invading the adjacent structures, extending through the softtissues or cortical bone.

Nodal staging is as follows: N1 denotes ipsilateral lymph node metastasisless than 3 cm in greatest dimension; N2, 3 to 6 cm; and N3 greater than6 cm. The presence of N2 or N3 disease indicates advanced-stage disease(stage IV).

Survival is excellent in early-stage disease, between 75% and 95%. However,in advanced-stage disease, survival decreases considerably, to between35% and 50%.

T-staging of oral cavity cancer is quite easy. However, T-staging oforopharyngeal tumors, especially tumors of the base of the tongue, maybe quite difficult. Some of these tumorsmay have considerable submucosalextension and may be difficult to evaluate.

Treatment

Early (T1 and T2) lesions of the oral cavity can be easily treated withsurgery alone with little loss of function and good long-term control ofthe cancer. Surgery may include marginal or segmental mandibulectomy, dependingon disease extent and proximity of the tumor to the mandible. If the mandibleis directly invaded by tumor, segmental mandibulectomy is generally required.Elective neck dissection is generally indicated for T2 cancers.

The surgical approach and exposure to the oropharynx may be quite difficult.T2-T3 tumors of the tongue base can be effectively treated with externalradiation and interstitial implantation.

Advanced tumors of the oral cavity have a much poorer control rate regardlessof the treatment employed. Multimodality treatment, including surgery andradiation therapy, is commonly used in stage III and IV cancers.

Quality-of-life issues are very important in patients with tumors ofthe oral cavity, especially those with advanced-stage disease. Problemsrelated to speech, swallowing, and mandibular reconstruction are extremelycritical. Microvascular free mandibular reconstruction with either fibularor iliac crest grafts has improved cosmetic results considerably. However,functional results are still quite limited. Patients with advanced cancerof the base of the tongue may require not only a subtotal glossectomy butalso a total laryngectomy in order to avoid problems related to persistentaspiration.

Postoperative radiation therapy is usually reserved for patients withadvanced cancers of the oral cavity. However, it may create problems relatedto osteoradionecrosis and dryness of the mouth.

References:

Horiot JC, Le Fur R, N'Guyen T, et al: Hyperfractionated compared withconventional radiotherapy in oropharyngeal carcinoma: An EORTC randomizedtrial. Eur J Cancer 26:779-80, 1990.

Lippmann SM, Benner SE, Hong WK: Cancer chemoprevention. J Clin Oncol12: 851-873, 1994.

Lotan, Xu X, Lippman SM, Ro JY, et al: Suppression of retinoic acidreceptor-B in premalignant oral lesions and its up-regulation by isotretinoin.N Engl J Med 332:1405-10, 1995.

Mashberg A: Erythroplasia vs. leukoplakia in the diagnosis of earlyasymptomatic oral squamous carcinoma. N Engl J Med 297:109-110,1977.

Merlano M, Vitale V, Rosso R, et al: Treatment of advanced squamouscell carcinoma of the head and neck with alternating chemotherapy and radiotherapy.N Engl J Med 327:1115-21, 1992.