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Surgical options for the treatment of oral cancer
.
Chairman Dept. of Maxillofacial / Head and Neck Surgery
,
Athens Greece
Surgery has traditionallybeen the treatment of
choice of squamouscell carcinoma of the
oral mucosa.
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Contemporary
oncological surgery ispart of a
multidisciplinarytherapeutic team thatprovides treatment for
head and neck
malignancies.
Surgical treatment of early (Stage I and II) disease
Surgery remains the mainstay oftreatment for early (Stage I and II)
squamous an non-squamouscarcinomas of the oral cavity
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Tongue CarcinomasPrimar A roaches
-
Local excision and skin grafting
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Local excision and neck dissection
Local excision and neck dissection
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Local excision, neck dissection and grafting
Local excision, neck dissection and grafting
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Local excision, neck dissection and grafting
Local excision, neck dissection and grafting
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Marginal resection
Marginal resection
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General principles regarding management of early oral cavity stage diseases
, ,
Frozen section analysis of all margins First surgery should be the best and only surgery
Initial biopsy should be limited and not sutured
Elective management of the neck utilized forinvasive carcinomas of the ton ue and floor ofmouth and other sites when ultrasound, FNA or
CT evidence su est l m h node involvement
Early Stage Oral Cavity Indications for Post Operative Adjunctive Treatment
Radiation Therapy Only When
Positive margins (note: radiotherapy is not a
Multiple positive nodes Multiple levels of lymph node metastases
Concomitant Chemoradiotherapy-Intensification
Extracapsular lymph node extension
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disease
UICC/AJCC Staging for advanced oral cavity cancer
T3-4, any N
T3 > 4cm T4a invasion of ad acent structures cortical
bone, deep tongue muscles, maxillarysinus, skin
T4b unresectable invasion of masticator, , ,
carotid encasement
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UICC/AJCC Staging for advanced oral cavity cancer
Regionally advanced
T1-T2 N2-3
metastases, one or more contralateral cervical
,
Primary surgery + radiation indicated for advanced oral cavity cancer:
advanced oral cavity (30-40%) and poor survival
Increased local control with surgery +
Zelefsky et al, Head Neck. 1990 Nov-Dec;12(6):470-5
Local control significantly improved for locallyadvanced T3, T4 oral cancers using surgery +pos opera ve ra o erapy vs. pr mary Fein et al. Head Neck. 1994 Jul-Aug;16(4):358-65
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Therapeutic management of advanced oral cavity cancer
radiotherapy +/- chemotherapy
eligible patients with good performance status Multi le nodes ECS
Positive margins, neural/vascular invasion
T3 or greater, N2 or greater
Oral/Oropharyngeal sites with level IV,V disease
Novel molecular directed therapies incorporatedinto next generation trials
The role of reconstruction in advanced cancer of the oral cavity
Without rec onstruc tion trea tment may be asc r pp ng as e sea se se
Allows more rad ic a l surgery and rad iotherapy
Breathing
Swa llowing
Speec h
mproves qua y o e n pa en s w owere eexpectancy
Allows a tient to soc ia ll re-inte ra te
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The evolution of reconstructive surgery in the head and neck region
Tube Pedicles1960s
D.P. Flap1965 - 1975
P.M.M.C. Flap1978 - 1990
Free Flaps Fibula
1990 - 2007
Radial forearm
Lateral thigh Rectus abdominis Latissimus Dorsi
to p lastic surgery can be ap tly
c ompared to the a dvent of avia tion
arry . unceClinical Professor of Sur er Universit of
California, San Francisco
July 16, 1922 - May 18, 2008
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Microsurgical free tissue transfer
More than 20free fla donor sites have been described for the head and neck
Reconstructive guidelinesReconstructive guidelines
FreeFree--tissue transfer is a successful methodtissue transfer is a successful methodfor repairing oral cavity defects and is safe evenfor repairing oral cavity defects and is safe evenin previously irradiated areasin previously irradiated areas
Most of the defects needing microsurgicalMost of the defects needing microsurgicalreconstruction can be successfull rehabilitatedreconstruction can be successfull rehabilitatedusing one of five major freeusing one of five major free--flap donor sitesflap donor sites
Microvascular success is very high (aboveMicrovascular success is very high (above95%) due to the vast experience gained over the95%) due to the vast experience gained over theyearsyears
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Free flaps used for head and neck reconstruction in the
1. soft tissues
ra a orearm, rec us a om n s, a ss mus ors
2. hard tissuesmandibular reconstruction fibula, composite radial forearm
maxillary reconstruction composite radial forearm, scapula, rectus abdominis
Tongue CarcinomasPrimar A roaches
Trans-oral
Mandibulotom
-
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Tongue CarcinomasPrimar A roaches
Trans-oral
Mandibulotom
-
Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
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Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
Shah JP 2003
Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
Shah JP 2003
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Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
Shah JP 2003
Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
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Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
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Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
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Hemiglossectomy, neck dissection, immediate reconstruction with radial forearm
Reconstruction of soft tissues of the head and neck
Hemiglossectomy: radial forearm
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Reconstruction of soft tissues of the head and neck
Hemiglossectomy: radial forearm
Reconstruction of soft tissues of the head and neck
Hemiglossectomy: radial forearm
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Tongue CarcinomasPrimar A roaches
-
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Shah JP 2003
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
Preoperative RT/CT (NR), total glossectomy, bilateral neck dissection, immediatereconstruction with rectus abdominis free flap
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Surgical Approaches
Transoral and Visor Approaches
Cosmetic but ma limit ex osure
Lip Splitting
o est cosmet c sa vantage w t exce entposterior exposure for mandibulotomy
Paramedian or midline mandibulotomy
reconstructiveoptions
1. Combination of soft tissuefree flaps and alloplasticmaterials
Lack ofLack of bonebonereconstruction roblems durin RTRT
2. Combination of freefreeand regional pedicledregional pedicledflaps
Insufficient regionalregionalflap versatility
na y o recons ruc aw e ec s
3.3. DualDualfree flap transfer
ProlongationProlongationof operation time
Need of two pairstwo pairsof anastomoses
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,
control of disease or survival of patients with either
It is clear that advances in the management of oralcavity carcinomas require the development of definedmolecular biologic, cellular and or humoral predictors
which provide biologic predictive assays and
mechanisms for novel targeted therapy
Rules and guidelines regarding the role of surgery in themanagement of squamous cell carcinoma of the oral cavity
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Surgical treatment ofcarcinoma of the oral cavit :
Is there any basic rule we must follow?
There is only one rule.
The rule is there is no rule. Each and everypatient should be treated individually to his
particular disease profile using all therapeuticoptions and treatment should follow the
guidelines set for him by the combinedoncological team.
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Second World Con ress of the
International Academy of Oral Oncology
IAOO
July 8 11, 2009
Sheraton Centre Toronto