Current concepts in management of oral cancer--surgery

Abstract

Oral cancer is the sixth most common cancer worldwide, with a high prevalence in South Asia. Tobacco and alcohol consumption remain the most dominant etiologic factors, however HPV has been recently implicated in oral cancer. Surgery is the most well established mode of initial definitive treatment for a majority of oral cancers. The factors that affect choice of treatment are related to the tumor and the patient. Primary site, location, size, proximity to bone, and depth of infiltration are factors which influence a particular surgical approach. Tumors that approach or involve the mandible require specific understanding of the mechanism of bone involvement. This facilitates the employment of mandible sparing approaches such as marginal mandibulectomy and mandibulotomy. Reconstruction of major surgical defects in the oral cavity requires use of a free flap. The radial forearm free flap provides excellent soft tissue and lining for soft tissue defects in the oral cavity. The fibula free flap remains the choice for mandibular reconstruction. Over the course of the past thirty years there has been improvement in the overall survival of patients with oral carcinoma largely due to the improved understanding of the biology of local progression, early identification and treatment of metastatic lymph nodes in the neck, and employment of adjuvant post-operative radiotherapy or chemoradiotherapy. The role of surgery in primary squamous cell carcinomas in other sites in the head and neck has evolved with integration of multidisciplinary treatment approaches employing chemotherapy and radiotherapy either sequentially or concurrently. Thus, larynx preservation with concurrent chemoradiotherapy has become the standard of care for locally advanced carcinomas of the larynx or pharynx requiring total laryngectomy. On the other hand, for early staged tumors of the larynx and pharynx, transoral laser microsurgery has become an effective means of local control of these lesions. Advances in skull base surgery have significantly improved the survivorship of patients with malignant tumors of the paranasal sinuses approaching or involving the skull base. Surgery thus remains the mainstay of management of a majority of neoplasms arising in the head and neck area. Similarly, the role of the surgeon is essential throughout the life history of a patient with a malignant neoplasm in the head and neck area, from initial diagnosis through definitive treatment, post-treatment surveillance, management of complications, rehabilitation of the sequelae of treatment, and finally for palliation of symptoms.

Figure 1

History of development of therapeutic modalities for cancer.

Figure 2

Risk of nodal metastases and death in relation to thickness of primary squamous cell carcinomas of the tongue and floor of mouth. (Adapted from Spiro, et al.)

Figure 3

Outcomes with single modality treatment (surgery or radiotherapy) by stage of disease for squamous cell carcinomas of the oral cavity, and factors affecting the choice of treatment.

Figure 4

Surgical approaches for oral cancer. (From Shah J and Patel S.)

Figure 5

Overall and disease specific survival for patients with squamous cell carcinomas of the oral cavity treated at MSKCC (1986–1995). (Adapted from Shah JP, Johnson NW, et al.)

Figure 5

Overall and disease specific survival for patients with squamous cell carcinomas of the oral cavity treated at MSKCC (1986–1995). (Adapted from Shah JP, Johnson NW, et al.)

Figure 6

Overall survival of patients with advanced stage oral cancer in three different time frames at MSKCC. New York. (From Shah J and Patel S.)

Figure 7

Role of various specialists during the life of a patient with head and neck cancer.