Oral Cavity and Oropharynx

Description of anatomy

On the anterior side, the oral cavity is bounded by the lips, whereas posteriorly the plane through the soft palate, anterior pharyngeal arches and circumvallate papillae is the boundary. Lip carcinomas of the mucosa are part of the oral cavity. Carcinomas of the oral cavity in general originate from the side of the tongue, the floor of mouth, alveolar proces and retromolar trigone and the cheek.

The oropharynx is bounded anteriorly by the plane through the soft palate, anterior pharyngeal arches and circumvallate papillae. Cranially the nasopharynx and caudally the hypopharynx starts below the level of the vallecula.

The are 4 regions within the oropharynx:

  • Posterior wall
  • Lateral wall (tonsils, tonsilar fossa, pharyngeal arches)
  • Anterior wall (base of tongue, vallecula)
  • Superior wall (soft palate and uvula)

In the AJCC  the “faucial pillar” is part of the upper wall whereas in the UICC it is part of the lateral wall. Also the posterior arch is part of the posterior wall in the AJCC and party of the lateral wall in the UICC.

Diagnostics

see also: introduction 

  • General anamnesis.
  • ACE-27 comorbidity assessment.
  • Head and neck examination.
  • Inspection + palpation tumor.
  • Consultation: dentist, oral hygienist, SLP (logopedist).
  • Panoramic dental X ray, MRI, US-FNAC nek, intra-oral US, Chest X-ray, routine laboratory testing.
  • PET-CT: 1. to exclude distant metastases: Stage 3 and 4 or in case of planned mutilating surgery; 2. to facilitate IMRT field definitions in case of radiotherapy.
  • Examination under general anaesthesia: on indication, mainly in oropharyngeal cancer (extent of tumor, exclusion of multiple primaries, dental extractions, extensive biopsies). No need for bronchoscopy, esophagoscopy on indication.

TNM-classification

Based on clinical examination, imaging as well as examination under general anaesthesia

  • Tis: pre-invasive carcinoma = carcinoma in situ = severe dysplasia
  • T0: no primary tumor
  • T1: tumor of 2 cm or less in largest diameter
  • T2: tumor between 2 and 4 cm
  • T3: tumor larger than 4 cm in largest diameter
  • T4a:
    1. Lip: tumor invading mandibular cortex, nervus alveolaris inferior, floor of mouth or skin of chin or nose
    2. Oral cavity: tumor invading mandibular cortex, deep (extrinsic) tongue muscles, sinus maxilaris, skin
    3. Oropharynx: tumor invading the larynx, deep tongue musculature, medial pterygoid muscle, palatum durum, mandibula
  • T4b:
    1. Oral cavity: tumor invading masticatory space, pterygoid plates, skull base, carotid encasement.
    2. Oropharynx: tumor invading lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base, carotid encasement

N- en M-classification: see introduction

ORAL CAVITY

 Lip carcinoma

N0

  • T1: Less than 1/3 lip (< 1 cm): surgery if possible, 4-6 mm margin. Frozen sections in case of clinical doubt; Size 1 – 2 cm: radiotherapy (orthovolt or brachy). In case of superficial lesions < 5 mm: PDT is a good alternative (measurement by endo-sonography).
  • T2: Radiotherapy, preferably brachytherapy. In case of superficial lesions < 5 mm: PDT is a good alternative (measurement by endo-ultrasound). No elective neck treatment, but strict US-FNAC follow-up (every 3 months, one year).
  • T3-4: Surgical treatment with reconstruction and postoperative radiotherapy or chemoradiation (positive resection margins that cannot be managed with further surgery or extra nodal spread or massive bilateral metastases. Elective neck treatment (either  selective neck dissection levels 1-3, or radiotherapy). In case it is not operable, chemoradiation is an option.

ATTENTION

Upper lip and angelus tumors can metastasize to the nasolabial and parotid lymph nodes.

 

N+

  • In case of primary radiotherapy (mainly T1-2): also radiotherapy of the neck.
  • In case of primary surgery (mainly T3-4): Comprehensive Neck dissection (levels 1-5), or SND (1-4) in case of N1 in level 1. On indication a parotidectomy. Postoperative radiotherapy/chemoradiation on indication
  • N3: in case operable: comprehensive neck dissection with postoperative chemoradion. In case of inoperability: chemoradiation if possible and feasible.

Floor of Mouth and Alveolar Process

NO

  • T1-2: Transoral excision, sometimes with marginal mandibulectomy and a margin of at least 1 cm if possible. Frozen sections in case of clinical doubt. In cases with difficult exposure, a cheek flap or pull through procedure, combined with a selective neck dissection (levels 1-3) and a reconstruction (for T2) can be indicated. In mid-sized tumors reconstruction with a non-vascularised skin graft can be used. Photodynamic therapy is alternative in case depth infiltration is less than 5 mm, as measured by endo-sonography (most accurate). If endo-sonography is not possible / unreliable: clinical examination and MRI can be helpful. In case of positive resection margins: re-excision when possible, otherwise postoperative radiotherapy.
    • Neck management (T1-2N0): in case depth is < 5 mm: Sentinel node procedure or Wait and See (US-FNAC every 3 months for one year). In case depth of infiltration is 5 mm or deeper: Elective neck dissection (levels 1-3) or sentinel node procedure.
  • T3-4: Combined approach resection with either cheek flap, mandibular split, pull through, marginal or segmental mandibulectomy. At least 1-1.5 cm margin, Frozen sections in case of clinical doubt. In general with reconstruction (Soft tissue and/or bone). Ipsilateral or bilateral elective neck dissection. Postoperative (chemo)radiation (recession in case of tumor positive resection margins is in general not feasible).
  • T3-4 In case of irresectable tumors (functional or anatomical): chemoradiation or cetuximab with PORT when cisplatin is not possible.
    • Marginal mandibulectomy: no or minimal invasion on examination and MRI/CT/Tc-SPECT, minimally 1 cm height should be left after resection
    • Segmental mandibulectomy: massive bone invasion, atrophic thin mandible, involvement mandibular nerve

N+

Resectie of the primary with comprehensive neck dissection (levels 1-5). In case of N1 disease in level 1 or 2, a selective neck dissection of levels 1-4 can be considered.
Postoperative radiotherapy/chemoradiation in case of T3 and T4 tumors and according to guidelines.  In case of anatomically or functionally inoperable tumors: chemoradiation or radiotherapy with cetuximab when cisplatin is not possible.

ATTENTION

Commandoprocedure: This term originates from around 1945 and was introduced by the Memorial Hospital (Sloan Kettering Cancer Center) in New York. It is now replaced by a combined approach resection.

Tongue

N0

  • T1-2 Surgical resection with at least 1 cm margin. Frozen sections in case of clinical doubt. In case of positive resection margins: re-excision (when not possible, radiotherapy can be considered). Reconstruction is rarely indicated. In superficial tumors with extensive leukoplakia  (<0,5 cm, clinical and endo-sonography): photodynamic therapy can be an alternative.
    • Neck management (T1-2N0): in case depth is < 5 mm: Sentinel node procedure or Wait and See (US-FNAC every 3 months for one year). In case depth of infiltration is 5 mm or deeper: Elective neck dissection (levels 1-3) or sentinel node procedure.
  • T3-4: Combined approach resection with either cheek flap, mandibular split, pull through, and rarely marginal or segmental mandibulectomy. At least 1-1.5 cm margin, Frozen sections in case of clinical doubt. In general with reconstruction (Soft tissue and/or bone). Ipsilateral or bilateral elective neck dissection: levels 1-4. Postoperative (chemo)radiation (re-excision in case of tumor positive resection margins is in general not feasible).
  • T3-4: In case of irresectable tumors (functional or anatomical): chemoradiation or cetuximab with PORT when cisplatin is not possible.

N+

Resectie of the primary with comprehensive neck dissection (levels 1-5). In case of N1 disease in level 1 or 2, a selective neck dissection of levels 1-4 can be considered.
Postoperative radiotherapy/chemoradiation in case of T3 and T4 tumors and according to guidelines. In case of anatomically or functionally inoperable tumors: chemoradiation or radiotherapy with cetuximab when cisplatin is not possible.

Cheek

N0

  • T1-2 Surgical resection with at least 1 cm margin. Frozen sections in case of clinical doubt. In case of positive resection margins: re-excision (when not possible, radiotherapy can be considered). Reconstruction with a skin graft can be indicated to prevent trismus. In superficial tumors with extensive leukoplakia (<0,5 cm, clinical and endo-sonography): photodynamic therapy can be an alternative. Brachytherapy can be an alternative as well.
    • Neck management (T1-2N0): in case depth is < 5 mm: Sentinel node procedure or Wait and See (US-FNAC every 3 months for one year). In case depth of infiltration is 5 mm or deeper: Elective neck dissection (levels 1-3) or sentinel node procedure. met zonodig marginale of segmentale resectie mandibula.
  • T3-4: Surgical resection. Mandibular or maxillary resection can be indicated.  At least 1-1.5 cm margin, Frozen sections in case of clinical doubt. In general with reconstruction (Soft tissue and/or bone). Ipsilateral elective neck dissection: levels 1-3 and sometimes parotidectomy. Postoperative (chemo)radiation (re-excision in case of tumor positive resection margins is in general not feasible).
  • T3-4: In case of irresectable tumors (functional or anatomical): chemoradiation or cetuximab with PORT when cisplatin is not possible.

N+

Resectie of the primary with comprehensive neck dissection (levels 1-5). In case of N1 disease in level 1 or 2 or parotis, a selective neck dissection of levels 1-4 can be considered.
Postoperative radiotherapy/chemoradiation in case of T3 and T4 tumors and according to guidelines. In case of anatomically or functionally inoperable tumors: chemoradiation or radiotherapy with cetuximab when cisplatin is not possible.

Palatum durum

N0

  • T1-4 Surgical resection / partial or total  maxillectomy (and orbit) when resectable (not in ethmoid or pterigopalatine fossa). Reconstruction by either and obturator and a good dental plan or a (bony) reconstruction with a good dental plan, which can give better functional results. Reconstruction can also be performed at a later stage. Advantages of secondary reconstruction are that tumor positive resection margins can be re-excised and the cavity can be inspected. Disadvantage is that most patients do not want secondary surgery.  No elective neck treatment, but regular US-FNAC follow-up: every 3 months for one year.
  • T1-2: Photodynamic therapy can be an alternative when the lesion is superficial (<0,5 cm, clinically/endo-sonography/MRI and no bone invasion):
  • Radiotherapy or brachytherapy by iridium-moulage can be an alternative in limited lesions (T1-2) or postoperatively in case of tumor positive resection margins that cannot be re-excised.
  • Postoperative radiotherapy in case of T3-4 lesions, or in case of positive resection margins when re-excision is not possible.
  • T3-4: In case of irresectable tumors (functional or anatomical): chemoradiation or cetuximab with PORT when cisplatin is not possible.

N+

Maxillectomy and comprehensive neck dissection (levels 1-5)
Postoperative radiotherapy/chemoradiation on indication.

OROPHARYNX

Soft Palate

N0

  •  Tis/T1: CO2 laser (or surgical excision) or photodynamic therapy in case of lesions infiltrating 4 mm or less (using endo-sonography or MRI for assessment). No elective neck dissection. Follow-up of the neck using US-FNAC every 3 months for one year. Local radiotherapy is good alternative.
  • T2: Locoregional radiotherapy (neck levels to be discussed). Photodynamic therapy in case of lesions infiltrating 4 mm or less (using endo-sonography or MRI for assessment). No elective neck dissection. Follow-up of the neck using US-FNAC every 3 months for one year in case no elective treatment is given.
  • T3-T4: Locoregional chemo-radiation. Surgery is an alternative with elective neck dissection(s) (level 1-4) and postoperative radiotherapy or chemoradiation.

N+

  • T1-4 N3  locoregional chemoradiation.  A neck dissection (and transoral resection of a small primary)  before chemoradiation can be considered, but salvage neck dissection if indicated is to be preferred. In case of an ulcerating neck mass, a neck dissection can be mandatory before chemoradiation.
  • T1-2N1-2ab
  • T3-4N1-2abc with ENS on MRI: locoregional chemoradiation
  • T1-2N2c: chemoradiation or radiotherapy in case of very limited neck disease.

Tongbasis- en tonsiltumoren

N0

  • T1-2 robotresectie (of CO2 laser bij T1). Electieve selctieve halsklierdissectie of eventueel stricte follow-up met echo. Alternatief: locoregionale radiotherapie.
  • T3 Locoregionale chirurgie (commandoprocedure), waarbij de behandeling van de hals kan variëren van een selectieve halsklierdissectie bijvoorbeeld niveaus I t/m IV (anterolateraal) t/m (gemodificeerde) radicale nekdissectie). Postoperatieve radiotherapie of chemoradiatie. Indien (functioneel) inoperabel: chemoradiatie.
  • T4: Chemoradiatie.

N+

  • T1-2 N3 locoregionale chemoradiatie na halsklierdissectie indien operabel (I t/m V).
  • N1-2ab zonder aanwijzingen kapseldoorbraak: locoregionale radiotherapie. Bij kleine primaire tumoren kan overwogen worden een superselectieve halsklierdissectie te verrichten om histopathologisch kapseldoorbraak uit te sluiten.
  • N1-2ab met aanwijzingen kapseldoorbraak of N2c: chemoradiatie.
  • T3N1-2ab Locoregionale chirurgie (commandoprocedure) met postoperatieve radiotherapie of chemoradiatie. Indien (functioneel) inoperabel: chemoradiatie.

Pharynxachterwandtumoren

N0

  • T1-2 Radiotherapie. Bij Tis/T1: CO2 laser of fotodynamische therapie indien oppervlakkig (<0,5 cm voor PDT, klinisch/MRI), en stricte follow-up van de hals met echo en CT.
  • T3-4 Meestal functioneel inoperabel: chemoradiatie.

N+

  • Bij N3 (unilateraal) oropharynxcarcinomen eventueel eerst halsklierdissectie niveaus I t/m V indien operabel gevolgd door locoregionale chemoradiatie.
  • N1-2ab zonder aanwijzingen kapseldoorbraak: locoregionale radiotherapie. Bij kleine primaire tumoren kan overwogen worden een superselectieve halsklierdissectie te verrichten om histopathologisch kapseldoorbraak uit te sluiten.
  • N1-2ab met aanwijzingen kapseldoorbraak of N2c: chemoradiatie.