This document provides information on the management of oral cavity cancers. It discusses that oral cavity cancers make up approximately 30% of head and neck cancers, with 80% being tobacco related. The anatomy and subsites of the oral cavity are defined. Pre-malignant lesions that can progress to cancer are described. The pathological classifications, clinical presentation, diagnostic workup, staging, prognostic factors, and principles of treatment for squamous cell carcinoma are outlined. The document discusses the surgical management of the primary tumor and neck, including different types of neck dissections. It also covers reconstructive surgery and the applications and delivery of radiotherapy.

1. MANAGEMENT OF ORAL CAVITY
CANCERS
DR. KUNAL KISHOR GUPTA
2ND YEAR PGT
DEPARTMENT OF RADIOTHERAPY
IPGMER AND SSKM HOSPITAL
KOLKATA

2. INTRODUCTION
• Oral cavity cancers are approximately 30% of head and neck cancers.
• 80 % cases are tobacco related, 0 – 20 % can be positive for HPV 16 DNA.
• Oral leukoplakia (4–18 %) and erythroplakia (30 %) can proceed to cancer.
• 1.5 % will have synchronous cancers; 10–40 % will develop second primaries.
• In India:
• Approximately 1 lac new cases (out of 6 lacs worldwide) and more than
50,000 deaths occur yearly.
• Ranks first among male and the third among female population.

3. ANATOMY
BORDERS
 ANTERIOR-- SKIN- VERMILLION JUNCTION.
 SUPIRIOLY-- EXTENDS POSTERIORLY TO JUNCTION OF HARD AND SOFT
PALATE.
 INFERIORLY-- EXTENDS TO THE CIRCUMVALLATE PAPILLAE.
ORAL CAVITY CONSIST OF {SUBSITES}
 LIP
 ORAL TONGUE (ANTERIOR 2/3rd)
 FLOOR OF THE MOUTH
 RETROMOLAR TRIGONE
 ALVEOLAR RIDGE
 BUCCAL MUCOSA
 HARD PALATE

4. PRE MALIGNANT LESIONS
 LEUKOPLAKIA
 ERYTHROPLAKIA (HIGHEST CHANCEOF MALIGNANT TRANSFORMATION )
ORAL SUBMUCOSAL FIBROSIS
LICHEN PLANUS
 A base line biopsy should be done to established diagnosis and rule out malignancy.
 Premalignant lesions showing clinically or histologically aggressive features ,
demonstrating dysplasia , should be excised.
 A routine and close followup should be done with local examination and
investigations.

5. PATHOLOGICAL CLASSIFICATION
Normally, Oral cavity is lined by non-keratinized stratified squamous epithelium except
dorsum of the tongue, hard palate and attached gingiva lined by keratinized squamous
epithelium.
Squamous cell carcinoma – 90%
• Basaloid – worse prognosis
• Verrucous (Often associated with snuffs and oral chewing tobacco)
• Sarcomatoid
Non Squamous cell carcinoma − 10%
• Minor salivary gland tumors – adenoid cystic carcinoma, mucoepidermoid
carcinoma, and adenocarcinoma
• Soft tissue tumours − Kaposi sarcoma, lymphoangioma, focal oral mucinosis.
• Lymphoepithelial carcinoma (Often associated with epstein barr virus)
• Haematolymphoid tumours
• Secondary tumours

6. Clinical Presentation
• Non-healing painful ulcer
• Mucosal growth , plaque
• Poorly fitting denture
• Advanced lesion:
• Neck lymphadenopathy – 30-40% (frequency of neck metastases can range from 15%
to 75%, depending on the size of the primary lesion)
• Dysphagia (difficulty in swallowing)/ Odynophagia (pain while swallowing)
• Speech alteration or hoarseness
• Trismus (extension into pterygoid muscles)
• Otalgia (CN V)
• Facial Numbness (CN V)
• Hypoesthesia of the face, lips, or mandible (perineural spread along inferior alveolar
nerve after penetration of the mandible)
• Hypersalivation
• Limited tongue movements

7. Diagnostic Workup
History
 Tobacco, Smoking, Alcohol
 Weight loss
 Dysphagia/ Odynophagia
Physical examination
 Oral Cavity Palpation to assess bony involvement, tongue fixation and bimanual
assessment for depth of involvement
 Cervical lymph nodes
 Oral Hygiene
 Indirect laryngoscopy
 Mirror examination – nasopharynx
 Biopsy of tumor and FNAC of LN
 Blood investigations including CBC, KFT, LFT
 HPV testing in the biopsy specimen

8.  Nutrition, speech and swallowing evaluation/therapy, and baseline audiogram as
clinically indicated
 Dental evaluation
 Multidisciplinary consultation as clinically indicated
Radiographic –
 Chest X-ray
 Plain radiograph of mandible (panoramic radiograph or pantomogram /OPG)
 CECT (before biopsy) - method of choice – with “puffed cheek” technique
 MRI (selected cases) - for tongue and hard palate – for soft tissue delineation and
perineural extension
 Ultrasound neck for screening enlarged neck nodes that are not detected clinically ± USG
guided FNAC of suspicious lymphadenopathy
 FDG-PET for stages III–IV. Otherwise CT chest to rule out metastatic disease.
Cont……

9. T CATEGORY T CRITERIA
Tx Primary tumor cannot be assessed
Ti Carcinoma in situ
T1 Tumor ≤ 2 cm in greatest dimension; DOI ≤ 5 mm
T2 Tumor ≤ 2 cm, DOI > 5 mm but ≤ 10 mm
OR
Tumor >2 cm but ≤ 4 cm in greatest dimension and ≤ 10 mm DOI
T3 Tumor > 4 cm OR any tumor > 10 mm DOI
T4a Moderately advanced local disease
T4b Very advanced local disease
AJCC TNM Staging
• T0 (No evidence of primary tumor) removed in 8th edition

10. T CATEGORY T CRITERIA
T4a(oral cavity) Moderately advanced local disease
Tumor invades adjacent structures
• cortical bone of mandible or maxilla, or
• maxillary sinus, or
• skin of face
T4a(lip) Moderately advanced local disease
Tumor invades adjacent structures
• cortical bone
• floor of mouth
• skin of face(chin/nose)
•inferior alveolar nerve
T4b Very advanced local disease
Tumor invades masticator space, pterygoid plates, or skull base
and/or encases internal carotid artery

11. N
category
Clinical N criteria (cN) Pathological N criteria (pN)
Nx Regional lymph nodes cannot
be assessed
Regional lymph nodes cannot be
assessed
N0 No regional lymph node
metastasis
No regional lymph node metastasis
N1 Metastasis in a single ipsilateral
lymph node ≤ 3 cm in greatest
dimension and ENE (-)
Metastasis in a single ipsilateral
lymph node ≤ 3 cm in greatest
dimension and ENE (-)
N2a Metastasis in a single ipsilateral
lymph node > 3 cm but ≤ 6 cm
in greatest dimension and ENE
(-)
Metastasis in a single ipsilateral
lymph node, larger than 3 cm but not
larger than 6 cm in greatest
dimension and ENE (-)
OR
Metastasis in a single ipsilateral or
contralateral node ≤ 3 cm in greatest
dimension and ENE (+)
Regional Lymph Nodes

12. N
category
Clinical N criteria (cN) Pathological N criteria (pN)
N2b Metastasis in multiple ipsilateral
lymph nodes ≤ 6 cm in greatest
dimension and ENE (-)
Metastasis in multiple ipsilateral
lymph nodes, none more than 6 cm in
greatest dimension and ENE (-)
N2c Metastasis in bilateral or
contralateral lymph nodes,none
> 6 cm in greatest dimension and
ENE (-)
Metastasis in bilateral or contralateral
lymph nodes, none more than 6 cm in
greatest dimension and ENE (-)
N3a Metastasis in a lymph node > 6
cm in greatest dimension and
ENE (-)
Metastasis in a lymph node, larger
than 6 cm in greatest dimension and
ENE (-)
N3b Metastasis in any lymph node(s)
with clinically overt ENE (+)
Metastasis in multiple ipsilateral,
contralateral or bilateral lymph
node(s) with ENE (+)
OR
Metastasis in single ipsilateral node,
larger than 3 cm in greatest
dimension and ENE (+)

13. AJCC Prognostic Stage Grouping
T N M STAGE
Tis N0 M0 0
T1 N0 M0 I
T2 N0 M0 II
T3 NO MO III
T1,T2,T3 N1 M0 III
T4a N0,N1 M0 IVA
T1,T2,T3,T4a N2 M0 IVA
ANY T N3 M0 IVB
T4b ANY N M0 IVB
ANY T ANY N M1 IVC

14.  Location/thickness/depth of primary tumor
 Staging
 Type of histology
 Grading
 Presence of perineural spread
 Mandibular invasion
 LN extension (Level, size, extracapsular EXTENSION)
Prognostic Factors

16. PRINCIPLES OF TREATMENT FOR SQUAMOUS CELL
CARCINOMA
SURGERY AND RADIATION THERAPY ARE ONLY CURATIVE TREATMENT FOR HEAD
AND NECK CANCER. CHEMOTHERAPY ALONE IS NOT CURATIVE , IT ENHANCES THE
EFFECT OF RADIATION THERAPY.
Advantages of Surgery compared with RT
 Limited amount of tissue is exposed to t/t.
 Treatment time is shorter.
 The risk of immediate and late RT sequeal is avoided.
 RT reserved for a head & neck Secondary Primary Tm (SPT).
Advantages of RT compared with Surgery
 Risk of major post Op. complications is avoided.
No tissue are removed so that the probability of a functional/Cosmetic defect may be reduced.
 Selective neck RT can be included with little added morbidity.
 The surcical salvage of RT failure is probably more likely than the salvage of a surgical failure.

17. Treatment of Oral Cavity Cancer
• AIM : Highest loco-regional control (anatomical) with functional preservation and
minimize sequelae of treatment
• Stage I / II disease - Single modality ( Surgery or RT )
• Comparable results
• Choice depends on:
• Tumor factors - Site, Size, Type
• Patient factors
• Facilities available
• Stage III / IV disease – Combined modality
• Surgery + post-op RT (in most patients)
• Chemotherapy + RT in selected patients
• RT → Surgery (Pre-op RT)
• Surgery + RT (Intra-operative RT)
• Surgery → RT (Post-op RT) – standard of care
• Radical RT → Salvage Surgery

18. SURGICAL MANAGEMENT OF PRIMARY TUMOR
 It is recommended that the margins be taken from tumor specimen rather from tumor bed as later is
associated with high risk of local recurrence.
 The ability to obtain clear 3dimensional margin is the most important factor in selecting the surgical
approach and is typically guided by size and location of the tumor as well as factors related to patients
dentition as well as presence of trismus.
Surgical Margins
 A clear margin is defined as the distance from the invasive tumor front that is 5 mm or more from the
resected margin.
 A close margin is defined as the distance from the invasive tumor front to the resected margin that is less than
5 mm.
 A positive margin is defined as carcinoma in situ or as invasive carcinoma at the margin of resection.
 The decision of marginal / segmental mandibulectomy is based on pre operative assessement of invasion of
periosteum and cortex.
INDICATIONS OF MANDIBULECTOMY
 pre or intra operative findings of bone invasion
 tooth loss with low mandibular bone height.
 bone that has been previously irradiated.

19. Surgery for Oral Cavity Cancers
• Excision of primary with neck dissection.
• Surgical approaches to cancers of the oral cavity may either be transoral, transcervical
(pull-through) or via mandibulectomy.
• Tracheotomy is often necessary.
• It is commonly recommended to leave at least a 1-cm-thick segment of bone inferiorly.
following a rim mandibulectomy to reduce the risk of pathologic fracture.
SEGMENTAL
MANDIBULECTOMY MARGINAL MANDIBULECTOMY

20. Reconstructive Surgery
• ORAL CAVITY IS CRITICAL FOR SPEECH , SWALLOWING AND
APPEARANCE(COSMETICS).
• Skin graft – small defects
• Regional flap-
• large defects
• include pectoralis major flap, trapezius flap and lattismus dorsi flap
• Free flap –
• radial forearm flap, antero-lateral thigh flap, rectus abdominis flap and fibula flap.
• Total glossectomy defects are well suited.
• Reconstruction of mandible requires free flap from fibula flap, iliac crest flap and
scapular flap

21. Management of the Neck
The selection of type and extent of neck dissection depends on whether the patient is
clinically node negative or positive based on physical examination and imaging.
• node negative node positive
A neck dissection is considered elective therapeutic neck dissection
Types of neck dissection
• RND
• Modified RND
• Selective ND
• Supra-omohyoid SND (Level I-III/IV)
• Lateral SND (Level II-IV)
• Posterolateral SND (Level II-V)
• Anterior SND (Level VI)
• Extended ND

23. Modified RND type 1,2,3.

24. Management of clinically negative Neck
• Depth of invasion > 2mm TO <4MM require surgical intervention as it is significant predictor of
regional metastasis.
• Recently, role of sentinel lymph node biopsy (SLNB) in patients with small volume (T1– 2) oral
squamous cell carcinoma have been studied.
• SLNB is a less invasive approach used to accurately identify occult metastasis in early stage oral cancer.
• SLNB provides excellent sensitivity (∼90% to 100%) and negative predictive value (∼95%) with no
compromise of local control in the Neck.
 Selective node dissection – Cervical lymphedenectomy with preservation of one/more LN groups that
are routinely removed in RND.
 It is removal of selected group of lymph nodes in the neck with or without
sacrifice of additional non lymphatic structures.
 It is recommended for the CNo neck , for selected clinically positive necks(mobile 1 to 3 cm LNs)
and for removing residual disease after RT when there has been excellent regression of N2/N3 disease
 It is more limited and induce the resection of lymph node level that are at great risk for nodal
metastatic risk. example
a) Lateral - resection of LN level ii, iii, iv
b) Posterolateral – level ii, iii, iv ,v
c) Supraomohyoid - i, ii ,iii

25.  Elective neck dissection is considered if there is a high risk that there is microscopic(hidden/not
clinically apparent cancer in the lympnodes(>20%). The extent of neck dissection depends on−primary
site of cancer, pattern of spread, clinical evidence of spread into lymphnodes.
The general pattern of spread and elective neck dissection:
 level i , ii, iii – oral cavity
 Level ii, iii, iv – larynx , oropharynx and hypopharynx
 Level v- scalp, facial skin
 Level vi- thyroid, larynx
 Level vii- thyroid
 Salvage neck dissection This is neck dissection in previously treated neck wether previously
treated by CT/ Surgery. It is more difficult to do because of previously treatment scarring effect. It
usually indicated that the cancer cells are more aggressive and resistant to treat than they typically are.
 Complications of neck dissection
 Hematoma, seroma,lymphedema
 Wound infection, dehiscence
 Damage to cranial nerves(7,10,11 n 12)
 Carotid exposure and rupture
 Pain and scar

26. Radiotherapy
Applications:
• Radical : early stage
• Palliative : advanced total control not possible.
• Combined therapy
• Preoperative (neoadjuvant)
• Postoperative (adjuvant)
• Mode of delivery:
• External beam radiation therapy (EBRT)- By Telecobalt, Gamma knife ,
Linear accelerator, Cyber knife
• Brachytherapy – By Intra cavitary, Surface mould , Interstitial Brachytherapy.

27. Radiotherapy alone
• Tumor are classified as T1 and early T2 tumors.
• Combined approach including both external beam radiation and interstitial brachytherapy
is often recommended for optimal outcome.
• The normal tissue toxicity may render radiation therapy a less attractive option or single
modality treatment.
• Sites- lip, floor of mouth, oral tongue.
• The outcome for advance lesion of the oral cavity (T3 and T4) are less than satisfactory
with either surgery or radiation alone.

28. Nodal Treatment By Tumor Site
INDICATION IRRADIATION
Oral cavity
T2N0 with well-lateralized primary
T2N1 with well-lateralized primary
T2N0 with primary approaching
midline, all T3N0 and T4N0
All others
Levels I and II on the same side
Levels I to V on the same side
Levels I, II and III bilaterally
Levels I to V bilaterally

29. Definitive RT alone : PTV
High risk:
Primary tumor and involved lymph nodes (this includes possible local subclinical
infiltration at the primary site and at the high risk level lymph node(s):
 Fractionation(standard): 66 to 70 Gy (2.0 Gy/fraction);
daily Monday–Friday in 6–7 weeks
Accelerated fractionation with split: 67.2 Gy/6weeks (1.6 Gy/
fraction) with 2 week rest after 38.4 Gy.
 Concomitant boost accelerated RT:
72 Gy/6 weeks (1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during
last 12 treatment days)
 66–70 Gy (2.0 Gy/fraction; 6 fractions/wk accelerated)
 Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice daily)
• Low to intermediate risk:
 Sites of suspected subclinical spread
 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)

30. Post-op RT
• Takes care of microscopic disease after removal of gross disease.
• Considered when risk of loco regional failure > 20%
• Commonly done in stage III, IV tumors and selectively in early stages.
• Advantages:
• Better information about the tumor pathology
• Knowledge of tumor spread
• Tailoring of radiation dose and volume
• Disadvantages:
• Potential delay in starting RT
• Tumor hypoxia
• Wound healing

31. • Post-op RT superior to pre-op RT in H&N Cancer (RTOG, 73-03) trial, 1991
• Timing of postop RT critical - Within 4-6 weeks of surgery, >6 weeks delay detrimental
• Optimal dose considerations (60-64 Gy/30-32#/6-6.5 wks)
• Absolute Indications :
• Microscopically involved mucosal margins of resection
• Extra capsular extension
• Relative indications :
• Close margins (<5mm)
• Multiple positive neck nodes (2 or more)
• pT3-T4 with negative margins
• Perineural spread or microvascular emboli
• Mandibular bone involvement
• Level IV-V nodes

32. • With Concurrent chemotherapy :
• Microscopically involved mucosal margins of resection
• Extra capsular extension
 Concurrent cisplatin 100 mg/m2 q3 weeks x 3c
 Alternatively cisplatin 40 mg/m2 weekly x 6c
• Drug Radiation Interaction Mechanisms:
1. Enhancement of tumour Radio-response
2. Inhibition of repair of Sublethal radiation damage or recovery from Potentially lethal
damage
3. Cell cycle redistribution & synchronization
Post-op RT Doses
• High risk: Adverse features such as positive margins
60–66 Gy (2.0 Gy/fraction); daily Monday–Friday in 6–6.5 weeks
• Low to intermediate risk: Sites of suspected subclinical spread
44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)

33. Targeted Therapy
Targeted therapy works by targeting the cancer’s specific genes, proteins, or the tissue
environment that contributes to cancer growth and survival. These genes and proteins
are found in cancer cells or in cells related to cancer growth, like blood vessel cells.
 Cetuximab with RT
• Cetuximab: 400 mg/m2 IV loading dose, 1 week before radiation therapy, then 250 mg/m2 IV weekly
• Radiation therapy: 200 cGy/day for 5 days per week (total dose,70 Gy)
• Over expression of EGFR in SCCHN
• Synergistic action of cetuximab and RT
• Inhibits radiation-induced DNA damage repair
• Decreases tumor repopulation and improves re-oxygenation.
 CONCERT trials (CONcomitant Chemotherapy and/or EGFR inhibition with Radiation
Therapy) Panitumumab cannot replace cisplatin in the combined treatment with radiotherapy for
unresected stage III– IVb HNSCC.

34. Cont…
 EXTREME Trial: Erbitux in First-Line Treatment of Recurrent or Metastatic
Head and Neck Cancer In the cetuximab arm of this study.
(Platinum/5-FU with or without cetuximab in recurrent/metastatic SCCHN)
• Addition of Cetuximab to first-line therapy therapy resulted in significantly
prolonged OS with a median of 2.7 months compared to chemotherapy alone
 Immunomodulating agents targeting PD-1 receptors and its ligand (PD-L1) ex-
Pembrolizumab , Nivolumab with personalized approach to immunotherapy
treatment translates into improved outcomes for patients with this disease.

35. Pre-op RT followed by Surgery
• Borderline operable lesions
• Have been used for RMT tumors
• Advantages:
• Well oxygenated tumors
• Reduces the viability of tumor
• Improves resectability
• Disadvantage:
• Delayed wound healing
Chemotherapy Dose Schedules
TPF Induction Chemotherapy → Carboplatin + Radiation Therapy
 Docetaxel: 75 mg/m2 IV on day 1
Cisplatin: 75–100 mg/m2 IV on day 1
5-Fluorouracil: 1000 mg/m2/day IV continuous infusion on days 1–4
Repeat cycle every 3 weeks for 3 cycles followed by:
Carboplatin: AUC of 1.5, IV weekly for 7 weeks during radiation therapy
Radiation therapy: 200 cGy/day to a total dose of 7400 cGy
• At the completion of chemoradiotherapy, surgical resection as indicated

36. • Trial • Description
TAX 324 (Posner
NEJM 2007, Lorch
Lancet Oncol 2011):
• Randomized 501 patients with stage III–IV H&N SCC to TPF
(docetaxel, cisplatin, 5-FU) vs. PF induction chemotherapy
followed by carboplatin chemo-RT (70–74 Gy).
• TPF improved median PFS (13 → 38 months) and OS (35 → 71
months).
• More acute hematologic toxicity with TPF, but more treatment
delays with PF.
• No significant difference in late toxicity
Neoadjuvant Therapy
• Largely experimental
Intra-op RT
• IORT-Electron
• Accessible lesion
• More homogenous dose distribution
• IORT – HDR
• Less accessible
• Heterogeneous dose (200% of prescribed dose at surface)

37. Radiotherapy Techniques
• Simulation :
• Patient is treated in supine position with extended neck
• Palpable lymph nodes are marked with wire
• Depress the tongue away from hard palate
• Immobilize with a thermoplastic head and shoulder mask, neck rest and shoulder
retractors

38. Conventional fields
• Superior: 2 cm above primary tumor
• Inferior: below hyoid bone.
• Lymph node (+): level III is included
• Anterior: 2 cm in front of primary tumor (usually in front of mandible).
• Posterior: Back of vertebral corpuses.
• Lymph node (+): back of vertebral spinous processes.
• Two lateral parallel–opposed fields are used.
• Lymph node (+): neck and supraclavicular field is also treated

39. Anterior and I/L field with wedges
for small tumors of buccal mucosa
2 anterior wedged fields for anterior T1 and
small T2 floor of mouth tumors

40. Role of 3D CRT
• Achievement of dose escalation:
• To improve loco-regional control
• To increase overall survival
• Reduction of normal tissue complications:
• To improve quality of life

42. Role of IMRT
• Despite high dose PORT in patients with locally advanced HNC with certain
high risk factors, locoregional recurrences rate is about 30 %.
• IMRT has a potential to reduce the radiation accompaniments - damage to
major salivary glands (xerostomia) and to the mandible (osteoradionecrosis)
• Ideal candidates for IMRT include patients with T1–4 primary lesions with less
than or equal to N2b neck disease
• In lateralized disease, contralateral neck be included when ipsilateral neck
involvement is greater than N1.

43. Brachytherapy
• Interstitial brachytherapy is considered for selected cases.
• May be useful as an adjunct to EBRT or as definitive therapy in early stage tumors,
especially in cases of re-irradiation.
• LDR brachytherapy (0.4–0.5 Gy per hour):
Consider LDR boost 20–35 Gy if combined with 50 Gy EBRT or 60–70 Gy over
several days if using LDR as sole therapy.
• HDR brachytherapy:
Consider HDR boost 21 Gy at 3 Gy/fraction if combined with 40–50 Gy EBRT or 45–
60 Gy at 3–6 Gy/fraction if using HDR as sole therapy.
• For lesions >2.5 cm, part of the treatment should be given with external-beam
radiation to supplement the dose to the cold spots.
• For lesions that are very close to the mandible, brachytherapy is contraindicated
because of the risk of osteoradionecrosis.

44. Techniques of Implantation
• The commonest techniques used for brachytherapy in the oral tongue are:
• Hypodermic needle technique
• Guide-gutter technique
• Plastic loop technique
Hypodermic Needles
• Hollow, bevelled needles with outer diameter
of 0.8mm and variable length (4 to 8 cm),open
at both ends.
• Cause little trauma - can be directly inserted
in the tissues
• The rigid steel and template system avoids
displacement of the sources due to the elasticity of
the soft tissues
• Can be used in lip tumours of ≤3cm in largest
diameter, not involving the lateral commissurae.

45. Guide Gutter Technique
• Iridium hairpins with a fixed separation
of 12 mm are used
• This limits width of volume which can
be treated to approximately 15 mm and
the technique can therefore only be used
for smaller tumours (≤30 mm in length).
• The guide gutter is first inserted and
when they are in position, the
radioactive hairpins can be cut to the
desired length
• The pre-prepared suture is then tied
over the bridge of the hairpin to secure
it within the tongue

46. Plastic Tube Loop Technique
• This allows a wider separation between the
sources - can be used to treat larger volumes.
• Remote after-loading that reduces the risk of
exposure
• In case of local oedema inducing the risk of
displacement of the plastic tubes, we can wait for
an acceptable local status before loading the
iridium wire.
• Self retaining assembly, no suturing required.

48. Intraoral Cone
• Enable boosting of radiation dose to sites within the oral cavity while avoiding direct
dose to the mandible
• Anterior oral cavity lesions upto 3 cm in edentulous patients
• Either 100- to 250-kilovolt (peak) x-rays or electron beams in the 6- to 12-mev range
• Major advantage - highly focal to the tumor bed and non-invasive
• Requires careful daily positioning and verification - equipped with a periscope to
visualize the lesion.
• Cone abuts the mucosa and is centered directly over the lesion.
• Intraoral cone treatment should take place prior to external beam radiation so that the
lesion can be adequately visualized.

50. Fractionation in Head and Neck
• Squamous cell carcinoma - higher α/β ratio as compared to late responding normal tissues
• Propensity for accelerated repopulation after onset of therapy
• Accelerated repopulation starts around 28 days after starting radiation
• Suboptimal results in locally advanced carcinomas
• Compensate with dose increase of about 0.6 Gy/day
Hyperfractionation
• Total tumour dose: INCREASED
• No. of fractions: INCREASED
• Dose/fraction: DECREASED
• Overall time: UNCHANGED
• For comparable toxicity in fibrovascular tissues,2Gy/# replaced by 2# per day,1.15 – 1.2Gy/#
• Inter-fraction interval not less than 6 hours
• Useful when α/β ratio of tumour greater than dose limiting normal tissue
• Inevitably, more severe acute reactions

51. Accelerated Fractionation
• Overall treatment time: significantly reduced
• Total dose, fraction size: some change
• Aim is to minimize tumour regeneration during therapy
• ‘Pure’ and ‘hybrid’ types of schedules
• No. of fractions/day varies

52. • Trial • Description
RTOG 90–03 (Fu
IJROBP 2000; Beitler
IJROBP 2014):
• 268 patients with locally advanced H&N SCC randomized to standard
2/70 Gy vs. hyperfractionated 1.2 BID/81.6 Gy vs. concomitant boost 72
Gy (1.8/54 Gy plus BID 1.5 Gy last 12 days)
vs. split-course 1.6 BID/67.2 Gy (2 week break).
• At 5 years, reduction in LRF vs. standard was 6.5%, 6.6%, and 1.1%.
Overall survival was nonsignificantly improved for hyperfractionated
and concomitant boost.
• All non-standard fractionation increased acute side effects, and
accelerated fractionation increased late side effects
MARCH meta-analysis
(Bourhis Lancet
2006):
• 15 phase III trials of 6515 patients with H&N SCC.
Significantly improved OS (3.4% benefit) and LRC (6.4% benefit) at 5
years for altered fractionation vs. conventional fractionation, with most
benefit seen for hyperfractionation.
• Decreasing benefit with increasing age.
Altered Fractionation

53. Trial Description
MACH-NC Metaanalysis
(Pignon
Radiother Oncol
2009) :
• 93 phase III trials and 17,346 patients. 5-year OS benefit
4.5% with chemo-RT vs. RT alone.
• Greater OS benefit for concurrent (6.5%) vs. induction chemo
(2.4%), no benefit from adjuvant chemo.
• Similar results with post-op RT, conventional, and altered
fractionation.
• More benefit with regimens containing platinum. Decreasing
chemo-RT benefit with age; none observed if age > 70 years
ChemoRT+/-Altered Fractionation

54. Dose Limitations
• Spinal cord ≤ 45 Gy
• Brainstem ≤ 54 Gy
• D50 of total parotid < 30 Gy and mean dose atleast in one gland <26 Gy; V20 ≤ 50 %
• Submandibular ≤ 39 Gy
• Cochlea mean ≤ 37 Gy, max ≤ 45 Gy
• Retina ≤ 35 Gy
• Mandible and TMJ max ≤ 70Gy or 1cc PTV not more than 75Gy
• Larynx ≤ 32 Gy and V50 ≤ 66%

55. Treatment Sequelae
 Acute
• Mucositis
• Xerostomia
• Loss of taste
• Skin reaction
 Late
• Trismus
• Dental caries
• Osteoradionecrosis
• Grade I- Exposed alveolar bone is observed.
• Grade II- ORN that does not respond to hyperbaric oxygen therapy and requires
sequestrectomy/ saucerization.
• Grade III- Full thickness involvement or pathologic fracture

56. Recurrence
Appropriate management of recurrent oral cavity cancer depends largely on the extent of
disease, prior therapy administered, and whether recurrences are local, regional or both.
 Systemic therapy, reirradiation, and palliative resection can be considered.
 In case of small recurrence at the primary site in patients whose index therapy was
surgical excision only , further excision with post operative radiotherapy is often
recommended.
 For large recurrence in patients who received radiation as a part of their initial
management, the rate of surgical salvage is quite low.
 In case of distant metastasis / recurrence , systemic therapy will likely assume primary
importance.
i. A combination of docetaxel, cisplatin and 5FUor a platinum doublet (plus a taxane or
5FU) combine with Cetuximab are commonly used regimen for first line treatment of
recurrence or metastatic squamous cell carcinoma.
ii. Immunomodulating agents targeting PD-1 receptors and its ligand (PD-L1) ex-
Pembrolizumab , Nivolumab with personalized approach to immunotherapy treatment
translates into improved outcomes for patients with this disease.

57. Systemic Therapy
TIP
• Paclitaxel: 175 mg/m2 IV over 3 hours on day 1
• Ifosfamide: 1000 mg/m2 IV over 2 hours on days 1–3
• Mesna: 400 mg/m2 IV before ifosfamide and 200 mg/m2 IV, 4 hours after ifosfamide
• Cisplatin: 60 mg/m2 IV on day 1
• Repeat cycle every 21–28 days
Paclitaxel + Carboplatin
• Paclitaxel: 175 mg/m2 IV over 3 hours on day 1
• Carboplatin: AUC of 6, IV on day 1
• Repeat cycle every 21 days
Metastatic Head and Neck Cancer 2009
• Platinum/5-FU with or without cetuximab in recurrent/metastatic SCCHN
• Addition of Cetuximab to first-line therapy therapy resulted in significantly
prolonged OS with a median of 2.7 months compared to chemotherapy alone
• Gefitinib and Erlotinib in patients of recurrent/metastatic HNSCC : good response, better
survival and longer PFS, and can be used in patients with poor PS.

58. Follow up Recommendations
 Major Goal of Surveillence
Early diagnosis of recurrences
Early diagnosis of 2nd primary tumor
Management of ongoing sequele of head and neck cancer treatement.
• 85–90% of locoregional recurrences occur within 3 years.
• If recurrence suspected but biopsy is negative, follow up monthly until resolved
 Work up at follow up
• History and physical examination every 1–3 months for first year, every 2 – 6 months in
2nd year, every 4 to 8 months from 3 to 5 years and then annually.
• Imaging of the head and neck (whenever patients develop new signs or symptoms
suggestive of recurrence) – Post treatment PET/CT has high predictive value for long-
term outcomes(Base line imaging within 6 months of therapy).
• Imaging of the thorax recommended annually.
•Thyroid function test(TSH) every 6 to 12 months.

59. •Ongoing dental evaluation focused on patients education, prevention, management of
caries, xerostomia,osteoradionecrosis and oral candidiasis.
• Supportive care and Rehabilitation
i. Speech/ hearing and swallowing evaluation
ii. Nutritional evaluation
iii. Ongoing surveillance for depression
iv. Smoking cessation and alcohol counselling
• Smoking cessation counseling
• Dental care after treatment : non invasive 3 and invasive 6 months

65. Thank You