1. Adjuvant Therapy Of Oral Cancers
Dr Sapna Nangia
Chief Radiation Oncologist
International Oncology Centre
Fortis Hospital
Noida

3. Oral Cavity Subsites : Adjacent But Disparate
5.00% 4.70%
4.50% 4.30%
4.00% Tongue
3.50%
FOM
3.00%
2.50% LIP
2.00%
Gingivum
1.50%
1.00% 0.90%
0.70% Others ( Buccal, RMT,
0.50% 0.30% palate)
0.00%
Relative Proportion
Number of Incident Cancers by Five Year Age Group and Site Males, Chennai
National Cancer Registry

4. Factors That Determine Adjuvant Treatment
 Adequacy of Surgery
 Margin
 Lymph nodes dissected
 Gross & microscopic characteristics of the primary
lesion
 Gross & microscopic characteristics of dissected lymph
nodes
 Patterns of spread
 Frequency and pattern of lymph node involvement

5. Factors That Determine Adjuvant Treatment
 Patterns of spread
 Frequency and pattern of lymph node involvement
 Site
 Size
 Location, especially with relation to midline
 Histomorphological features , endophytic vs exophytic,
tumour thickness, differentiation

6. Buccal Mucosa, Alveolar &
Retromolar Trigone Lesions

7. Buccal Mucosa , Alveolar, and Retromolar Trigone
Lesions
 Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
 Alveolar and retromolar trigone lesions
involve bone early;
 Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
 Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
 INTRATEMPORAL FOSSA

8. Buccal Mucosa , Alveolar, and Retromolar Trigone
Lesions
 Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
 Alveolar and retromolar trigone lesions
involve bone early;
 Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
 Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
 INTRATEMPORAL FOSSA

9. Buccal Mucosa , Alveolar, and Retromolar Trigone
Lesions
 Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
 Alveolar and retromolar trigone lesions
involve bone early;
 Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
 Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement.
 INTRATEMPORAL FOSSA

10. Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions
 Buccal Mucosa lesions involve the
buccinator muscle and buccal fat pad
 Alveolar and retromolar trigone lesions
involve bone early;
 Mandibular canal and inferior alveolar
nerve / maxillary antrum and floor of
nose – potential routes & sites of
spread, respectively.
 Bone Involvement : Absence of fixation
to bone / small size of a mandibular
lesion, does not rule our bone
involvement. Yao et al IJROBP 2007
 INTRATEMPORAL FOSSA
55 pts, oral cancer alone. Mostly
postoperative IMRT
2/9 locoregional failures in the
infratemporal fossa

11. Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions
MDSCC Rt Gingivum
Bone Involvement Present
Margins & Lymph Nodes
Free

12. Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – Lymph Node Involvement in N0 neck
Level I Level II Level III Level IV Level V
Buccal 44 11 0 0 0
Mucosa
Alveolus 27 21 6 4 2
Retro Molar 19 12 6 6 0
Trigone
A minimum ?? nodes must be removed in an adequate SOND Gregoire, R O 2000, 56, 135

13. Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – Lymph Node Involvement in N+ neck
Level I Level II Level III Level IV Level V
Buccal 82 42 65 65 0
Mucosa
Alveolus 54 46 19 17 4
Retro Molar 50 60 40 20 0
Trigone
Gregoire, R O 2000, 56, 135

14. Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – The Contralateral Neck

15. Buccal Mucosa, Alveolar and Retromolar Trigone
Lesions – The Contralateral Neck
 145 patients  However
 77% had Stage III – IV disease Unilateral RT Bilateral RT
 120 patients ( 83%) received
unilateral radiotherapy
 CCRT for ECS, N2 disease and N2 38 pts 15 pts
positive margin
 3/120 failures in contralateral neck
ECE 84 pts 11 pts
 Author’ conclusion : Do not treat
contralateral neck for buccal
mucosa lesions
Conclusion : Do not treat contralateral neck routinely, except in lesions close to midline . Evidence
unclear for N2 neck

16. Buccal Mucosa, Alveolar and Retromolar
Trigone Lesions – a Summary
Indications Doses
T3, T4, Some T2 66Gy /33/fx for positive margins,
ECE.
Bone involvement
Skin involvement 60 Gy/30 fx for primary and involved
Close or positive margins lymph node levels.
Inadequate neck dissection 50Gy/ 25fx – 60 Gy/30 fx for
Positive neck nodes elective nodal irradiation.
Lymphovascular space involvement
ChemoRT for positive margins / ECE
Perineural Spread Consider for T3, 4, LVSI, PNI, N2+,
Extracapsular spread Level IV, V disease

17. Buccal Mucosa, Alveolar and Retromolar
Trigone Lesions
Ca Left RMT, post WLE
marginal mandibulectomy,
Margin Positive,
2/26involved, ECE Nil,
Bone free

18. Oral Tongue

19. Oral Tongue: Indications of post operative
radiotherapy
 T3 T4 tumours ? T2
 Positive nodes
 Extracapsular involvement
 Close or positive margins
 Lymphovascular space involvement
 Perineural spread

20. Oral Tongue- Lymph Node Involvement in N0 &
N+ neck
Level I LevelII Level III LevelIV Level V
BuccalMucosa 44 11 0 0 0
Oral Tongue 14 19 16 3 0
N0
Oral Tongue N1 32 50 40 20 0
Gregoire, R O 2000, 56, 135

21. Oral Tongue : Impact of Tumour Type on
Lymph Node Involvement
LN Involvement
70% 62%
60%
50%
35%
40%
LN Involvement
30% 20%
20%
10%
0%
Exophytic Superficial Ulcerative/
/Nodular Invasive

22. Oral Tongue – When can nodal irradiation
be avoided
 < 8mm ( Matsuura) ,< 5 mm( O Charoenrat), < 4 cm (
Fakih) < 2 mm ( Spiro)
 Adequate nodal dissection that includes Level IV lymph
nodes and pathologically negative
60 51.2 52.3
Shrime et al cta Otolary Head
50 41.4
37.9 39.9 Neck Surg 2010
40 Retrospectiev analysis of 1539 pts
Surgery with T1,T2,N1 disease
30
17.7 Surgery + RT
20
10 OS
0
All T2N1 FOM

23. Oral Tongue – Local Radiation Alone, In Very Select Situations.
May Use Brachy therapy Instead

24. Oral Tongue – Dose Painting with Neck
Irradiation
Ca left lat border tongue,
1.5cm, all margins free,
LVSI +, PNI +, 2/26 Lymph
Nodes Positive

25. Oral Tongue – Dose Painting with Neck
Irradiation
Ca left lat border tongue,
1.5cm, all margins free,
LVSI +, PNI +, 2/26
Lymph Nodes Positive

26. Oral Tongue – When to Irradiate The
Contralateral Neck
 Fakih et al ( 1989) Contralateral failure higher in patients
who have undergone neck dissection along with surgery.
 Kowalski ( 1999) Tumours >4 cm in size, poorly
differentiated, ipsilateral positive nodes and floor of mouth
involvement have contralateral spread
 Bier Lanning et al( 2009) Treat the contralateral neck if
thickness of primary > 3.75mm

27. Lip
 Lymph Node Involvement lower than other oral cavity
sites
 Avoid elective lymph node irradiation in T1 T2 lesions
 Include facial and preauricular nodes for upper lip
lesions
 Perineural spread an issue in advanced tumours

28. Status of chemoradiotherapy
EORTC 22931 Both RTOG 9501
Stage III & IV disease ECE Two or more positive
Positive Level IV /V Surgical margins nodes
lymph nodes in Oc/Op involved
primaries
Vascular embolisation
Perineural spread
Bernier & Cooper, The Oncologist

29. Stauts of chemoradiotherapy
60% 53%
50% 47%
40%
40% 36%
31%
30% RT
ChemoRT
20% 17%
10%
0%
DFS OS LRF
EORTC trial. ( RTOG trial : No impact on OS, differnence in no. of N2,3 and margin +ve patients )
Early reactions higher, other parameters : No significant impact.

30. Mandibular health in the era of IMRT
( & ? Improved dental prophylaxis)
 Ben David et al ( IJROBP 68(2) 396
 176 patients, 50 % receiving > 70 Gy to > 1 % of
mandible
 Sharp dose gradient across mandible ( average 11 Gy)
 Strict protocol based dental prophylaxis
 No osteoradionecrosis at a median of 34 months

32. Special Thanks to Dr Anchal Agarwal