Oral cancer Seminal

TMH Publications
Sudhir V Nair MS MCh
Professor, Head and Neck Service
Tata Memorial Centre
Head and neck oncology: The Indian
scenario
• Oral cancer forms the bulk of cancer work in head and neck service
at TMH
• More than 200 indexed original articles in the last 20 years
• Selected articles relevant to the current meeting
• These papers cover various aspect of oral cancer management
• Related to Primary tumors – Outcome and treatment
• Management of Neck
• Adjuvant treatment
• NACT
Resection Margin

• Final histopathological margin of 5mm is significant in reducing local recurrence

• Maximum mucosal shrinkage occurs after surgery.
• The mean shrinkage from the pre-resection to the post resection measurement
was 3.18 mm.

27 Patient samples
Site Mean Shrinkage Site Mean Shrinkage
Tongue 3.71mm Male 3.13 mm
Buccal Mucosa 2.4 mm Female 3.27 mm
T1, T2 tumors 3.59mm Age <45 4.04mm
T3, T4 tumors 1.4mm Age >45 2.59mm
Frozen section
2013

• prospective study on 145 consecutive patients

• 93% Oral cavity tumours
• With a gross post resection tumor free margin of 7mm, frozen
section did not added value in detecting involved margin.

HEAD & NECK—DOI 10.1002/HED MONTH 2013

Buccal mucosa cancers
- Patient Factors
PARAMETERS Pathak et al. (2005) Walvekar et al. (2009) Mair et al. (2018)
Time period Jan 1994- Dec 1995 Jan 1997- Dec 1999 Jan 2010- Jan 2014
Mean age at presentation 50.8 51 T4a- 49
(in Yrs.) T4b- 48
Sex ratio (M:F) 7:3 2.4:1 4.67:1
Subsite Gingivo-Buccal Complex Gingivo-Buccal Complex Buccal mucosa cancers
(buccal mucosa, (buccal mucosa, lower
gingivobuccal sulcus, gingivobuccal sulcus,
lower gingiva, lower
and RMT) alveolus, and RMT)
Study design Retrospective Retrospective Prospective
Inclusion criteria T2, T3, and T4 cases Stage III and IV Locally
advanced T4a and T4b
HISTOPATHOLOGICAL FACTORS
PARAMETERS Pathak et al. (2005) Walvekar et al. (2009) Mair et al. (2018)
Bone involvement on 40% 37.3% 63.8%
HPE
Skin involvement on   13.4% 30.5%
HPE
Nodal involvement on 47% occult metastasis- 52.85%
HPE 29.6%
regional metastasis-
48.7%
Margins Close- 7% Close- 6.9% Close/Positive- 9.4%
Positive- 13% Positive - 14%.
 SURVIVAL TRENDS
PARAMETERS Pathak et al. (2005) Walvekar et al. (2009) – Mair et al. (2018)
T2/T3/T4 T3/T4
DFS 64% (2 years) 63.8% (2 years) 65.3% (T4a , 3 years)
42% (T4b , 3 years)
Factors • Skin infiltration, • Cervical node metastasis • Margin positivity
influencing DFS • ENE + • Tumor depth >4mm • Masticator space
• Adjuvant RT • PNI involvement
• 48.7% patients were
pathologically N+ • Nodal involvement
• Level I was most • PNI
commonly affected
(86.9%)
OS     49.6 % (T4a)
41.1% (T4b)
• There were 173 males (82.38%) and 37 females (17.61%).
• The median age of the study patients was 49 years (range: 26–73
years).
• Among these 210 patients, 135(64.28%) were classified as T4a and
75(35.71%) as T4b based on clinico-radiological findings.
• Nodal metastasis in 111 patients (52. 85%).
• Majority of all recurrences were
locoregional
• All recurrences happened within 24
months
• Factors affecting DFS and OS
• Nodal mets
• PNI
 • All T4b buccal cancers
are not unresectable
• With radical treatments,
they have better
survival and good
quality of life than
palliative care patients

7. Patil VM, Prabhash K, Noronha V, et al. Neoadjuvant chemotherapy followed by surgery in very locally
advanced technically unresectable oral cavity cancers. Oral Oncol 2014;50(10):1000–4
Pattern of recurrence
T Stage Local Regional Distant
T4a (n = 135) 52% 19% 25%
T4b (n = 75) 50% 14% 30%

Over all recurrence rates

• T4a: 51/135 (38%)
• T4b: 44/75 (59%)
 Parameters
Treatment Period 2007 -2010
586 treatment naïve tongue cancers surgically
treated at TMC
Mean and Median age 47, 48 yrs
Pattern of disease failure Local – 18.5%
Regional – 46.5%
Distant - 20.0%
Loco-regional Second primaries – 15.0%
recurrence 65% Pathological node status N0 : 275 (47%)
N+ : 311 (53%) – 66% had ECS
Perineural invasion
Yes 25.9%
No 74.1%
 Factors predicting nodal metastasis
also impact the survival.

 Nodal mets, ECS, PNI and Tumor

thickness predicts are prognostic
factors in tongue cancers
• 11 Participating institutes with 3781 Oral cancer cases.
• On multivariable analysis, DOI was a significantly associated with
disease-specific survival (P < .001)
• Optimal cutpoints of 5 mm in T1 and 10 mm in T2-4 category disease
Management of the neck
• First reported prospective randomized trial addressing itself to
management of the No neck
• A total of 100 patients were entered into the protocol between July 1985
and September 1988
• Hemiglossectomy group and the hemiglossectomy with radical neck
dissection group
• 95 patients completed the primary treatment.

THE AMERICAN JOURNAL OF SURGERY VOLUME 158 OCTOBER 1989

• A tumor depth of 4mm was found to have higher risk of nodal metastasis
Hemi Hemi glossectomy +
glossectomy RND • In the hemiglossectomy and radical
DFS 52% 63% neck dissection group, 10 of 30
T1 64% 70% patients (33%) had histologically
T2 46% 60% involved nodes.
• In the hemiglossectomy alone
• Higher contralateral nodal relapse in group 57% developed subsequent
END arm ipsilateral neck nodes
• 2004 – 2014
• 596 patients randomized
• 85% tongue tumors.
• OS as the primary endpoint
 Absolute overall survival benefit of 12.5% Over TND (80.0% Vs 67.5%)
 Disease-free survival benefit of 23.6 %
 Significant increase in lymph-node positivity was observed with increasing depth of
invasion from 3 mm (5.6%) to 4 mm (16.9%).
  depth (≤3 mm) of invasion benefit of END is doubtful
• Prospectively collected data on neck dissection
• Defined the pattern of neck node metastasis.
• There were no skip
metastases to levels IV
and V in any patient.
 Contralateral Neck?

•• Contralateral
Contralateral nodal
nodal metastases
metastases were
were present
present in in 71
71 of
of 243
243
patients (29%)
patients (29%) who
who underwent
underwent bilateral
bilateral neck
neck dissection.
dissection. Of
Of
these 71
these 71 patients,
patients, 69
69 patients
patients (97%)
(97%) had
had ipsilateral
ipsilateral nodal
nodal
metastasis.
metastasis.

•• In
In carcinoma
carcinoma ofof the
the tongue,
tongue, where
where lesions
lesions reach
reach or
or cross
cross the
the
midline, the
midline, the chance
chance ofof contralateral
contralateral nodal
nodal metastases
metastases without
without
ipsilateral nodal
ipsilateral nodal metastasis
metastasis isis extremely
extremely rare.
rare.
• hospital database of 414
patients during 1994 – 2001.

Oral Oncology (2006) 42, 837– 841

• Locally advance oral cancers with borderline resectability (n = 721)
• Inoperable tumors excluded
• 90% received 2 drug regimen (mainly combination of docetaxel with
cisplatin / carboplatin)
• 10% had 3 drug regimen and had the best response rate (50% , p >
0.05)
Borderline resectablitiy
 OS months CI
Whole group 10.8 9.84–11.75
months
Surgery 19.6 9.59–25.21
months
Non surgical 8.16 7.57–8.76
months

42.5% had sufficient response and underwent tumor resection and all had R0
resection
AND MANY MORE ….

THANK YOU!