4. What type of surgery is indicated?

Operative findings:

• 3 x 2 cm ulcer of the lower gingiva with invasion into the mandible

• 5 x 4 cm well-encapsulated firm mass located at the submandibular triangle (level 1 to level 2 )

• Multiple pinkish-red, firm, grossly enlarged nodes (1-2 cm) along the jugular chain (levels 2 to 4)

• 4 x 3 cm well encapsulated firm mass at the subclavicular area

TNM StagingT N

M

Stage IVA

Operation done

• Wide excision of the ulcer with segmental mandibulectomy with modified radical neck dissection, left: the defect was reconstructed using titanium plates.

Segmental Mandibulectomy• removes an entire segment of the mandible,

disrupting continuity of the bone. This is performed when tumor invades bone.

• may be performed in the setting of a composite resection, – resection of a segment of mandible in continuity

with a cancer of the oral cavity or oropharynx or a primary cancer of the alveolar ridge.

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• Advantages– Adequate margins of resection– Excellent exposure– Ease of exposure

• Disadvantages• Cosmetic and functional consequences

Final histopath:

• Well differentiated squamous cell carcinoma with metastasis to 5/20 lymph nodes, the largest measures 2 cm with extracapsular invasion; margins clear; with bony invasion

5. What adjuvant treatment is required

Radiation

• Pre and post-op radiation– Improves local/regional control in HNSCC– within 6 weeks of surgery– 50 to 70 Gy over 5 to 7 weeks

• Adverse reactions:– acute: mucositis, skin erythema– Late: fibrosis, xerostomia, altered state

Chemotherapy

• No survival advantage compared to surgery and/or radiation– Cisplatin, carboplatin, 5-FU

• Palliation of recurrent or unresectable disease, combined with radiation