Oral Cancer

Professor Ravi KantMS, DNB, FRCS (Edin.) ,FRCS( Glasg.), FACS , FICS, MNAMS,

WHAT IS NEW IN HEAD AND NECK CANCERS?

Dr. K.A.Pathak, MS, Dip NB, FRCS, FRCSEd.

Associate Professor in Head & Neck Oncology

Tata Memorial Hospital, Mumbai

New Molecular Model

Normal

HPV

9p,3pDysplasia

CISHNSCC

p53

13q,17p

? 6p

14q,8p

11q,4q

Califano et al , Cancer Research 1996

What is New in Imaging?

• Ultrasonography and Guided FNAC

Real time

Inexpensive

Quicker but operator dependent

Doppler can show flow characteristics

• CT Scan with 3 D views

• Virtual Laryngoscopy

CT Scan with 3 D views

Virtual Laryngoscopy

MRI and MR Angiography

Residual / recurrent locoregional disease

Detection of occult primaries in MUO

Occult metastatic disease in the neck

Synchronous primaries or metastasis

18FDG-PET

What is New in Staging ?

T4 lesions have been divided into T4a (resectable) and T4b (unresectable)

Stage IVA T4a N0 M0T4a N1 M0T1-4a N2 M0

Stage IVB T4b Any N M0Any T N3 M0

Stage IVC Any T Any N M1

(AJCC 6th Ed, 2000)

What is New in Surgery?Oral cavity: Pattern of Mandibular invasion

Mandible Preservation

Larynx: Endoscopic Laser ExcisionConservative laryngectomyPrimary voice rehabilitation

PNS Tumors: Endoscopic Sinus SurgeryCranio-facial Excision

What is New in Chemotherapy ?

Category Hazard ratioCT effect Abs. benefit (p) 2yrs 5yrs

Adjuvant 0.98 0.74 1% 1%

Neo-adjuvant 0.95 0.10 2% 2%

Concomitant 0.81 <0.0001 7% 8%

Total 0.90 <0.0001 4% 4%

MACH-NC, LANCET 2000

Laryngeal Preservation• VALCSG 1991

Larynx preserved in 64% patients

No change in overall survival

• EORTC 1996

42% functioning larynx-3 yrs, 35% -5 yrs

• RTOG 2003

88% functioning larynx at 2 years

22% loco- regional failures

What is New in Radiotherapy ?

Techniques • Alt. Fractionation- Accelerated & Hyperfr.• 3D Conformal Radiotherapy & IMRT • Stereotactic/ Fr. Stereotactic Radiothearpy• Neutron Beam/Charged Particle RT• Intraoperative Radiotherapy

Radiation Induced Xerostomia• Pharmacological Agents- Amifostin, GMCSF• Submandibular Gland Transfer (Seikaly et al)

Newer Targets of Therapy

• Photodynamic Therapy: Palliation

Curative intent- Small primary tumor

Second primary/ Recurrent tumor

Premalignant lesions

• Antibody based Therapy

Monoclonal Ab against EGFr-C225

Inhibitors of EGFr-ZD1839, Erlotinib HCl

• Gene Therapy

Gene Therapy- ApproachesAugmentation therapy

Immunotherapy: Cytokine gene transfer- IL-2,IL-12, IFN- Vaccination Tumor specific antigen

Co-stimulator molecule

Foreign antigenChemotherapy: HSV TK

Drug sensitization / Drug resistanceGene replacement

Replace tumor suppressor gene- p53Inhibit an oncogene- Antisense c DNA

Adjuvant Therapy- Post CT / RT/ Surgery

Chemoprevention Possible Roles

• Reversal of oral pre-cancerous lesions• Chemoprevention of SPT• Primary chemoprevention in high-risk

Phamacological Agents• Beta Carotene• Retinoids- 13cRA,Vitamin A• Retinamides tocopherol

Overview

• Molecular Basis of Carcinogenesis

• Imaging- 3-D CT , MR Angio, FDG-PET

• Staging- Changes in TNM (6th Ed. AJCC)• Concurrent Chemo- RT- MACH- NC, RTOG

• Advances in Radiotherapy Techniques

• Improved Quality of Life- Post Surgery/RT

• Newer Targets for therapy

• Advances in Chemoprevention