1. ORAL CAVITY AND OROPHARYNX
Mostafa EL-Haddad
Ass. Prof. Of Oncology
Kasr Al-Ainy Hospital
Cairo University
(NEMROCK)

2. Oral Cavity

3. Upper and Lower Gingiva Retromolar Trigone or (Retromolar Gingiva
ANATOMY
Hard Palate
Upper and Lower Gingiva
Lip
Oral Tongue
Ant 2/3
Buccal Mucosa
Floor Of mouth
Buccal Mucosa
Retromolar Trigone or (Retromolar Gingiva

4. Anatomy

6. Notes
Retromolar trigone??:- Apex in line with maxillary tuberosity (behind last molar teeth), the lateral border extend with buccal mucosa, medially it blends with anterior tonsillar pillar, base is formed by the last lower molar and the adjacent gingivolingual sulcus.

8. Other Trigones
Trigone of bladder: a triangular region of the wall of the urinary bladder, the three angles corresponding with the orifices of the ureters and urethra; it is an area in which the muscle fibers are closely adherent to the mucosa. 

9. Carotid trigone:  the triangular area bounded by the posterior belly of the digastric muscle, the sternocleidomastoid muscle, and the anterior midline of the neck.

10. Olfactory trigone: The triangular area of gray matter between the roots of the olfactory tract.

11. Oral Tongue
Intrinsic Muscles (speech)
Longitudinal, vertical and transverse
Extrinsic Muscles (move body)
Genio, hyo, stylo glossus
There are six pairs of muscles that form the oral tongue. Three of these muscles are extrinsic, while the other three are intrinsic.
The extrinsic muscles include the genioglossus, hyoglossus, and styloglossus.
The intrinsic muscles include the lingual, vertical, and transverse muscles.
The former primarily move the body of the tongue, while the latter alter the shape and conformation of the tongue during speech and swallowing.

18. Four taste qualities, a novel taste, that
is referred by the Japanese word umami
which means delicious, ‘‘fifth taste’’.
Umami taste is found in a diversity of foods (e.g. fish, meat, milk, tomato and some vegetables) and is elicited by monosodium glutamate and certain ribonucleotides.

19. Aging, pregnancy and menopause
Aging, pregnancy and menopause. Poor dentition and hygiene, alcoholism and/or excessive smoking are common conditions that affect taste.
Patients with xerostomia, Sjogren syndrome, vitamin and zinc deficiency liver and kidney disorders, endocrine disorders, diabetes mellitus, psychological disorders,
central nervous system disorders, and surgical procedures around the chorda tympani or gloss opharyngeal nerve.

20. Floor of Mouth
A semilunar space extending from the lower alveolar ridge to the undersurface of the tongue.
The floor of the mouth overlies the mylohyoid and hyoglossus muscles.

21. 10-12 SMALL DUCTS TO
SUBLINGUAL FOLDS (PLICAE SUBLINGUALIS)

22. Tongue Nerve Supply Lingual (Meneeein). Chorada Tympani.
Hypoglossal Nerve.

23. Staging
As other Head and Neck but not Nasopharynx.

25. T4a and T4b Usually T4b tumor control probability is very low.
Resectability is impossible.

28. Examination Under Anesthesia can be done with the surgeon to assess the disease similar to that of the Cervix.

29. Start by Support Nutritional support. Dental Support.
Psychological Support.
Speech and Swallowing Consult.

30. Node Story

31. The 5-year cancer-specific survival can be as high as 70% to 90% for patients without lymph node metastasis but drops by half for patients with node-positive disease.

32. Staging and Node in Head and Neck Cancer
N2 disease put patient Stage IVA.
N3 disease put patient Stage IVB.

33. should be treated prophylactically Level I to III.
Nodes N0
should be treated prophylactically Level I to III.

34. Treatment

35. ORAL CAVITY BASICS ASK YOUR SELF THREE QUESTION?
Is it small (T1 or T2 ) or large (T3 or T4)?.
Is the lesion Central or Lateralized?.
Is the Nodes negative or Positive?.

36. Rules
The closer to the midline the primary, the greater the risk of bilateral cervical nodal spread.
The mucosa of the upper and lower alveolus and hard palate is fixed to the underlying periosteum so invasion of the adjacent bone occurs relatively early making these tumors less suitable for primary radiotherapy

37. Early Lesion
Surgical resection: where rim rather segmental resection should be performed. Situations where removal of the bone is required to achieve clear margin.
Re-resection should be performed to achieve clear histological margins if the initial resection has positive margins.

38. submandibular and subdigastric nodes
Lymphatics
first echelon
Second echelon
upper gingiva
lower gingiva
hard palate
retromolar trigone
submandibular and subdigastric nodes
subdigastric nodes
anterior
cervical nodes
incidence of clinical nodal positivity at presentation
according to anatomic subsite:
20 – 30% for gingival and retromolar trigone tumors (with slightly higher risk of nodal disease for lower gingival vs upper gingival tumors) and 10% for hard palate tumors
- incidence of clinically positive bilateral nodes rare
incidence of occult nodal disease overall: 20%

41. Planned Neck dissection
What does it mean?
Controversy continue.

42. Lip Cancer

43. In Early stage T1 and T2 surgery results equal to RT.
So How to choose?

44. LIP Surgery may be preferred in :
- T1 lesion with good functional and cosmetic outcome.
- Young patient with outdoor sunlight exposure.
- Diffuse superficial lesion of the vermillion, or presence of severe actinic keratosis adjacent to carcinoma.

45. N0 disease
In the N0 neck, occult metastases are estimated to occur in 5% to 10% of cases.
Therefore, elective neck dissection is not routinely performed in the N0 neck.
Neck dissections are generally performed when cervical metastases are clinically or radiographically apparent.

46. WHEN? Primary Radiotherapy Target Volume: Tumor with a margin
Tumor with a margin+first echlon lymph nodes.
Tumor with a margin + whole neck .
WHEN?

47. LIP What is the likely diagnosis?
How would you treat this patient (describe your technique in detail)

48. Oral Tongue

49. Tumor Thickness in Oral Tongue
Po demonstrated that tumor thickness in oral tongue carcinomas was the only significant factor that had significant predictive value for subclinical nodal metastasis, local recurrence, and survival in multivariate analysis.
With the use of 3-mm and 9-mm division, tumor of up to 3 in mm thickness is associated with an 8% risk of subclinical nodal metastasis, zero local recurrence, and 100% 5-year actuarial disease-free survival; tumor thickness of more than 3 mm and up to 9 mm carried a risk of 44% subclinical nodal metastasis, 7% local recurrence, and 76% 5-year actuarial disease-free survival; tumor of more than 9 mm carried a 53% risk of subclinical nodal metastasis, 24% local recurrence, and 66% 5-year actuarial disease-free survival

50. External beam alone may not be very successful.
Boost using brachytherapy is recommended.

51. Oral Tongue
Before external-beam RT, the cancer is photographed and diagrammed to document its extent at the time of the implant.
Sometimes, the anterior and posterior borders of the lesion are tattooed with two tiny (1–2 mm) marks.
Under no circumstances should the ink that is used to tattoo the patient be injected under pressure (e.g., with a syringe), because the ink may diffuse over a large area.

52. If teeth with metal fillings lie against the tongue or buccal mucosa, a thin layer of gauze (a few millimeters thick) is inserted between the teeth and tongue or buccal mucosa to prevent a high-dose effect secondary to scattered low-energy electrons.

54. Tongue depressor may be different
Spot the difference?

56. Advanced Stage
Patients with resectable disease who are fit for surgery should have surgical resection with reconstruction.
Patients with node positive should be treated with modified radical neck dissection.
Elective dissection of the contralateral neck should bee considered if the primary tumor is locally advanced arises form the midline or there are multiple ipsilateral nodal involvement.

57. Advanced Stage Ctn When Concurrent CRT Only
Tumor can not be resected.
General condition is inadequate.
Patient doesn’t wish to go for surgery.
Nodal level I to IV should be irradiated.

58. Nodal Disease
Patients with N1 disease should be treated by chemoradiotherapy to the primary and node.
Patient with N2 or N3 disease should be treated by chemoradiotherapy followed by planned neck dissection.

59. When Chemotherapy is not Suitable
Cetuximab with radiotherapy should be considered.
Where radiotherapy to be used without chemotherapy or cetuximab,
A modified fractionation schedule should be considered.

60. Management Gingival and hard palate cancer Retromolar trigone cancer
Early (T1 – 2) tumors
Surgery is recommended over radical irradiation due to the high incidence of bone involvement – irradiation risks bone exposure after treatment of the tumor
Very superficial tumors may be treated with radical irradiation
Adjuvant irradiation is added for adverse primary (i.e., high-grade mucoepidermoid or adenoid cystic pathology) or neck pathology
Advanced (T3 – 4) tumors
Surgery and adjuvant irradiation is recommended
Unresectable disease may be treated with adjuvant irradiation followed by attempted resection or hyperfractionated irradiation alone
Retromolar trigone cancer
early (T1 – 2) tumors: radical irradiation is recommended over surgery due to more favorable morbidity profile
advanced (T3 – 4) tumors
surgery and adjuvant irradiation is recommended
unresectable disease may be treated with neoadjuvant irradiation followed by attempted resection or hyperfractionated irradiation alone

61. Results gingival cancer hard palate cancer retromolar trigone cancer
M. D. Anderson (see Leibel, p. 475) treated 48 patients with radical irradiation
survival: 5YOS of 46%
patterns of failure: local control of
70% for T1 – 2,
59% for T3,
29% for T4
hard palate cancer
Memorial (Evans. Am J Surg 142: ) treated 49 patients with surgery with or without adjuvant irradiation
survival
surgery alone: 5YDFS of 75% for stage I, 46% for stage II, 40% for stage III, and 8% for stage IV disease
surgery and adjuvant irradiation 5YDFS of 25% for stage IV disease
retromolar trigone cancer
M. D. Anderson (Lo. IJROBP 13: ) treated 159 patients with retromolar trigone and anterior tonsillar pillar tumors with radical irradiation with surgery reserved for salvage
survival: 5YCSS of 83%
patterns of failure: local control
after irradiation: 70% for T1 – 2, 76% for T3, and 60% for T4
after surgical salvage: < 90% for all T stages

62. Standard ttt T1-T2,N0 Any site (except retromolar trigone)
Surgery alone with staging neck sampling:
Plus adjuvant radiotherapy for high risk situation
Microscopic margins <5mm (irrespective of intra-operative revision or additional post-resection sampling of the surgical site)
> 1 additional features at primary:
Poorly differentiatied
Peri-neural spread
Angiolympatic invasion
Lymph node involvement at pathology:
Extracapsular extension in positive lymph nodes
Multiple lymph nodes
>3 cm lymph nodes

63. Standard ttt. T1-T2 N0 Retromolar trigone
Radiotherapy Alone with surgical Salvage 􀂾
60 Gy in 25 fractions ?
4-6 MV beam quality
Homolateral wedge pair (preferable) in lateralised lesions: 􀂃
disease limited to 1 cm of palate involved 􀂃
disease limited to 1 cm of tongue involved 􀂾
Parallel opposed as necessary 􀂾
3 phases (including cord shield where appropriate) 􀂾
Augment posterior neck with electrons after cord Pb where appropriate 􀂾
Ant or Ant/Post ‘low’ neck parallel opposed (4-6 MV) or hemisplits in unilateral techniques

64. Standard ttt. AnyT, N+ or T3-T4, N0 (except retromolar trigone) M0
Surgery with neck dissection +/- adjuvant post-operative radiotherapy:
Plus adjuvant radiotherapy for high risk situation
Microscopic margins <5mm (irrespective of intra-operative revision or additional post-resection sampling of the surgical site)
> 1 additional features at primary:
Poorly differentiatied
Peri-neural spread
Angiolympatic invasion
Lymph node involvement at pathology:
Extracapsular extension in positive lymph nodes
Multiple lymph nodes
>3 cm lymph nodes
Surgically ‘unstaged’ neck:
No surgery to a neck
Especially if imaging incomplete

65. Standard ttt. POST-OPERATIVE XRT
60 Gy in 30 fractions for original site of gross disease where feasible using reducing field techniques
66 Gy in 33 fractions to sites of positive margins
50 Gy to other potentially involved nodal sites
Parallel opposed (4-6 MV) or ipsilateral wedge pair for lateralized lesions

66. RADIOTHERAPY ALONE Retromolar Trigone (AnyT, Any N)
Primary radiotherapy indicated all cases. Exception is gross bulk disease extending through bone and/or skin involvement where surgery should be considered followed by adjuvant radiotherapy.
All Oral cavity T3-T4 or Any N +
Where surgical morbidity at primary site anticipated and considered not appropriate
where patient declines surgery
or neck disease is unresectable and primary not yet treated surgically
Unresectable neck and primary already resected:
assess risk to the primary and consider inclusion in plan for neck to administer 70 Gy in 35 fractions with Cisplatin

67. Doses & Beam arrangement
Dose fractionation schedules +/- chemotherapy
70 Gy in 35f with Cis-Platin (Intergroup usually) or
60 Gy in 25f (reserve for frail or ‘patient preference’ declining ‘standard’ treatment)
Beam arrangement (technique)
Parallel opposed or angled down wedge pair as necessary with (4-6 MV)
Ant or Ant/Post ‘low’ neck if parallel pair
Augment posterior neck with electrons after cord Pb

68. Targets for non-surgical treatments (any T, any N, M0) -PMH
Primary and gross neck node(s):
Phase 1 : 1.5 cm CTV margin (superior: mastoid to inferior: clavicle)
Phase 2 : 1.5 cm CTV margin (cord shield, including custom ‘Step back’ shape for posterior mid-line disease)
Phase 3 : 0.5 cm CTV margin on primary or gross nodes

69. Lymph nodes management
Node inclusion:
Zones 2 to 5 included to adjuvant dose (50 Gy in 25 fractions or equivalent) (Leuven/Rotterdam consensus)
Retropharyngeal nodes if extensive other nodal involvement
Dose fractionation:
Gross nodes always receive full dose with minimum CTV margins as used for the primary, unless planned surgery is undertaken.
Gross nodes undergoing planned surgery (see below) should receive a minimal ‘microscopic’ dose, depending on the overall dose-fractionation chosen, prior to planned surgery.
Uninvolved node regions within the risk zones should be treated to a ‘microscopic’ dose depending on the overall dose-fractionation chosen.

70. Radiotherapy technique
External Beam alone???

74. Organ Preservation
You still can Try CRT if organ preservation is required. (provided salvage surgery may still be an option. e.g. patient reliable for good follow-up. Surgeon reliable for good surgery.
Famous Laryngeal preservation trials:
-Veterans Affairs (larynx neoadjuvant), EORTC (Hypopharynx neoadjuvant),
(RTOG larynx Concurrent CRT value).
-Urba et al JCO 2006(NEW is the use of concurrent CRT if good response to the neoadjuvant treatment.
Veterans affair NEJM 1991, EORTC JNCI 1996, RTOG NEJM 2003, Urba et al 2006

75. Patient Preparation Dental. Nutritional. Psychological. Council.
Immobilization.
Simulation.

76. Immobilzation
Max. Extension still possible for easily shielding of the oral cavity.
Tongue bite? What was the question?
You said before that when we want to protect the upper jaw and when we want to protect the lower jaw? But here I am protecting the whole cavity so whats the aim.?

77. Portal Arrangements
Opposed –lateral photon fields, with the patient immobilized in supine position are used for treatment of most cancers :
oral cavity, Larynx, pharynx.

78. In General: Either it will be
Superior border: Determined by the location of the known disease and likely spread pattern.
In General: Either it will be
1- At the base of skull when we want to include the retropharyngeal node, e.g. Hypopharynx.

79. Superior border: Nasopharynx Hypopharynx Oropharynx Oral cavity:
Larynx
Above skull base. because the primary at skull base.
Skull base? Retropharyngeal nodesz
Skull base? Primary at skull base.
Do you want lymph node?
So skull base/If not take only a margin (1 to 2 cm).
Glottic? Above the glottis.
Supraglottic? Lymph nodes so skull base.
Subgltic (very rare) only margin above the larynx.
Glottic with extensive supra? Skull base.

81. Eisbruch et al. established dose thresholds for the parotid gland: mean dose ≤24 Gy and ≤ 26 Gy for unstimulated and stimulated salivary flow,
respectively. Also, partial volume thresholds were established:
67%, 45%, 24% of the parotid gland volume
receiving ≥ 15 Gy, ≥ 30 Gy, ≥ 45 Gy, respectively. They observed that if the dose to the parotid glands exceeds (one or more of) these thresholds, Parotid salivary flow would significantly decrease

82. Lucite oral cavity mouthpiece fabricated at the University of Wisconsin for patients with oral cavity carcinomas. Upper dentition or maxillary alveolus links to u-shaped notch and tongue rests beneath smooth undersurface of mouthpiece. Note embedded solder wire in mouthpiece floor to facilitate visualization of tongue positioning at the time of simulation and beam design

83. Oropharynx

84. Base of Tongue.
Tonsil and Faucial arche.
Soft Palate.