THERAPEUTIC PROCEDURES OF ORAL CANCER

Oral cavity cancer treatment should be multidisciplinary involving several specialist areas, namely:

• Oncologic Surgeon

• Plastic and reconstructive surgeon

• Radiation oncologist

• Medical oncologist

• Dentist

• Rehabilitation specialists

Some of the things that must be considered in the treatment of oral cancer is the eradication of the tumor, the return function of the oral cavity as well as aspects of cosmetic / appearance of the patient.

Several factors need to be considered in determining the kind of treatment are:

a. patient age

b. general state of the patient

c. facilities available

d. the ability of doctors

e. patient choice

For small lesions T1-T2, surgery or radiation alone can provide a high cure rate. Note that radiotherapy alone in T2 provides a fairly high recurrence rate than surgery. T3-T4 therapy to surgery and radiotherapy combinations give better results. Provision of neo-adjuvant radiotherapy and or chemotherapy before the operative actions can be administered in a cavity cancer locally advanced (T3-T4).

Radiotherapy can be administered interstitial or external, exophytic tumor with small size will be more successful than endophytic tumors with a large size. The role of chemotherapy in the treatment of cancer of the oral cavity is still not much, in the research stage, chemotherapy is only used as a preoperative neo-adjuvant or adjuvant post-operative for sterilization possibility of micrometastases.

As a guideline for the treatment of cancer of the oral cavity:

ST        T.N.M            Radiotherapy Surgery Chemotherapy

I           T1N0M0         Radical excision or Curative, 50-70 Gy Not recommended

T2N0M0         II Excision radical Or Curative, 50-70 Gy Not recommended

III        T3N0M0         T1,2,3 N1M0 radical excision and Post op 30-40 Gy (AND) CT

IVA     T4N0M0        EACH, N2M0 radical excision and Post op 30-40 Gy IVB EACH T n3m0

-OPERABEL

-INOPERABEL

Radical excision and Palliative Post op 30-40 Gy, 50-70 GY (AND) CT

IVC     EVERY N      M1 T EACH LOCAL residif palliative palliative surgery for recurrent post RT  for recurrent post-op CT metastases Not recommended CT

Carcinoma of the lip

T1: wide excision or radiotherapy

T2: if the commissure wide excision, radiotherapy will provide healing with better function and cosmetic

T3: wide excision + deseksi suprahioid + postoperative radiotherapy

Carcinoma of the mouth

T1: wide excision or radiotherapy

T2: not attached to the periosteum →Gluey wide excision with periosteum →wide excision with marginal mandibulektomi

T3,4: wide excision with marginal mandibulektomi + dissection supraomohioid + Postoperative radiotherapy

Carcinoma of the tongue

T1,2: wide excision and radiotherapy

T3,4: wide excision + dissection supraomohioid + postoperative radiotherapy

Carcinoma of the buccal

T1,2: wide excision when the commissure, radiotherapy will provide healing with better function and cosmetic

T3,4: wide excision + dissection supraomohioid + postoperative radiotherapy

Gingival carcinoma

T1,2: wide excision with marginal mandibulektomi

T3: wide excision with marginal mandibulektomi + dissection supraomohioid + postoperative radiotherapy

T4 (infiltration of bone / tooth extraction after a tumor): wide excision with mandibulektomi marginal + dissection supraomohioid + postoperative radiotherapy

Carcinoma of the palate:

T1: wide excision to the periosteum

T2: wide excision to the underlying bone

T3: wide excision to the bone underneath + dissection supraomohioid +  radiotherapy
        Postoperative

T4 (infiltration of bone): maksilektomi infrastructural partial / total depending on the area of lesions + dissection supraomohioid + postoperative radiotherapy

For carcinoma of the oral cavity

T3, T4 N0 handling can be performed selective neck dissection regional or postoperative radiotherapy. While N1 obtained on each T radical neck dissection should be performed. Where possible wide excision of the primary tumor and neck dissection should be performed in an end-block. Giving regional radiotherapy after surgery depends on the results of pathological examination of the lymph nodes metastases (number of positive lymph nodes metastasis, lymph node capsule penetration / extra lymph) (Manuaha, 2010).

Curative therapy

Curative treatment for cancer of the oral cavity are given in the oral cavity cancer stage I, II, III.

1. The Main therapy

The main therapy for stdium I and II is that surgery or radiotherapy that each has advantages and disadvantages. Whereas for stage III, IV are still operable is a combination of surgery with postoperative radiotherapy.

At curative therapy should be considered:

a. According to the correct procedure, because if one of the results not be curative

b. The function of the mouth to talk, drink, eating, swallowing, breathing remains good

c. Cosmetically enough to be accepted

• Operations

Indication of operation:

1. Operable cases

2. The relatively young age

3. The general condition good

4. There are no severe co-morbidities

The basic principle of the oral cavity tumor surgery:

1. The opening should be large enough to be able to see the entire tumor with extension

2. tumor exploration, to assess tumor extension area

3. wide excision of the tumor

a. tumor does not invade the bone, wide excision of tumors 1-2 cm beyond

b. invades bone resection with wide excision of bone invaded

4. The regional lymph nodes dissection (RND = radical neck disection or modifications thereof), if there are regional lymph nodes metastases. This dissection is done enblok the primary tumor if possible.

5. Specify radicality durante operation of edge incision surgery with frozen section examination. If you do not create a radical new incision line wider until tumor free

6. Reconstruction occurring defak

• Radiotherapy

Indications of radiotherapy:

1. Operable cases

2. T1,2 specific place (see above)

3. The base of tongue cancer

4. Relatively old age

5. No severe co-morbidities that radiotherapy can be given by:

a. Teletherapy wear ortovoltase, cobalt 60, Linec with a dose of 5000-7000 rads

b. Braki therapeutic, as a booster with intratumoral implantation, needles irridium radium 192 or 224 at a dose of 2000-3000 rads (Taso, 2004).

2. Additional therapy

a. Radiotherapy

Additional radiotherapy is given on the case with its main therapeutic operations.

1. Postoperative radiotherapy is given to T3 and T4a after surgery, the case can not be done radical excision, radicalism, doubtful or contamination operating field with cancer cells.

2. The pre-surgical radiotherapy

Pre-surgical radiotherapy is given in cases of doubt operabilitasnya or inoperable.

b. Surgery

Operations carried out in cases of primary radiotherapy treatment after surgery or radiotherapy becomes operable esidif arise after radiotherapy

c. Chemotherapy

Chemotherapy is done in the case of contamination of the operating field by cancer cells, cancer stage III or IV or arising or recurrent after surgery and radiotherapy.

3. Treatment of complications

a. Treating the complications of the disease

In general, stage I to II, no complications of the disease, but can be complications due to treatment.

Treatment depends on the complications that exist, such as:

1. Pain; analgesic

2. Anemia; haematinics

3. Infections; antibiotics (Taso, 2004)

Treating the complications of therapy

1. Surgery complications; according to the type of complication

2. Complications of radiotherapy; according to the type of complication

3. Complications of chemotherapy; according to the type of complication

4. Assisted therapy can be given proper nutrition, vitamins, etc.

5. If there is a secondary treatment of secondary illnesses, given the appropriate therapy type of illness

2. Palliative therapy

Palliative therapy is to improve the quality of life of patients and reduce complaints, especially for patients who can not be cured anymore. Palliative therapy given to patients with oral cavity cancer:

1. The stage IV who have demonstrated distant metastases

2. There are heavy komordibitas with a short life expectancy

3. Curative therapy fails

4. Very advanced age

Palliation complaint must include:

1. Lokoregional

a. Ulcers in the mouth or neck

b. Painful

c. Difficulty eating, drinking, swallowing

d. Halitosis

e. Anorexia

f. Oro-cutaneous fistula

2. Systemic

a. Painful

b. Cough

c. Breathless

d. Weight decreased

e. Inarticulate

f. Weakness

The Main therapy

1. Without distant metastases, radiotherapy with a dose of 5000-7000 rads, if necessary, in combination with surgery

2. There are distant metastases, chemotherapy

Chemotherapy to do is

a. Epidermoid carcinoma of drugs that can be used: cisplatin, methotrexate, bleomycin,
     Cyclophosphamide, adryamycin with remission rate of 20-40% for example

a). A single drug: metrotrexate 30 mg / m2 2xseminggu

b). Drug combinations: V: vincristine: 1.5 mg / m2 hl

B: Bleomycin: 12 mg / m2 repeated every 2-3 weeks hl

M: Metrotrexate: 20 mg / m2 h3, 8

b. Adenocarcinoma: drugs that can be used include: Flourouracil, Mithomycin-C, Ciplatin, Adyamycin, with a remission rate of 20-30%. For example:

a). A single drug: Flourouracil beginning dose: 500 mg / m2 dose of maintenance: 20 mg / m2 every 1-2 weeks

b). Drug combinations: F: flourouracil: 500 mg / m2 h1,8,14,28 A: adryamycin: 50 mg / m2 repeated every 6 weeks h1,21 M: Metrotrexate: 10 mg / m2 h1

If you need additional therapies: surgery, chemotherapy, radiation therapy complications

1. Pain; analgesic in accordance with the "Step Ladder WHO"

2. Shortness of breath; tracheostomy

3. Difficult to eat; gastrostomy

4. Infection; antibiotics

5. Halitosis; mouthwash

Therapeutic assistance

1. good nutrition

2. vitamin

Secondary treatment

If there is a secondary disease, the appropriate therapy the disease in question Leukoplakia / erythroplakia account the factors causing exfoliative cytology (papnicoleau) Class 1 Class II Class III Class IV Class V 3 months Replay cytologic biopsy When two replications cytology results remained Class I -III Suspect carcinoma of the oral cavity, N0, M0 <> 1 CM Biopsy excisional incisional biopsy (wide excision) malignant non-malignant Operable inoperable / Not Radical Radical excision doubt T1 T2 T3 Kemoth / and or radoth / Re-excision / radioth / wide excision of local wide excision preoperative Radioth / local deseksi neck kgb selektivadioth / lokoregional operable inoperable morbidly radical radical radioth / lokoregional + sitostatika Re excision / meta kgb (+) meta kgb (-) local Radith radioth / lokoregio T low T high grade grede + sitostatika radioth local radioth / lokoregional.

Procedure Follow Up

Schedule follow-up is recommended as follows:

1. in the first 3 years: every 3 months

2. in 3-5 years: every 6 months

3. after 5 years: every year up to a lifetime on annual follow-up, the patient should be examined fully, physically, x-thorax, liver ultrasound and bone scan to determine the patient completely free of cancer or not.

At follow-up is determined:

1. The long-life in years or months

2. Old cancer-free interval in years and months

3. The patient complaints

4. The general status and appearance

5. The status of the disease:

a. cancer free

b. metastases

c. residif

d. cancer arise or new disease

6. Complications of the disease

7. Measures or therapies that have been granted

1. Surgery

Surgery is recommended if not complete cosmetically disturbing. In the case does not allow a complete resection, the initial biopsy followed by chemotherapy is the right thing. The second surgery can be done in two different circumstances. In the case of complete remission seen, a second surgery was intended as a method to look at pathological response. In addition, a second surgery is intended to resect complete after definitive local therapy.

2. Chemotherapy

Prior to the combination therapy, surgery alone generates resistance rate <20%. The development of therapies have increased survival of patients is about 60%. Materials used in chemotherapy is vincristine (V), aktinomisin D (A), doksurubisin (Dox), cyclophosphamide (C), ifosfamide (I), and etoposide (E), VAC has been the gold standard for the combination chemotherapy in the treatment of tongue cancer ,

3. Radiotherapy

Radiotherapy plays an important role in the treatment of tongue cancer. Radiotherapy is an effective method for achieving local control of tumor for patients with microscopic residual disease or large after biopsy, initial surgical resection, or chemotherapy. The recommended initial dose is 5,500 to 6,000 CG ƴ to control the area of ​​primary tumur (Manuaba, 2010).

Management

Management varies with the nature of the lesion, the way chosen physician, and patient selection:

1. Small lesions (T1, T2) main treatment is surgery and radiotherapy.

Radiotherapy may memberiikan curative results at T1 and T2 lesion with preservation of anatomical structures and functions normally. However, radiotherapy often lead to complications such as tongue edema requiring tracheostomy, xerostomia, dysgeusia and osteoradionecrosis, this has resulted in less desirable action (Suyanto, 2010).

2. Surgical treatment

On the tongue cancer is wide excision with tumor-free incision limits (frozen section confirmation). This action requires partial glosectomy and generally good postoperative function. Local control for 5 years was 85% in T1 and T2 is 80%. At T3 and T4 primary treatment is surgery. Results can only be achieved invitation curative en bloc resection of the tumor and complete of all of the tissues surrounding the tumor-free by microscopic incision. RND (Radical Neck Dissection) should be made on positive clinical N, RND is the removal of lymph nodes of the neck level I to V, musculus ternokleidomastoid, internal jugular vein, and nerve accessories (en bloc). Limit dissection, the superior is musculus trapezius, anterior lateral edge musculus is sternohiod and limit the inside is cervical fascia that covers the musculus levator scapulae and scalenus. SND (selective neck dissection) is done at the level of 1-3 N0 SND should be done by the high incidence of occult metastatic cervical lymph nodes. SND is the removal of lymph nodes at a certain level at high risk of metastasis by maintaining assesorius nerve, internal jugular vein and sternocleidomastoid musculus. Surgery gives curative better than radiotherapy and allows for evaluation of pathology prognostic factor. Sometimes needed immediate reconstruction (myocutaneous flap or free flap vacular) to maintain the function and cosmetic (Suyanto, 2010).

Surgical resection of oral cancer include mandibulectomi partial or total hemiglossectomi glossectomi, and resection of the base of the mouth to the buccal mucosa. Surgical procedures include surgical removal of the neck muscles of the neck with the other, the internal jugular vein, thyroid, submandibular gland, and additional spinal nerve. Handling patients suffering from oral cancer is managed by the whole health team. References to speech therapy, occupational therapy, psychologists, and dietitians is very important because it deals with issues that may arise from these verbal communication, chewing, and swallowing which brought changes in appearance and self-esteem. (Lukito, 2010).

Prognosis

Small tongue carcinoma without lymph node metastasis was good. However, when there is metastasis to lymph prognosis worsens. For T1 and T2 lesions of the average 5-year disease free survival was 80-90% with curative therapy. The average 5-year survival for stage III and IV is 30-50%. Metastasis to the lymph nodes of the neck decrease 15-30% survival. Fatherly evaluation of prognosis and treatment outcomes are better, some research attention to growth factors and tumor markers. Over expression of EGFR (epidermal growth factor) which is very useful for predicting therapeutic outcome and survival (Suyanto, 2010).