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REVIEW ARTICLE
Year : 2020  |  Volume : 57  |  Issue : 5  |  Page : 6-8
 

Indian clinical practice consensus guidelines for the management of oral cavity cancer


1 Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Department of Medical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, Karnataka, India
4 Department of Surgical Oncology, Cochin Cancer Research Centre, Cochin, Kerala, India
5 Department of Oral Medicine and Radiology, KLE Society's Institute of Dental Sciences (KLESIDS), Bangalore, Karnataka, India
6 Department of Radiation Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
7 Department of Medical Oncology, HCG Cancer Centre, Ahmedabad, Gujarat, India
8 Department of Radiodiagnosis and Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
9 Department of Radiation Oncology, Civil Hospital, Shillong, Meghalaya, India
10 Department of Medical Oncology, Indraprastha Apollo Hospital, New Delhi, India
11 Department of Radiation Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
12 Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Centre, Bangalore, Karnataka, India
13 Department of Medical Oncology, Rajiv Gandhi Cancer Institute & Research Centre, New Delhi, India
14 Department of Radiotherapy, Christian Medical College, Vellore, Tamil Nadu, India
15 Department of Surgical Oncology, Max Super Speciality Hospital, Saket, New Delhi, India
16 Department of Surgical Oncology, HCG Cancer Centre, Bangalore, Karnataka, India
17 Department of Radiation Oncology, Shri Mata Vaishno Devi Narayana Superspeciality Hospital, Jammu, Jammu and Kashmir, India
18 Department of Radiation Oncology, National Cancer Institute, All India Institute of Medical Sciences, Delhi, India

Date of Submission25-Jul-2019
Date of Decision13-Nov-2019
Date of Acceptance29-Dec-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.278975

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How to cite this article:
Chaturvedi P, Prabhash K, Babu G, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of oral cavity cancer. Indian J Cancer 2020;57, Suppl S1:6-8

How to cite this URL:
Chaturvedi P, Prabhash K, Babu G, Kuriakose M, Birur P, Anand AK, Kaushal A, Mahajan A, Syiemlieh J, Singhal M, Gairola M, Ramachandra P, Goyal S, John S, Nayyar R, Patil VM, Rao V, Roshan V, Rath G K. Indian clinical practice consensus guidelines for the management of oral cavity cancer. Indian J Cancer [serial online] 2020 [cited 2022 Nov 29];57, Suppl S1:6-8. Available from: https://www.indianjcancer.com/text.asp?2020/57/5/6/278975



 » Diagnosis Workflow for Evaluation of Clinical Stages Top


Routine examination includes history, physical examination, chest X-ray, and examination under anesthesia with endoscopy, if indicated. Computed tomography and/or magnetic resonance imaging (with contrast) of primary and neck and fluorodeoxyglucose-positron emission tomography/computed tomography (in selected cases of advanced stages) for stage III–IV diseased should be performed. Dental evaluation, nutrition, speech, and swallowing evaluation/therapy should be performed.[1] Pure tone audiometry may be performed prior to administering cisplatin[2] (evidence level [EL] 2 and EL 4; Grade A).


 » Treatment of Oral Cavity Cancer Top


Treatment primarily depends on the location, tumor size, and feasibility of organ preservation in patients with negative margins. The choice of treatment should be decided by the multidisciplinary team. In particular, surgery and radiotherapy (RT) are the recommended treatment options for early-stage and locally advanced resectable oral cavity cancer (OCC). However, surgery has a similar outcome in early-stage tumor but better outcome in locally advanced tumor; hence, it is the preferred modality in OCC. Organ preservation using systemic therapy is a less preferred choice of most panel members.

Localized OCC (T1–2, N0)

Surgery

Early-stage disease is generally treated using a single modality. In India, owing to the limited number of facilities for brachytherapy, surgery is the preferred choice of the treatment for oral cancers. Apart from that, Surgery (a single day procedure) allows RT as an option for treatment for the second primary tumor being available. Elective neck dissection in early oral cancers with clinical node-negative oral squamous-cell cancer has been shown to be beneficial than therapeutic neck dissection, as it offers decreased relapse rates and better survival rates.[3],[4],[5],[6] In patients with T1N0 or T2N0 stage OCC, resection of the primary tumor site ± ipsilateral/bilateral neck dissection and resection of primary tumor site ± sentinel lymph node (SLN) biopsy are the two alternative options for surgical therapy.[4],[5] To assess the presence of occult metastatic disease, SLN biopsy in early OCC is recommended.[7] Postsurgery in case of adverse features, adjuvant chemoradiotherapy (CTRT)/RT (EL 1; Grade A) is recommended.[8],[9]

Definitive RT

Selected patients, who are medically inoperable or refuse surgery, should be given a definitive RT, an alternative option for surgery. It can include conventional fractionation (66 Gy [2.2 Gy/fraction] to 70 Gy [2.0 Gy/fraction]; daily Monday–Friday in 6–7 weeks) (Grade A; EL 1) or concomitant boost accelerated RT (72 Gy/6 weeks [1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during last 12 treatment days]) (EL 1; Grade A).

Locally advanced OCC (T3, N0; T1–3, N1–3; T4a, N0–3)

Surgery

Studies have shown that patients who underwent surgery + concurrent RT and CT have better outcomes.[8],[9],[10] Patients with resectable cancer lesion should be treated with combined modality (surgery followed by RT/CTRT).

Adjuvant Treatment

The choice of adjuvant treatment should be based on the presence of adverse features post-surgery/neck dissection.[11] Among patients with extranodal extension, chemoradiation is recommended; among patients with positive margins, re-resection followed by RT is recommended if it is not feasible than CTRT is recommended; and in patients with other risk factors (pT3/pT4, N2/N3, nodes at IV or V, perineural invasion, lymphatic invasion, vascular embolism), RT or CTRT is recommended.[10],[12],[13] In patients with higher nodal disease burden (two or more lymph nodes positive), CTRT is preferred. Suitable adjuvant CTRT regimens are given in [Box 1].




 » Technically Unresectable Disease Top


Technically unresectable disease like edema up to zygoma, involvement of vallecula, disease close to hyoid or involving high infratemporal fossa above the sigmoid notch, neoadjuvant chemotherapy is the treatment of choice. Responder may go for surgery followed by CTRT and if no response then CTRT or RT or palliative treatment can be offered. Algorithm for management of OCC is given in [Figure 1]. Appendix 1 gives the summary of clinical evidences in OCC.
Figure 1: Algorithm for management of OCC

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Acknowledgement

We acknowledge the significant contribution of J Balawardana, C Vithanage, S Resnayaka from Sri Lanka during the meeting and S Ghosh Laskar, S Ranjan, P Chavan, R Halkud and C Ramachandra for their involvement and insights. We also acknowledge the medical writing support provided by an independent medical writing agency, IQVIA. We are fully responsible for the content of this manuscript and the recommendations described in the review reflect the views and opinions of the authors only.

Financial Support and Sponsorship

Oral Cancer Task Force (OCTF) with a multidisciplinary expert panel, has a long standing commitment to work for early detection and management of oral cancer in underserved populations. The task force members have taken this educational initiative of developing India specific consensus guidelines for management of head and neck cancer under its ambit. The meeting and supplement were supported by an unrestricted grant by Biocon Foundation.

Conflicts of interest

Oral Cancer Task Force (OCTF) members and authors do not have any conflicts of interest.

 
 » References Top

1.
National Comprehensive Cancer Network (NCCN). Guideline Version 2.2019. Head and neck cancers. Available from: https://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf. [Last accessed on 2019 Dec 01].  Back to cited text no. 1
    
2.
Kalyanam B, Sarala N, Azeem Mohiyuddin SM, Diwakar R. Auditory function and quality of life in patients receiving cisplatin chemotherapy in head and neck cancer: A case series follow-up study. J Can Res Ther 2018;14:1099-104.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Fasunla AJ, Greene BH, Timmesfeld N, Wiegand S, Werner JA, Sesterhenn AM. A meta-analysis of the randomized controlled trials on elective neck dissection versus therapeutic neck dissection in oral cavity cancers with clinically node-negative neck. Oral Oncol 2011;47:320-4.  Back to cited text no. 3
    
4.
D'Cruz AK, Vaish R, Kapre N, Dandekar M, Gupta S, Hawaldar R, et al. Head and neck disease management group. Elective versus therapeutic neck dissection in node-negative oral cancer. N Engl J Med 2015;373:521-9.  Back to cited text no. 4
    
5.
Massey C, Dharmarajan A, Bannuru RR, Rebeiz E. Management of N0 neck in early oral squamous cell carcinoma: A systematic review and meta-analysis. Laryngoscope 2019;129:E284-98.  Back to cited text no. 5
    
6.
Huang SF, Chang JT, Liao CT, Kang CJ, Lin CY, Fan KH, et al. The role of elective neck dissection in early stage buccal cancer. Laryngoscope 2015;125:128-33.  Back to cited text no. 6
    
7.
Liu M, Wang SJ, Yang X, Peng H. Diagnostic efficacy of sentinel lymph node biopsy in early oral squamous cell carcinoma: A meta-analysis of 66 studies. PLoS One 2017;12:e0170322.  Back to cited text no. 7
    
8.
Cooper JS, Pajak TF, Forastiere AA, Jacobs J, Campbell BH, Saxman SB, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med 2004;350:1937-44.  Back to cited text no. 8
    
9.
Cooper JS, Zhang Q, Pajak TF, Forastiere AA, Jacobs J, Saxman SB, et al. Long-term follow-up of the RTOG 9501/intergroup phase III trial: Postoperative concurrent radiation therapy and chemotherapy in high-risk squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys 2012;84:1198-205.  Back to cited text no. 9
    
10.
Bernier J, Cooper JS, Pajak TF, van Glabbeke M, Bourhis J, Forastiere A, et al. Defining risk levels in locally advanced head and neck cancers: A comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (# 9501). Head Neck 2005;27:843-50.  Back to cited text no. 10
    
11.
Noronha V, Joshi A, Patil VM, Agarwal J, Ghosh-Laskar S, Budrukkar A, et al. Once-a-week versus once-every-3-weeks cisplatin chemoradiation for locally advanced head and neck cancer: A phase III randomized noninferiority trial. J Clin Oncol 2018;36:1064-72.  Back to cited text no. 11
    
12.
Fan KH, Chen YC, Lin CY, Kang CJ, Lee LY, Huang SF, et al. Postoperative radiotherapy with or without concurrent chemotherapy for oral squamous cell carcinoma in patients with three or more minor risk factors: A propensity score matching analysis. Radiat Oncol 2017;12:184.  Back to cited text no. 12
    
13.
Bernier J, Domenge C, Ozsahin M, Matuszewska K, Lefèbvre JL, Greiner RH, et al. Postoperative Irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med 2004;350:1945-52.  Back to cited text no. 13
    


    Figures

  [Figure 1]

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