Principles of surgery in recurrent oral cancer

Gopal Iyer, MD PhD, FRCS

Acting Chair, Division of Surgical Oncology
Chief, Head and Neck Surgery
 Disclosures
• Advisory board, Invitrocue
• “Centre of excellence program”, Johnson & Johnson
• Licensing of patent PCTSG2016-050231 to Vivo Surgical
• Spouse, Ad hoc advisory board, Astra Zeneca
 Oral squamous cell cancers
• Prompt diagnosis and accurate staging
• Management priorities in head and neck cancer
– Eradication of disease with prevention of recurrence and prolongation
of survival
– Preservation of function (speech, swallowing, voice, shoulder) and
cosmesis
• Multi-disciplinary setting

Iyer NG et al, Nat Rev Clin Oncol 2018

 Oral squamous cell cancers
• General guidelines:
– Stage I and II cancers: single modality therapy
– Stage III and IV cancers: multimodality treatment combining surgery,
followed by radiation therapy +/- chemotherapy
• Mainstay of curative treatment should be SURGERY
– Primary- wide resection
– Cervical lymph nodes- neck dissection  elective vs therapeutic
• Radiation therapy (+/- chemo) is second choice: Iyer NG et al, Cancer 2015
– Lack of expertise
– Medical contraindication
– Patient’s will
 Recurrent oral cancers
• Essential to diagnose early and institute aggressive treatment
• Recurrent disease is often more difficult to treat than the
original lesion
– Biologically aggressive, potentially radiation-resistant.
– Lack of a fixed pattern of spread
– Limitation of treatment options:
• Patients who have undergone prior irradiation, now have limitations in re-
irradiation dose, field, and greater toxicities.
• Technical difficulties operating in a previously irradiated or operated field
• Higher complication rates associated with salvage surgery
• Frequent need for reconstruction
 Recurrent oral cancers
• Early diagnosis is essential
• 80% of recurrences occur within the first 2 years after initial therapy
• Most guidelines recommend surveillance ranging from 1-3
months for first 2 years, depending upon the presenting stage
and the expected risk for recurrence
• Imaging
– inaccessible to physical examination, not amenable to palpation
(fibrosed neck) or visualization
– CT or MRI
– PET scan
 Surgery for recurrent oral cancers
• Multi-disciplinary approach is critical
• Depends on several factors:
– Extent of tumor
– Previous treatment modalities used
– Patient co-morbidities and fitness to undergo aggressive therapy
– Expertise available eg plastics expertise impacts on and flap choice for
use in reconstruction
 Patterns of disease failure
• Related to original stage and treatment rendered

• Primary site or local failure

SURGERY
• Regional or lymph node recurrence
• Distant metastasis
 Primary site or local failure
• Occurs in 20-30% of all patients
• Post-surgery - usually at margins of resection or areas with
devoid of normal fascial barriers (eg tongue musculature)
• Post-radiation - usually at the epicenter of the tumor where
cells are hypoxic, or regions which are inadequately radiated
due to technical errors or marginal misses
 Primary site or local failure
• Risk factors:
– Positive surgical margins
– Perineural and lymphovascular invasion
– Depth of invasion
– Subsite of disease
• Eg buccal cancers have a higher propensity to recur locally than floor of
mouth cancers – treatment related?
 Case 1
• 45 y.o. male presented with painless left tongue mass
• 3 cm tumor left anterior tongue, mobile
• No cervical lymphadenopathy was palpable.
• Initial staging T2N0M0
• SURGERY: partial glossectomy and SOHD
• Represented 9 months later with:
– worsening pain, trismus and ankyloglossia
– left lateral tongue mass extending to the floor of mouth,fixed to the
lingual surface of the lower gingiva / mandible and to midline
– No overt cervical lymphadenopathy
Physical exam
Imaging- MRI
Imaging- PET/CT
 Surgery
• Staged as rT4N0M0
• Rule out distant mets
• Discussed at MDT
• Surgery:
– Segmental mandibulectomy
– Comprehensive neck dissection
– Free ALT flap reconstruction
Surgery
Surgery
Surgery
 Principles of surgery for primary site recurrence
• Aggressive approach
• Margins need to be wide, especially within the tongue
musculature- 2 cm soft tissue margins
• Need for wide margins may necessitate resection of adjacent
structures
• Frozen section examination is often used to assess
intraoperative margins
• Concept of compartment resection
Compartment resection for oral cancers- tongue
Compartment resection for oral cancers- RMT/buccal
Compartment resection for oral cancers- RMT/buccal
Compartment resection for oral cancers- RMT/buccal
 Principles of surgery for primary site recurrence
• Reconstruction
– Like for like where possible
– Soft tissue is priority
– Free flap preferred (ALT workhorse)
– Pect major is life-saver
• Appropriate treatment for the neck
– Comprehensive dissection or convert selective to comprehensive
 Regional or lymph node recurrence
• Occurs in 10-15% of patients
• ?failure to adequately treat nodal basin during primary
treatment
• Redirected / abnormal lymphatic flow following prior therapy
may lead to unpredictable patterns of spread outside of the
treated field
• More likely with aggressive disease that traverses tissue
planes (eg extra-capsular spread of nodal disease)
 Regional or lymph node recurrence
• Risk factors:
– Higher number of metastatic nodes
– Larger size of metastatic focus
– Contralateral nodal disease vs. Ipsilateral nodal disease
– Extracapsular spread
– Level of spread: metastases to second and third echelon of nodes
worse outcome than first echelon nodes
• Outside treatment field:
– Parotid, level 2B, occipital, low level 4, central compartment
– contralateral
 Case 2
• 58 y.o. male smoker presented with right buccal cancer T2N1
– 2.5 cm level 2 node, irregular margin
• Radiotherapy to primary site and right neck at outside
institution
• Represented 14 months later with:
– Right neck mass
Physical exam
Imaging- CT
 Surgery
• Modified radical neck dissection
• Clear level 1-5
• Be radical
• Preserve only if possible
• Single transverse incision
preferred
Surgery- plastysma with node
Surgery- SAN
Surgery-SAN
Surgery-IJV
Surgery-IJV
Surgery
 Principles of surgery for nodal recurrence
• Comprehensive neck dissection:
– Post RT- levels 1-5
– Previous surgery- remaining levels
• No role for selective neck dissection
• Aggressive approach:
– Adjacent structures: SCM, IJV, spinal accessory nerve
– Others: external carotid, hypoglossal, phrenic, vagus
– Remove previous scar
– Other muscles
• Carotid sheath is a clean plane
 Principles of surgery for nodal recurrence
• Skin coverage where necessary
– Free or pedicled flaps
• Consider contralateral neck
– Level 1 involvement
– Primary tumor crossing midline
• Other tips and pearls:
– nerve monitoring for vagus
– marking suspicious sites with liga clips
– Number of nodes harvested
– Get to the carotid sheath
 Summary
• Essential to diagnose early and institute aggressive treatment
• Recurrent disease more difficult to treat than original lesion
• Surgery is only curative option
– Technical difficulties operating in a previously operated/ irradiated
field related to tissue fibrosis and impaired wound healing
• Flap reconstruction may be essential
• Adjuvant therapy including re-irradiation
– Get involved in RT planning
Thank you
gopaliyer@nccs.com.sg