Oral Cavity Cancer

Routes of Spread

  • similar risk of metastasis to the submandibular nodes (Ib) as to the mid-jugular nodes (II)

Treatment of the Cancers of the Oral Cavity

Primary Therapy (Surgery in General)

T1 or T2, N0

  • Surgical resection +/- unilateral or bilateral selective neck dissection
  • Definitive Radiation

T3, N0

  • Excision of primary and unilateral or bilateral selective neck dissection

T1-3 with N1-3

  • Excision of primary and unilateral or bilateral selective neck dissection

T4a and any N

  • with bone invasion, Surgical resection
  • without bone invasion, concurrent chemoradiation

Post Operative Therapy

Minor risk features:

  • pT3 or pT4 primary;
  • N2 or N3 nodal disease,
  • nodal disease in levels IV or V,
  • perineural invasion,
  • vascular embolism.

Major risk features:

  • positive margins
  • extracapsular nodal spread.


  • One minor risk feature: RT alone
  • One or more major risk features, or 2 or more minor risk features: Chemoradiation

Treatment of Oral Tongue

T1 and superficial T2

  • Surgery and RT are equally effective

RT Techniques

  • 50 Gy EBRT + 25 Gy Interstitial implant boost with Ir-192 afterloaded into angiocaths.
    • needles are inserted free-hand or with template at 1 cm apart.
    • if tumor get too large or close to mandible risk of osteoradionecrosis increases.
  • EBRT + Intraoral cone boost
  • interstitial implant alone (75 Gy)
  • EBRT alone suboptimal

Large T2 and T3

  • Partial glossectomy followed by postoperative RT


  • Total glossectomy and adjuvant RT
  • Pre-op RT may be given to unresectable tumors

Floor of the Mouth

T1 and small T2

  • Highly curable by surgery or irradiation
  • When radiation is used for early disease, it has been shown that results are improved when at least a portion of the treatment is delivered by an interstitial implant
  • Very small superficial lesions can be treated with interstitial implant 60-65 Gy or intraoral cone 45 Gy in 15 fractions.
  • T1 and early T2 treated with EBRT
    • 45 Gy EBRT + 25 Gy implant
    • 45 Gy EBRT + 20 Gy intraoral cone

T1 and small T2 that is Fixed or tethered to mandible

  • resection of the inner table with reasonable speech and swallowing
  • Lesions that abut or are tethered to the periosteum of the mandible are not good candidates for primary radiotherapy. Implants against the mandible can lead to osteonecrosis.

Advanced Disease

  • combined therapy of surgery and radiation is the treatment of choice.
  • Surgical resection
    • partial glossectomy and segmental mandibulectomy.
    • identify the inferior alveolar nerve to negative surgical margins by perineural spread.
    • Resection generally require removal of the entire thickness of the floor of mouth.
  • Radiation
    • Postoperative radiation entails doses in the range of 6000 to 6300 cGy at the primary site.
    • In instances of positive surgical margins, our policy is to treat the area of positive margins to 6300 cGy.
    • Certain patients with positive margins may be treated with adjuvant brachytherapy instead of external beam
  • Chemotherapy
    • Neoadjuvant chemotherapy reduces mandibuectomy or radiation therapy for resectable T2 to T4, N0 to N2, M0. [4]
  • Neck
    • Elective and/or therapeutic neck dissections are considered necessary in each case.
    • Bilateral neck dissections are indicated for those lesions which approach or cross the midline.

Referred Pain

1. Cox J, Ang K. Radiation Oncology: rationale Technique Results. 8th ed. New York: Mosby, 2003.
2. Gunderson L, Tepper J: Clinical Radiation Oncology. 2nd ed. China: Elsevier 2007.
3. Devita V, Hellman S, Rosenberg S: Cancer: Principles and practice of Oncology. 7th ed. Philadelphia: Lippincott, 2005.
4. Licitra L, Grandi C, Guzzo M, Mariani L, Lo Vullo S, Valvo F, Quattrone P, Valagussa P, Bonadonna G, Molinari R, Cantù G. Primary chemotherapy in resectable oral cavity squamous cell cancer: a randomized controlled trial. J Clin Oncol. 2003 Jan 15;21(2):327-33.
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