Scottish Cancer Network: Clinical Management Pathways
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Offer flexible nasoendoscopy/EUA and biopsy.
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Restorative Dentistry - offer assessment and treatment prior to radical cancer treatment.
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Where surgical resection is likely to result in loss of teeth or impact on the wear of a prosthesis, primary dental implants, consider +- plan by a Consultant in Restorative Dentistry (CRD) in conjunction with the reconstructive team.
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Where surgical resection of the jaws is planned, use digital implant planning software to assess the feasibility and plan primary dental implants by the CRD. Carry this out in conjunction with the reconstructive surgical team and the maxillofacial prosthetic team. If surgical guides are to be used for composite resections and reconstructions, consider utilising this for the placement of primary dental implants.
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Where resection of facial skin, maxillectomy, rhinectomy or orbital exenteration is required, pre-surgical consultation with a Maxillofacial Prosthetist / Reconstructive Scientist is indicated in addition to Restorative Dentistry.
Oral cavity squamous cell cancer (SCC)
This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of the Clinical Management Pathway (CMP), taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
Primary surgery is the recommended definitive treatment for all resectable oral cavity SCC.
Margin status
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Offer wide local excision for small tumours to achieve R0 margin status and 5mm histopathological disease clearance. In the majority of scenarios this will require 1cm macroscopic resection in all dimensions. Reconstruction may be indicated but is usually not required.
Nodal staging
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Offer surgical staging of regional lymph nodes by selective neck dissection or sentinel lymph node biopsy is recommended for suitable patients who have more than early invasive/superficial SCC (defined as <2mm). Present the relative merits of both options to all suitable patients. Consider elective selective neck dissection including levels I-III for oral cavity SCC. Level IIb may be omitted depending on surgeon/patient preference. For posterior tumours consider including levels IIb and IV.
Non-lateralised N0
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Consider contralateral elective selective neck dissection for non-lateralised tumours (defined as oral cavity cancers within 1cm of midline, including those abutting the midline, or those with extension into the floor of mouth, base of tongue or palate). The associated swallowing morbidity and negative impact on options for subsequent reconstructive procedures should be considered.
Nodal surveillance
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Offer counselling to patients in relation to the options and risks of adopting a ‘watch and wait’ approach to management of the N0 neck which may be opted for in patients who place a higher value on avoiding neck surgery than on the survival advantage surgical staging offers.
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For loco-regionally advanced disease (T3/4 Nany or Tany N+) when multi-modality treatment (surgery then adjuvant (chemo) radiotherapy) is indicated, consider prior to initiating any management:
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- Balance long term control/cure with acute and late morbidity from treatment.
- Patient suitability and likelihood of completing whole package of treatment.
- Alternative non-curative options.
- Counsel patients carefully on all these factors prior to commencing radical treatment pathway.
Margin status
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Offer excision if likely to achieve R0 margin status and 5mm histopathological disease clearance. In the majority of scenarios this will require 1cm macroscopic resection in all dimensions. The necessity to preserve vital structures may preclude this in some zones of a 3-dimensional resection and preoperative imaging can assist with planning. Reconstruction is usually required, and free flap surgery is generally the standard of care.
Lateralised N0
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Offer ipsilateral elective selective neck dissection in the N0 neck in lateralised tumours of at least levels I-III and other nodal levels may be included based on the balance of risk and patient preference.
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Consider contralateral elective selective neck dissection (weighing up risk of contralateral microscopic nodal disease, risk of requiring/avoiding bilateral neck adjuvant radiotherapy, low success rate of salvage versus morbidity, impact on further reconstruction procedures and lack of evidence regarding survival advantage).
- Discuss with clinical oncology regarding adjuvant radiation volumes prior to committing to contralateral elective neck dissection. Whenever bilateral neck dissection is performed attempt to preserve the cervical plexus.
Non-lateralised N0
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Consider bilateral selective elective neck dissection for adequate staging in the N0 non-lateralised tumours weighing up the risk of microscopic disease and impact on outcome against the associated swallowing morbidity and the negative impact on options for subsequent reconstructive procedures (weighing up higher risk of contralateral microscopic nodal disease, risk of requiring/avoiding bilateral neck adjuvant radiotherapy, low success rate of salvage versus morbidity and impact on further reconstruction procedures).
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Discuss with clinical oncology regarding adjuvant radiation volumes prior to committing to contralateral elective neck dissection. Whenever bilateral neck dissection is performed attempt to preserve the cervical plexus.
N+ neck
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For the N+ neck, include at least levels I to IV in neck dissection of the involved side(s). Consider modified radical neck dissection for removal of structures directly invaded by tumour. When oncologically safe to do so, retain uninvolved structures (IJV, SCM, accessory nerve).
- When assessing patients with N+ neck disease, consider a radiological assessment of extra-nodal extension to inform the clinician and patient regarding feasible treatment options. This approach can assist with surgical planning to achieve R0 operative margins and likely need for adjuvant treatment, to fully assess patient fitness for treatment, and to counsel the patient in advance.
N+ neck: contralateral management
- Consider elective selective neck dissection of the contralateral N0 neck in ipsilateral N+ disease as there is an increased risk of contralateral node involvement. The associated swallowing morbidity and negative impact on options for subsequent reconstructive procedures should be considered. Discuss with clinical oncology regarding adjuvant radiation volumes prior to committing to contralateral elective lymphadenectomy.
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Consider definitive margin assessment on the basis of formalin fixed paraffin embedded surgical specimen and not frozen section findings. Consider performing in-continuity resection of the primary tumour with lymphadenectomy where extension of the former requires it to achieve R0 margin status. Consider submitting the in-continuity specimen to pathology orientated to allow accurate margin assessment. Submit neck dissection specimens orientated with levels carefully marked. Margin status of lymph node excision is prognostic and reported and ex-vivo division of lymphadenectomy specimens into constituent levels by the surgical team may preclude specimen orientation in the laboratory. Consider cervical lymphadenectomy including only those additional structures required to achieve nodal disease clearance with preservation of major vascular, neural, and muscular elements where oncologically safe to do so.
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Consider re-excision for involved margin at the primary site alongside considering any existing indications for adjuvant treatment.
Consider prior to initiating any management for salvage:
- Balance of chance of long term control/cure versus.
- Likely acute and late morbidity from additional treatment.
- Likelihood of requiring adjuvant treatment to achieve disease control/cure and patient suitability and likelihood to be offered this depending on patient factors and previous treatment.
- Alternative non-curative options.
Counsel patients carefully on all these factors prior to commencing salvage treatment pathway.
Salvage surgery is usually undertaken in the context of recurrent disease after primary surgery with or without adjuvant treatment.
- Patients with recurrent/persistent resectable disease at the primary site may be considered for salvage surgery in the absence of distant disease. Consider salvage surgery in the event of recurrence taking into account patient factors including age, co-morbidities, and preferences. Anticipate poor functional outcomes (speech and swallowing).
- Reconstructive flap surgery is usually required.
- Isolated regional recurrence in a previously untreated nodal basin should be treated with neck dissection and adjuvant therapy as indicated by final histopathology. Regional recurrence within previously treated nodal echelons have a low likelihood of salvage.
- Patients with relapse at the primary site as well as regional recurrence have a poor prognosis.
- Patients with a short disease-free interval have a poor prognosis
For patients not suitable for radical treatment consider debulking and/or discuss tracheostomy in event of airway crisis to elicit patient wishes and assist with advance care planning.