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Treatment outcomes and complications  

Oral cancer is a malignant disease that spreads to the locoregional areas via infiltration and lymphatic spread. Most patients with oral cancer die due to uncontrolled disease. Hence locoregional control of disease is very important. Local forms of treatment like surgery and radiotherapy play an important role in the management of these tumours.

Early stages (I and II) are managed by surgery or radiotherapy, which give almost equal results. The choice of treatment is influenced by various factors such as clinical appearance of the tumour (exophytic vs infiltrative), site and size of tumour, age, other associated illnesses, expertise and treatment infra structure available, functional and cosmetic outcome of treatment, and patient desire. The management of the neck depends on the chance of having occult disease in the regional nodes. Advanced stages are managed by combined modality of treatment involving surgery and radiotherapy. Chemotherapy is increasingly being used along with radiotherapy for organ preservation and avoiding surgery, but without compromising on survival. A recent meta analysis showed 4.4% absolute benefit at 5 years for chemotherapy when added to locoregional treatment in advanced head and neck cancers . However, this benefit decreases with increasing age. Chemotherapy alone is sub-optimal and should never be resorted to for curative treatment of head and neck cancers. It is considered mainly for palliation of symptoms in advanced incurable tumours.

Radiation therapy for oral cancers can be external beam therapy or interstitial therapy. Small superficial tumours can be treated with local interstitial brachytherapy alone. Larger tumours are generally managed with external beam radiotherapy to cover primary tumours along with regional nodes, even if they are not clinically involved. Interstitial treatment can be used as a boost to a large primary lesion or bulky node for better locoregional control.

Early superficial lesions of the oral cavity can be managed by wide excision. If regional nodes are involved, or if the chance of having occult nodal disease is high (thick infiltrating lesions of tongue or floor of mouth), cervical node dissection is carried out in continuity with primary resection. The need for post-operative radiotherapy is based on the histopathological evaluation of the resected specimen. Large tumours require proper reconstructive methods and prosthodontic rehabilitation to ensure the best possible quality of life. Both modalities, surgery or radiotherapy, produce 70–90% cure rates in early lesions with no regional lymphnode involvement.

Indications for post-operative radiotherapy:

• Positive resected margin
• Multiple involved nodes
• Extracapsular extension
• Perineural spread
• Lymphovascular emboli
• Locally advanced tumour regardless of margin

If postoperative radiotherapy is indicated, it should be given as early as possible after the wound has healed properly. Any delay in starting radiotherapy beyond 6 weeks following surgery will adversely affect the locoregional control of the tumour.

For patients with advanced disease (Stages III & IV), combined modality treatment is recommended. Patients without gross bone involvement can be managed with chemo-radiotherapy and surgery reserved for residual/recurrent disease, or by surgery and post-operative radiotherapy. Chemotherapy can be given before (induction or neoadjuvant) or during radiotherapy (concurrent or concomitant). Studies have shown that concurrent chemradiotherapy is superior to induction chemotherapy and radiotherapy(167). Chemotherapy, when given following locoregional treatment (surgery and/or radiotherapy), is called adjuvant chemotherapy. However, this does not have a major role in the management of head and neck cancers including oral cancer. In advanced disease with gross bone involvement, surgery and radiotherapy is preferred. The control rate in advanced cancers is around 40%.

Side Effects of Radiotherapy:

Side effects of radiotherapy are broadly classified into acute, occurring during or immediately following the treatment, and late, occurring six months later. Acute reactions are self-limiting and generally resolve within 2-3 weeks.

Acute effects:

These reactions are due to the inflammation of the tissues within the radiotherapy field. Alteration of taste, pain, difficulty in taking food, mucosal ulceration of the oral cavity, superadded bacterial and fungal infections, increased thickness of saliva, discolouration of the overlying skin and desquamation, epilation within the field of treatment and oedema of the skin are the major side effects. During treatment the skin within the radiotherapy field will become inflamed and may break down with even minor trauma. Scratching, rubbing the skin with a rough cloth and application of irritants should be avoided. The skin should be kept dry. Maintenance of good oral hygiene, frequent cleaning of the oral cavity with soda-saline solution, analgesics and control of infection are recommended for conservative management of these side effects. Good hydration, high calorie diet and avoidance of spicy and hot food are recommended.

Late effects:

This is the dose limiting toxicity and generally occurs months or even years after treatment. This depends on dose per fraction, total dose and the type and volume of the tissue irradiated. This includes loss of hair within the irradiated area, xerostomia, subdermal fibrosis, dental caries and radionecrosis of the bone. Damage to critical organs like the spinal cord, brain stem, optic chiasm are extremely rare. With modern radiotherapy techniques the risks of developing injury to critical organs are extremely rare. Late complications of radiotherapy can be minimized by proper pre- and post-therapy dental care and continuation of good oral hygiene. Cholinergic agonists such as pilocarpine tablets and saliva substitutes are used for the management of xerostomia. Any traumatic dental procedures following radiotherapy should be done under antibiotic cover, and the periosteum should be sutured back to prevent osteonecrosis. If despite all efforts osteonecrosis does develop, it is managed conservatively using antibiotics, and surgical management is reserved only for progressive or persistent cases.

Complications of surgery:

The common complications of surgery are infection, hematoma, skin necrosis, flap failure and wound breakdown. Resorption of bone, osteomyelitis and salivary fistula can also occur. The incidence of complications increases following a simultaneous neck dissection. Fatal haemorrhage can occur if the carotid artery is exposed in the wound; hence proper covering of the artery with a muscle flap is advisable during the neck dissection. Resection of the structures can interfere with appearance and functions such as speech, swallowing and airway. These complications can be minimized through reconstructive surgeries and by good prosthetic rehabilitation.

Image	Caption
	Figure 1A: Advanced exophytic proliferative growth involving the whole left buccal mucosa, left side of both upper and lower lips and adjacent skin. Figure 1B: Picture of the same patient taken at the end of chemoradiotherapy showing confluent mucosal ulcerations of the oral cavity. C: Picture of the same patient taken 2 months after chemoradiotherapy.
	Figure 2: Osteoradionecrosis of left side of the mandible. Note the necrotic exposed area of the left mandible one year following radiotherapy for carcinoma of the left alveolus.
	Figure 3: Radiation mucositis of the left buccal mucosa 10 days after interstitial implantation.
	Figure 4: Acute radiation mucositis at the end of the radiotherapy treatment in a patient with carcinoma of the left buccal mucosa.
	Figure 5: Note the discharging sinus (arrow) on the left side of the lower jaw due to osteoradionecrosis in a patient who underwent surgery and radiotherapy four years earlier. There is no evidence of malignancy now.
	Figure 6: Osteoradionecrosis of right side of the mandible in a patient six years after radiotherapy.
	Figure 7: Dry desquamation of the skin (acute reaction) on the right side of the face of a patient undergoing external radiotherapy for carcinoma of right buccal mucosa.
	Figure 8: Dry desquamation (acute reaction) of the neck in a patient who recently completed radiotherapy treatment.
	Figures 9A and 9B: Ulceroproliferative growth involving the whole of the left buccal mucosa infiltrating the overlying skin. Figures 9C and 9D: Treatment response one month after radiotherapy. Figure E: Treatment response 3 years after radiotherapy.
	Figure 10: Acute radiation mucositis. Confluent yellowish mucosal ulcer seen on the left side of buccal muccosa in a patient who completed external beam radiotherapy for a carcinoma of the left buccal mucosa.