The Society of Surgical Oncology surgical practice guidelines focus
on the signs and symptoms of primary cancer, timely evaluation of the symptomatic
patient, appropriate preoperative evaluation for extent of disease, and
role of the surgeon in diagnosis and treatment. Separate sections on adjuvant
therapy, follow-up programs, or management of recurrent cancer have been
intentionally omitted. Where appropriate, perioperative adjuvant combined-modality
therapy is discussed under surgical management. Each guideline is presented
in minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aim of
the Society, the extensive development cycle necessary to produce evidence-based
practice guidelines did not apply. We used the broad clinical experience
residing in the membership of the Society, under the direction of Alfred
M. Cohen, MD, Chief, Colorectal Service, Memorial Sloan-Kettering Cancer
Center, to produce guidelines that were not likely to result in significant
Following each guideline is a brief narrative highlighting and expanding
on selected sections of the guideline document, with a few relevant references.
The current staging system for the site and approximate 5-year survival
data are also included.
The Society does not suggest that these guidelines replace good medical
judgment. That always comes first. We do believe that the family physician,
as well as the health maintenance organization director, will appreciate
the provision of these guidelines as a reference for better patient care.
Symptoms and Signs
- Early-stage disease
- Persistent sore in the oral cavity
- Swallowing difficulty
- Lesion discovered as an incidental finding on routine oral examination
- Pain and ulceration in the mouth
- Advanced-stage disease
- Pain, especially referred to the ear
- Slurred speech
- Difficulty in swallowing
- Neck mass
Evaluation of the Symptomatic Patient
- Examination of the head and neck, oropharynx
- Flexible laryngoscopy
- Punch biopsy in the office
- Biopsy, followed by examination under anesthesia to determine the stage
and extent of the disease, if office evaluation is unsatisfactory
- Appropriate timeliness of surgical referral
- Follow evaluation as described above (in patients having symptoms or
signs of early or advanced disease as soon as possible)
Preoperative Evaluation for Extent of Disease
- Physical examination
- Chest x-ray
- Panoramic x-ray of the mandible
- CT scan of head and neck
- Early stages
- T1 and T2 lesions of the oropharynx (base of the tongue, tonsillar
fossa, soft palate, pharyngeal wall) should be treated with radiotherapy
- Most T1 and T2 tumors of the oral cavity should be treated with surgery.
- Advanced stages (III and IV)
- Multimodality therapy indicated. Most T3 and T4 lesions should be treated
with planned surgery and radiation, with emphasis on primary reconstruction.
T3 exophytic tumors may be treated with radiotherapy alone.
- Surgical approach and exposure may be difficult.
- External radiation therapy coupled with interstitial implant (brachy-therapy)
to the base of tongue has shown control rates equal to those of surgery.
Appropriate selection is very important.
These guidelines are copyrighted by the Society of Surgical Oncology
(SSO). All rights reserved. These guidelines may not be reproduced in any
form without the express written permission of SSO. Requests for reprints
should be sent to: James R. Slawny, Executive Director, Society of Surgical
Oncology, 85 West Algonquin Road, Arlington Heights, IL 60005.
Approximately 39,750 new patients with tumors of the oral cavity (encompassing
the lip, buccal
mucosa, alveolar ridge and retromolar trigone, anterior two thirds of the
tongue, hard palate, and floor of the mouth) or oropharynx (including the
base of the tongue, tonsillar pillar and fossa, and soft palate) are seen
every year, and 8,440 patients die from these cancers. However, tumors
of the oral cavity alone are diagnosed in approximately 19,000 individuals
and account for 4,200 deaths. The tongue is the most frequent site of tumor
in the oral cavity, with an incidence of 5,550 patients per year
The most common etiologic agents are smoking and alcohol. Consumption
of betel nuts, which is very common in Southeast Asia, especially India,
has also been implicated. Other possible etiologic agents include chronic
irritation, ill-fitting dentures, and a history of syphilis.
The most common symptom related to cancer of the oral cavity is persistent
soreness. In other cases, such a lesion is found incidentally on routine
oral examination. Pain referred to the ear, slurred speech, difficulty
in swallowing, a neck mass, or occasionally in advanced cases, trismus,
are also clues to the diagnosis.
The work-up of a patient with a suspected oropharyngeal or oral cancer
includes a complete head and neck examination. Biopsy of a suspicious lesion
can be performed under local anesthesia
Preoperative evaluation should include indirect laryngoscopy and a chest
x-ray. A CT scan is indicated only for evaluation of an extensive cancer.
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