Surgical and non surgical treatment

OBJECTIVES This contribution aims to update the dentist on some important knowledge about cancer of the mouth, particularly on the surgical, medical and radiotherapy treatment in a multidisciplinary approach. MATERIALS AND METHODS The material reported here represents the most up-to-date data on the subject, in a sort of a summary of the indications found in the medical literature and the experience of operators engaged on a daily basis in the treatment of head and neck cancer patients. RESULTS As already reported in the previous Modules of this ECM Course, the neoplasms of the head and neck area, and of the oral cavity in particular, represent aggressive diseases, burdened by 50% of loco- regional recurrences or distant metastases. For this reason, their treatment requires an initial collaboration between surgeon, oncologist and radiotherapist. Moreover, there are many other figures who play a crucial role in the overall management of these patients. The choice of the optimal treatment option, in the single patient, has recently become more difficult in consideration of the different possibilities that derive from the advances in surgery, radiotherapy and medical treatment: only a multidisciplinary approach is able to offer the right treatment in the right patient. It is now widely known that carcinoma of the posterior third of the tongue that is HPV-positive (Human Papilloma Virus, HPV) has a better response to treatment if radiotherapy is provided, and better overall survival when compared with HPV-negatives case. Radiotherapy (RT) has become an integral part of the multidisciplinary approach and frequently accompanies the fundamental therapeutic strategy still represented by surgery. The adoption of Intensity Modulated Radiation Therapy (IMRT) has reformed the approach to oral cancer. IMRT has been shown to improve accuracy towards tumor tissue, reducing the involvement of surrounding healthy tissues, leading to lower general toxicities. Surgical intervention in the most advanced cases always requires large excisions followed by reconstructions with loco-regional flaps or free microvascular flaps. It is always necessary, when anatomicalpossibilità ly possible, to provide a margin of at least 1 cm of clinically healthy tissue and, in any case, intraoperative sections of frozen tissue allow to obtain confirmation of free margins. The optimal reconstructive option is represented by free microvascular flaps, which offer the best results obtainable in relation to speech and swallowing functions. With regard to medical therapy, cetuximab is one of the few drugs authorized for use in head-neck neoplasms. It is a monoclonal antibody, targeting Epidermal Growth Factor Receptor (EGFR), whose efficacy when used alone is rather modest. Other agents, such as cisplatin or 5-fluorouracil, which interfere with cell division, often used in combination with cetuximab increase responses. CONCLUSIONS The function of the multidisciplinary team in head-neck tumours is to bring together different healthcare professionals whose goal is to improve the prognosis and quality of life of patients. There are numerous clinical researches that testify to the advantages of this approach. Surgeons, radiotherapists and oncologists must be involved but also other figures (speech therapists, dieticians, psychologists, dentists… whose role will be described in the next Module). CLINICAL SIGNIFICANCE Only a multidisciplinary approach, with a careful initial assessment of the stage of the disease and of the psycho-physical conditions of the patient, is able to obtain the best possible results in the case of malignant neoplasms of the oral cavity and of the head-neck district.