Updated: May 2003
Squamous Cell Carcinoma of All Sites Except Nasopharynx
Dysplasia and squamous cell carcinoma in situ
Precipating or aggravating factors should be removed and where possible the area excised with clear margins. Persistent mild dysplasia may be treated with topical Vitamin A acid gel 0.01-0.05% applied QID. Topical Bleomycin or laser excision may be used to treat mild to severe dysplasia. When the lesion is inaccessible or recurs repeatedly after apparently adequate surgical management and/or topical treatment, radiation therapy may be considered.
Early invasive squamous cell carcinoma T1-2 N0-1
Surgery and radiation therapy both offer a high chance of cure. Surgery is usually chosen for tumours of the mouth and oropharynx that can be resected with a good functional outcome. Radiation therapy is chosen for most laryngeal and pharyngeal tumours or when the patient declines surgery. If the tumour recurs following radiation therapy, most patients will still be eligible for resection.
Most of these patients can be cured by using a once daily radiation therapy schedule. If the tumour is more bulky then a twice daily schedule may be recommended.
More advanced tumours - T3-4 or N2-3
These patients require a multidisciplinary assessment prior to definitive treatment and referral to a regional cancer centre is strongly recommended. Some may be curable by surgery or radiotherapy alone, but most will require a combined modality approach such as radiation therapy followed by a neck dissection, or surgery followed by postoperative radiation therapy. In many cases, surgery is likely to require sophisticated reconstructive expertise.
Patients with larger, node negative tumours and other tumours with involved lymph nodes that are all in close proximity to the primary tumour, will usually be offered a twice daily radiation therapy schedule. Those with widespread lymphadenopathy will be offered a combined chemotherapy/radiation therapy regimen.
Patients presenting with distant metastases or unresectable recurrence
Treatment for these patients is not usually curative. Management must be tailored for each individual to provide the best chance of symptom relief and improved quality of life. Most patients will be considered for chemotherapy, many will also require palliative radiotherapy either to the primary tumour or symptomatic metastases.
Carcinoma of the nasopharynx T1-4,N1-3,M0
These tumours are treated with primary radiotherapy using either daily or twice daily radiotherapy or combined chemotherapy and radiation. Patients with more advanced disease are currently offered the chance to participate in an international multicentre clinical trial which is coordianted by the Hong Kong Nasopharyngeal Cancer Study Group.
Patients presenting with distant metastases
The principles are the same as those stated above for squamous cell carcinoma.
Benign and malignant tumours of major or minor salivary glands
The treatment of choice for all but the most advanced of these tumours is surgery. Unresectable tumours may be treated with radiotherapy and, where appropriate, patients with advanced tumours may referred for treatment with neutron irradiation which appears to be particularly effective for these tumours.
Surgery alone is sufficient for most salivary carcinomas, but patients with high grade salivary carcinomas should be offered postoperative radiotherapy. This may also be recommended for pleomorphic adenomas that have been incompletely excised.