Oral Cavity Cancer Management

Initial Workup and Staging

Clinical examination with rigid head and neck endoscopy under general anesthesia is mandatory for all patients, as per the Annals of Oncology guidelines 1, 2
Contrast-enhanced CT and/or MRI of the head and neck is required to assess primary tumor extent and depth of invasion (DOI) 1, 2
Chest imaging with CT and/or FDG-PET is necessary to evaluate for distant metastases 1, 2
Pathological confirmation via biopsy is required before initiating treatment, as recommended by the Annals of Oncology 1
Endoscopic ultrasound is an option if early-stage disease is suspected, according to the Journal of the National Comprehensive Cancer Network 3
Pre-treatment assessment must include nutritional status with weight assessment, as per the Annals of Oncology guidelines 1, 4
Dental examination with rehabilitation planning is necessary if radiotherapy is anticipated, as recommended by the Annals of Oncology 1, 4
Cardiopulmonary and renal function evaluation is required, according to the Annals of Oncology 4
Performance status and comorbidity assessment is necessary, as per the Annals of Oncology guidelines 2, 4
Speech and swallowing function baseline is required, as recommended by the Annals of Oncology 2
If weight loss exceeds 10% in the 6 months before diagnosis, enteral nutrition via percutaneous gastrostomy should be initiated before starting treatment, according to the Annals of Oncology guidelines 1, 4

For early-stage oral cavity cancer, surgery is the primary treatment modality, with adjuvant therapy determined by pathologic risk factors, as per the Annals of Oncology guidelines 1
Wide local excision with 1 cm clinical margins is recommended for early-stage disease, as per the Annals of Oncology guidelines 1
Pathologic margins must achieve ≥5 mm clearance when possible, according to the Praxis Medical Insights guidelines 5
Depth of invasion (DOI) determines neck management, with DOI <5 mm and cT1N0 requiring active surveillance of the neck, as per the Annals of Oncology guidelines 1
For well-lateralized tongue tumors, ipsilateral selective neck dissection (levels I-IV) is appropriate, according to the Praxis Medical Insights guidelines 5
External beam radiotherapy or brachytherapy can be used as an alternative to surgery for selected stage I subsites, as per the Annals of Oncology guidelines 1
For locally advanced disease, surgery followed by risk-adapted adjuvant therapy is the standard approach, as per the Annals of Oncology guidelines 1, 6
Postoperative radiotherapy or chemoradiotherapy must begin within 6-7 weeks of surgery, with the entire treatment sequence completed within 11 weeks, as recommended by the Annals of Oncology guidelines 6, 9

Surgical specimens must be evaluated for tumor size and growth pattern, as per the Annals of Oncology guidelines 2, 4
Depth of invasion (DOI) is critical for oral cavity staging, as per the Annals of Oncology guidelines 1, 2
Total number of lymph nodes removed and number involved must be evaluated, as recommended by the Annals of Oncology guidelines 1, 2
Presence of extracapsular extension must be assessed, as per the Annals of Oncology guidelines 1, 2
Perineural and lymphatic infiltration must be evaluated, as recommended by the Annals of Oncology guidelines 1, 2
Surgical margin status (R0, R1, or R2) must be assessed, as per the Annals of Oncology guidelines 1, 2

Treatment depends on prior therapy and PD-L1 status, as per the Annals of Oncology guidelines 6, 8, 9
For PD-L1-positive tumors, pembrolizumab monotherapy is recommended, with a median OS of 12.3-14.9 months, as per the Annals of Oncology guidelines 6, 8, 9
For PD-L1-negative tumors, pembrolizumab plus platinum/5-FU is recommended, with a median OS of 13 months, as per the Annals of Oncology guidelines 8, 9
Locoregional recurrence requires referral to a tertiary center for multidisciplinary evaluation of salvage surgery or re-irradiation, as recommended by the Annals of Oncology guidelines 8, 9

Follow-up schedule includes clinical examination with flexible endoscopy every 2-3 months for the first 2 years, as per the Annals of Oncology guidelines 6
Imaging includes baseline post-treatment imaging at 3 months for locally advanced disease, as recommended by the Annals of Oncology guidelines 6
FDG-PET/CT at 3 months post-chemoradiotherapy is necessary to assess the need for neck dissection, as per the Annals of Oncology guidelines 1, 6
Ancillary monitoring includes TSH levels every 6-12 months following neck irradiation, as recommended by the Praxis Medical Insights guidelines 5
Dental evaluation every 6 months is necessary for patients who received radiotherapy, as per the Annals of Oncology guidelines 6
Tobacco and alcohol cessation counseling is recommended, as per the Journal of the National Comprehensive Cancer Network guidelines 10