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MICHAEL MARKIEWICZ: All right. Thanks, Dr. Singh, for introducing me. And thanks to Dr. Hicks and Dr. Isley for the invitation. It's actually really impressive on a Saturday to see this many dentists and health care providers here interested in oral cancer. It's a really cool thing to be here. I'm from I'm from the department of oral maxillofacial surgery in Buffalo. I also consulted Roswell Park Cancer Institute.

Only disclosure I have is that I am a consultant for Axogen Nerve Graft. I kind of have a boring talk today. I don't have any fancy pictures, but I do have something to talk about with regards to guidelines-- guidelines with regards to cancer therapy, but also what patients are thinking. And the important thing that patients are asking nowadays is what will be done?

Will I need radiation? Will I need a neck dissection? Will need resection of my tumor? And the new guidelines have some implications on that.

As every new cancer patient I see, I tell them whether you come here, to me-- Roswell Park-- Toronto, Columbia, Johns Hopkins, you're probably going to get the same treatment paradigm, because we all follow the same NCCN guidelines. So this is what we'll talk about today.

Really, the workup-- we talked about a little bit. And it's pretty standard. You do your history and physical, you do your head and neck exam, which is very important. And then once you send that patient and you have a biopsy proven squamous cell carcinoma, you're going to send that patient to your head and neck surgeon. That surgeon is going to order a head and neck CT, and that's to evaluate the primary tumor site and to see if there's anything different from the clinical exam, and also to evaluate the neck for neck metastasis-- any positive lymph nodes, which is so important in the diagnosis of these lesions.

And then they're going to order a chest CT, because the most common site of regional spread or distance spread would be the lungs for these lesions. So we want to rule out that. That changes treatment entirely.

The new guidelines is for advanced cancers. They're advocating PET/CT, which right, came from. We've got almost a PET for everyone. I'm glad to see here we don't do that for everybody.

Then you'll get your dental evaluation. It's critical to get your dental eval beforehand. That could be from you in the audience, or that could be from the oral oncologists at Roswell Park. Because this is going to have implications on radiation therapy and the time to radiation therapy to get those bad teeth out.

And obviously nutrition, speech, swallowing-- you want to get the whole team on board before evaluation. So really, it's history and physical, biopsy-- as we talked about-- incisional or excisional-- as with Dr. Hex-- head and neck CT, chest CT, PET/CT when advocated, and then dental consult. It was in 2018 that we implicated these changes. And there are some big changes with regards to how we stage these. We'll talk about that.

Traditionally, it was any tumor less than two centimeters was a T1, and that is not always true now, because for years now, we've known that depth of invasion-- how deep that tumor goes has been really important. But it was never incorporated into our guidelines.

The new 2019-- well, not '19, but it was implicated in 2018-- is depth. So you can actually now have a tumor less than two centimeters that is between five and 10 millimeters of depth, and that is considered a T2 tumor now, which upstages that patient and actually has an implication on their survival.

Same then to go with T3. And then T4a, now-- T4a is any tumor that's greater than four centimeters-- so that's a large squamous cell carcinoma-- and then greater than 10 millimeters of tumor thickness. So the depth of invasion-- just to review, we have known for some time now that it is critically important in staging these cancers, but it was really never made apparent in the guidelines until recently.

Spiro's data from long ago showed that three millimeters of depth invasion was critical, and now we know that between four and five is critical. And this is what your pathologist is going to give you when you take your incisional or excisional biopsy. This is going to have implications on what that patient gets for their therapy.

So for clinical staging-- clinical staging is the staging of the patient before they get their cancer resection therapy or treatment. And then pathological staging is actually what the pathologist looks at on the specimen and what the end all staging is of the patient once they get that big tumor in their hands and they look at the neck nodes. And there's macroscopic and microscopic. We won't go into the details of that.

The other critical change to the new guidelines is extra-nodal extension. And this is the same thing as depth of invasion-- we've known for some time now that this is very important clinically. Head and neck surgeons have known this is important, dentists, oral maxillofacial surgeons-- we were taught in dental school or medical school. If you see a fixed node in the neck, if a patient has a nerve dysfunction, motor changes, sensory changes, that is a really bad implication on their prognosis.

Size, laterality, and number of lymph nodes is always important. That's still critical in the lymph node staging section. It's extra-nodal extension in the single lymph node. Traditionally, if you had a less than three centimeter lymph node-- that should be-- you'd be at one. But now, we'll see how that changes. And also, there's a new N3a, which is rare.

In the clinical stage-- and this is before the patient undergoes their cancer surgery or the cancer therapy-- the big changes are that any patient that has clinically overt or imaging positive extra-nodal extension where you can see that node and what's thought to be cancer is coming out of the lymph node and is fixed to the skin, or the nerve dysfunction, those patients are automatically upstage to an N3b, which has gross implications on their survival.

Again, like Dr. Campbell, Dr. Goodlow, and all the surgeons here have said, a really good head and neck exam is critical to get this patient staged appropriately. Pathological staging. That is now moving to when the patient has their cancer surgery, the pathologist has the specimen and we talked about it at a tumor board. There's some changes here.

So as we've talked about, this N2a-- sorry about that.

This N2a here is new. Because traditionally, if you have a lymph node less than three centimeters, you consider it N1, and that's better for survival. But now, if you have less than three centimeters, and you have extra-nodal extension on your exam-- when the pathologist looks at your neck dissection and your lymph nodes in their lab and shows that the tumor is coming out of the capsule-- that has a poor prognosis. There's also this N3b, which is essentially a metastasis in any lymph node larger than three centimeters that has extra-nodal extension. Again, that automatically upstages that patient to an N3b.

This is something I actually had back on my DropBox from 2017-- the old NCCN guidelines. You can't find this now, because if you go to the website, it has the new ones. Really, the therapy has not changed so much. This is 2017. The kind of reorganized things a little bit, but it's really the same.

So if you have a T1, T2 tumor-- this is after the cancer operation. You have no positive nodes, no adverse features on there, you can follow up that patient with observation. But now we're starting to talk about-- if you have one positive node with no adverse features, no lymphovascular invasions-- so the vascular bodies around with those are involved-- and the nerves aren't involved, you could still consider radiation therapy for these patients.

And then if you have ENE-- extra-nodal extension, which is what we talked about, where the lymph node actually has cancer coming out of the fibrous capsule of it-- that's an indication for a systemic therapy-- chemotherapy and radiation. So surgery, fortunately for next surgeons and not for the patient, is still the preferred treatment for these patients. I tell patients, you want to be able to operate on this tumor, because if they are not a surgical candidate, usually that means it's non-resectable, and that really has a poor prognosis.

Stage one and stage two tumors are T1-- you know, the size of a T1 and T2 can be surgery alone sometimes. Stage 3 and stage 4 patients-- or those T3 and T4 patients-- are going to need chemotherapy and radiation.

Principles. So when you send the patient after your biopsy to the head and neck surgeon, what principles are they looking for? The end all be all is still that we want to get out of the primary with good margins. We want to take out that tumor in its entirety with good, tumor-free cells around. That still has the best prognosis as we know.

In-continuity neck dissection. So when we have tumor extension from the oral cavity or the oral pharynx into the neck, you want to perform that in-continuity with your specimen-- so the next dissection attached to the tumor. Resection is based on clinical examined imaging. This is really important in the oral cavity.

As I was taught long ago, all of these patients get a CT, and mostly for reconstruction purposes, we get a high grade CT and 3D reconstructions. But a panorex, actually, in dental imaging, can really allude you to cortical invasion, especially in the mandible. So it's really good to get a screening panorex and not forget that in your staging.

And then if there's medullary involvement-- if there is growth of the tumor into the bone of the mandible-- that patient's going to get a segmental resection with large margins. When we sit down in tumor board, this is always a topic of discussion. What is a clear margin? In surgery, we mark off our one to one and 1/2 centimeters, right? But then there's clear margins, which is five or less-- I'm sorry, five or more. Close is less than five, and then positive, which has indication on treatment.

Non-resectable is when you invade the muscles around the head and neck, superior pharynx, then you go to the mediastinum, the pre-vertebral fascia, or when you have subdermal cancer metastasis. Briefly, management of the neck. This is always a topic conversation. This is where tumor thickness comes into play. If there is a tumor thickness of greater than four, then that patient will get a neck dissection, where you'll have the manage their neck.

Between two and four, it's up to clinical judgment. And if it's less than two, it's only elective. Sentinal node biopsy is an option nowadays, and it's a topic that's probably a topic for another discussion.

Briefly, just to finish off-- summary of management of the neck is T1 and T2 tumors get a neck dissection based on depth and invasion, T3 and T4 tumors will always get a neck dissection.

Adjuvant treatment-- we already talked about that. Radiation therapy for adverse features. T3, T4 tumors are always going to get adjuvant therapy in the form of radiation. And systemic therapy-- for positive margins, when there's extra-nodal extension-- you want to consider it for T3 and T4 tumors. Thank you.

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