Download Oral cancer

‫جراحة \ خامس اسنان‬
‫د‪ .‬وفاء (م‪)8‬‬
‫‪2016 \ 12 \ 27‬‬
‫‪Oral Cancer‬‬
Anatomy
Lymphatic drainage of Head and Neck
levels of cervical lymph nodes
Oral cancer
Tumor:


Is a mass of cells,
tissues or organs
resembling those
normally present
but arranged
atypically and
behave abnormally.
Behavior is very
essential and is of great
importance.
Oral cancer
Classification:

Histogenetic:
•
•

Epithelial origin
connective tissue origin
Histological:
•
Degree of
differentiation.



Well
moderate
poorly differentiated

Clinical behavior:
• Benign:


slowly growing and expanding causing pressure
atrophy but remain within the capsule.
Very few mitosis could be seen.
• Malignant:



Invade surrounding tissues and locally invasive.
Progressive growth and metastasize to distant
organs, embolic spread due to lack of cell adhesion
Mitosis.
• Intermediate:

Locally invasive, no metastasis. Basal cell carcinoma
and Ameloblastoma
Pathways of cancer spread (Metastasis)
• Invasion into local stroma
• Lymphatic spread
• Vascular system (Hematogenous spread)
• Neural spread
• Circulation of the tumor and arrest at the distant
site
Epidemiology
•Oral cavity and oropharyngeal tumours
comprise 40% of cancers
•Greater in men than women
•It is most common in the 6th and 7th decades,
although there is evidence that it is increasing
in young adults
Aetiology
• smoking and consumption of alcohol
• diet containing high proportions of vegetables and fruit might
modulate carcinogenic effect
• Human papilloma virus (HPV) considers as a risk factor in
oropharyngeal squamous cell carcinoma
• Betel quid chewing is related to the high incidence of oral
cancer in India
Roles of the dentist with patients in oral cancer
• Recognition of Cancer and Medical Considerations
• Treatment Planning Modifications
Dental treatment planning for the patient with cancer begins
with establishment of the diagnosis. Planning involves the
following:
1- Pre-treatment evaluation and preparation of the patient
2- Oral health care during cancer therapy, which includes hospital and outpatient care
3- Post-treatment management of the patient, including long-term considerations
Reference: Dental Management. CHAPTER 26 - Cancer and Oral Care of the Patient
Premalignant conditions
Conditions of definite premalignant potential
• Leukoplakia
• Erythroplakia
• Chronic hyperplastic candidiasis
Conditions associated with an increased risk of malignant
transformation
• Lichen planus
• Oral submucous fibrosis
• syphilitic glossitis
Diagnosis of oral cancer
• Clinical finding
• Radiograph
• Biopsy
• Blood investigations
Malignant Tumors

CLINICAL DIAGNOSIS OF ORAL CANCER

Symptoms vary according to the site of the lesion
• painless in the early stages
• painful and tender when secondarily infected or involves a
sensory nerve
• painless lump or ulcer on the lip
• Posteriorly no symptom until it reach a size of 2-3 cm
swelling,

pain and difficulty in deglutition
• absence of symptoms until the tumor metastasize to regional
lymph nodes

hard lump on the neck
Malignant Tumors
• late symptoms:




pain due to secondary infection or nerve involvement
excessive salivation
difficulty in deglutition, speech
haemorrhage
• Within bone:





painless swelling involving the buccal and lingual or palatal
sulci
teeth become loose and painful -acute alveolar abscess
edentulous pt. the denture does not fit
denture hyperplasia
anaesthesia of the upper or lower lip and the cheek.
Lip Cancer
• Carcinoma of lip:
• age 50-70 years. Male lower class.
• Predisposition factor:
•
•
•
•
•
dirty, jagged and stained teeth
irritation.
tobacco smoker
leukoplakia.
intense solar radiation - blistering cheilitis due to sunshine.
Lip Cancer
• Lower lip affected in 93%
• Upper lip affected in 5%
• Angle of mouth affected in 2%
• Metastases within a year - submental, submandibular and upper
jugular.
•
Death due to infection and bronchopneumonia.
Tongue cancer
• Carcinoma of tongue
• Anterior 2/3, affect males
• Posterior 1/3 equal in both sexes.
• Age over 60 years.
• Predisposing factors:
• Bad oral hygiene
• Heavy alcoholic with element of Vit.B deficiency. Producing
precancerous mucosal atrophy
• Syphilitic and leukoplakia. 25% and 5%.
• Superficial glossitis, papilloma, fissures and non-specific ulcers.
Malignant Tumors
• Site & Types:
• 1. lateral edge of tongue 58%
• 2. tip of tongue
2-4%
• 3. dorsum. of tongue 7-15%
• 4. posterior 1/3
21-33%
•
•
•
•
•
1. ulcerative
2. fissured malignant
3. papillary
4. flat nodules
5. scirrhous or atrophic type
Diagnosis
• History of the disease (signs and symptoms)
• Investigations:
Plain radiography
(orthopantomogram “OPG” , occipito-mental, chest radiograph)
Contrast radiography
Sialography, carotid angiography, Barium swallow
Cross sectional imaging
Computerized tomography (CT)
Magnetic resonance imaging (MRI)
Nuclear medicine
Bone scinitigraphy
Position emission tomography (PET)
Ultrasonography
• Biopsy
Fine needle Aspirsation for cytology or biopsy
Biopsy
•
•
•
•
Incisional biopsy
Excisional biopsy
Fine needle aspiration biopsy
Fine needle Core biopsy
Nonspecific Blood Tests

Alkaline phosphatase:


Amylase:


Found to be elevated in diseases of the pancreas.
Bilirubin:


Found to be elevated in bone and liver disease.
Found to be elevated in Liver disease
Calcium:

Found to be elevated in cancer of the bone, parathyroid,
multiple myeloma and other diseases.

Creatinine:

to be elevated in kidney disease.
Clinical staging of oral cancer
TNM classification of head and Neck Tumour
•
•
•
•
•
•
•
•
•
•
•
•
TIS Tumour in situ
T1
0.1- 2.0 cm
T2
2.1 – 4.0 cm
T3
4.1 – 6.0 cm
T4
>6.1 cm or invading adjacent structures
N0
No regional adenopathy
N1
Ipsilateral adenopathy
N2
single Ipsilateral node 3-6 cm or multiple Ipsilateral
6.0 cm
N3
Massive Ipsilateral or contralateral nodes
M0
No evidence of Metastases
M1
Metastases beyond the cervical lymph nodes
Mx
Metastases not assessed
nodes <
Multidisciplinary Team (MDT)
• Oral and maxillofacial surgeons
• ENT surgeons
• specialist anaesthetists
• clinical / medical Oncologists
• specialist nurses
• specialist pathologists
• Specialist radiologists
• Speech and language therapists
• Dieticians
• Restorative dentists
• Dental hygienists
• Psychologists
Therapeutic options of oral cancer
• Surgery
• Radiotherapy
• Systemic anti-cancer therapies
Factors have a bearing on the choice of treatment:
• Site of primary tumour
• Stage of disease
• Proximity or involvement of bone
• Physical status of patient
• Patient performance
Surgery
• Conventional excision
• Laser surgery
• Thermal surgery
Access to the primary tumour
• Trans-oral route: anterior part of the oral cavity
• When the tumour increase in size and becomes more posterior, three main
alternative approaches can be applied:
A- Lip split and mandibulotomy
B- A ‘’ pull through’’ technique via the neck
C- For maxillary tumours, an upper lip and para-nasal incision (lateral infraorbital extension is rarely required and has a high complication rate)
Tracheostomy
Neck dissection
Radical neck dissection:
Refers to the removal of all ipsilateral cervical lymph node groups extending from the
inferior border of the mandible to the clavicle, from the lateral border of the
sternohyoid muscle, hyoid bone, and contralateral anterior belly of the diagastric
muscle medially, to the anterior border of the trapezius. Included are levels I
through V. This entails the removal of three important nonlymphatic structures—the
internal jugular vein, the sternocleidomastoid muscle, and the spinal accessory
nerve.
Modified radical neck dissection:
Refers to removal of the same lymph node levels (I through V) as the radical neck
dissection, but with preservation of the spinal accessory nerve, the internal jugular
vein, or the sternocleidomastoid muscle.
Neck dissection
Neck Access:
• Apron incision
• H incision
• MacFee incision
Reconstruction
• Speech
• Swallowing
• Eating
• Chewing
• Sensation
• Cosmesis
Reconstruction techniques:
1- Open wound (in case of laser)
2- Primary closure
3- Graft (it gains a new blood supply from the wound bed): Autogenous (same individual), Allograft (same
species but different individual) , Xenograft (different species).
Mucosa graft:
split thickness skin graft (epidermis and part of dermis), full thickness skin graft
Bone grafts
Cartilage grafts (ear, nose and rib)
4- Flaps (retaining its attached vascular supply)
Local, Regional and Distant flaps
5- Developments (tissue expansion and tissue engineering), it has limited roles in cancer patients
6- Implants
7- Prosthetic rehabilitation
Surgical complications
Immediate/ early complications
• Bleeding
• Airway obstruction an tracheostomy problems
• Seroma and salivary collection
• Infection
• Dehiscence/ failure of wound healing/ fistula
• Nerve injuries
• Flap failure
• Donor site morbidity
Surgical complications
Late complications
•
•
•
•
•
•
•
Recurrence
Altered sensation
shoulder and neck problems
Hypertrophic scars
Lymphoedema
Fatigue
Depression
Radiotherapy
• External beam radiotherapy
• Interstitial radiotherapy (brachytherapy)
Systemic anticancer therapies
• chemotherapy
• Gene therapy
• photodynamic therapy
Chemotherapy
• Timing of administration of chemotherapy
Neoadjuvant/ induction: prior to radiotherapy or surgery
Concurrent: administered during the radiotherapy treatment schedule (treatment
for tonsil, base of tongue and nasopharynx)
Adjuvant: Given after radiotherapy or surgery
Complications of chemotherapy:
Early complications:
severe mucositis, nausea and vomiting, weight loss, diarrhoea, bleeding, hair loss,
neurotoxicity, immunosuppression, neutropaenia, thrombocytopaenia and multiorgan failure.
Late complications:
Nephropathy, cardiomyopathy, pulmonary fibrosis and peripheral neuropathy
Photodynamic therapy
• Killing of cancer cells (by singlet oxygen) through administration of a
photosensitiser followed by non thermal laser light application
• Photosensitiser, light and oxygen
• Photosensitisers either topical or systemic
• light illumination either surface illumination or interstitial illumination
Surface illumination photodynamic therapy for tongue
squamous cell carcinoma using a microlens fiber.
Interstitial photodynamic therapy for base of tongue tumour.
Illumination with 652nm red laser light using fine optic fibers.
US scan was used as a guidance for fibers insertion.
Nutritional support
Speech and language therapy
swallowing assessment
Psychosocial aspects
quality of life assessment