Download 3. Prescribe treatment

MINISTRY OF HEALTH OF UKRAINE
VINNITSA NATIONAL PIROGOV MEMORIAL MEDICAL
UNIVERSITY
"CONFIRM"
at the methodical meeting
Department of Ray diagnostics,
Ray therapy and Oncology
Head of the department
As. of Prof., M.S.D. Kostyuk A.G.
________________________
"______" ________ 2013 year
METHODICAL GUIDELINES
For self-study for students in preparing for the practical (seminary) lessons
Subject of Study
Module No
Theme №
Topic of Lesson
Oncology
1
2
Lip cancer, tongue cancer. Tumours of salivary
glands. Distribution Risk factors, dysplasia.
Classification by TNM. Methods of diagnosis.
Clinics. Treatment: surgery,
radiotherapy, chemotherapy, combined.
Course
5
Faculty
General Medicine
Lip cancer, tongue cancer
Distribution Risk factors. Classification by TNM. Methods of diagnosis. Clinics.
Treatment: surgery, radiotherapy, combined.
1. Background.
Lip cancer is one of the most common types of oral cancers. It originates mainly in
the lips and can be very dangerous if not treated in time. Though the cases of this type of
cancer are rare worldwide, it is still a form of cancer and may spread to other organs also.
The damage may be irreparable and timely treatment is the only option to get rid of these
malignant cells.
Tongue cancer is a form of cancer characterized by uncontrolled division and
maturation of the cells lining the tongue as well as the oropharynx (a small part of the
throat located at the rear of the mouth). Tongue cancer is usually included under the
umbrella of "mouth cancer" and thus is sometimes also known as oral cancer. As per the
National Cancer Institute, approximately 10,000 cases of tongue cancer are diagnosed
annually in the US, out of which nearly 2000 die from the condition. Excessive use of
tobacco is often considered to be the prime risk factor for tongue cancer, accounting for
close to 75 percent of all cases worldwide.
2. Specific goals.
1. To know the etiology of cancer of the lip and tongue and the role of endocrine
pathology in the development of these diseases, their prevalence among different groups of
the population, the overall results of a special treatment ( = I)
2. To know the main cause of cancer of the lip and tongue, histologic classification
and classification system for TNM, clinical manifestations, depending on the stage of the
main methods of diagnosis and principles of radical and symptomatic treatment. ( = II)
3. To be able to examine patients with cancer of the lip and tongue, registering
patients at the dispensary into the registration Form 30. (=III)
4. To be able to interpret the exfoliating cytology and biopsy in patients with cancer
of the lip and tongue.
5. To be able to define a differentiated treatment policy in patients with different
stages of cancer of the lip and tongue. ( = III)
6. To acquire a deontological view when working with patients with cancer of the lip
and tongue and those who have complications which is the manifestation of the underlying
disease.
7. Develop a sense of responsibility for the timeliness proper medical diagnosis and
the correct choice of treatment tactics in this pathology.
3. Basic knowledge, skills, abilities, necessary for studying the topic (interdisciplinary integration).
Preceding Subject
Normal anatomy
Normal physiology
Biochemistry
Physiopathology
Morbid anatomy
To know
To be able
Operative
surgery
and Featuring a look of the
topographic anatomy of the lip and tongue and his
external and internal anatomy parts.
of lip and tongue, the
characteristic features of their
structure, blood supply (both
arterial and venous flow
characteristics) innervation.
Humoral and neuro-endocrine
regulation. The role of the
lymphoid tissue of lip and
tongue was normal.
The major classes of oral
hormones, their synthesis and
degradation.
Pathogenesis of endocrine
disorders in patients with
cancer of the lip and tongue.
Macroscopic forms of tumors Determine the stage of
of lip and tongue. Histological
classification of cancer of the
lip and tongue.
General Surgery
Methods of examination of
patients with cancer of the lip
and tongue: a survey, physical
examination.
Additional studies: endoscopy,
CT-scan, MRI, exfoliating
cytology and biopsy.
Operative Surgery and The main types of surgery in
topographical anatomy
patients with tumors of the lip
and tongue.
Diathermocoagulation,
indications and techniques of
conducting.
Resection of lip: indications,
contraindications,
technique
execution.
Tonguectomy:
indications,
technique execution.
Lymphodysection: indications,
contraindications,
technique
execution.
Interdisciplinary
Key diagnostic symptoms of
Intergation
tumors of the lip and tongue
field.
cancer of the lip and
tongue according to the
histological
classification
and
classification TNM.
Conduct a focused and
systematic collection of
complaints and medical
history of patients with
suspected cancer of the
lip and tongue. Conduct
physical
examination
patients with tumors of
the lip and tongue.
Surgical approaches to
define the line of the
face and oral wall
during these operations.
Identify
specific
manifestations
in
patients with cancer of
the lip and tongue,
interpretable additional
methods of examination
in these diseases.
4. Tasks for independent work in preparation for the occupation.
4.1. Theoretical issues to employment:
1. The spread of cancer of the lip and tongue.
2. Histological classification and TNM classification system of cancer of the lip and
tongue.
3. Mandatory and special methods of examination.
4. Differential diagnosis of cancer of the lip and tongue.
5. Surgical treatment of cancer of the lip and tongue.
6. Indications and contraindications for surgery.
7. Technique of radical surgery in patients with cancer of the lip and tongue.
8. Palliative surgery.
9. Preoperative preparation of patients, post-operative treatment and postoperative
complications.
10. Long-term results of treatment of cancer of the lip and tongue.
11. Combined treatment of cancer of the lip and tongue. Forecast.
12. Question dispensary patients on cancer of the lip and tongue.
4.2. Practical work (jobs) that need to perform in class:
1. Carefully collect history. Determine the history of symptoms of cancer of the lip and
tongue;
2. Physical examination the patient: palpation and assessment of lymph nodes,
including regional of the neck, palpation of the abdomen, liver;
3. Determine the methods of investigation: Ultrasound, chest radiography, laboratory
tests of blood and urine, endoscopy, CT-scan, MRI, exfoliating cytology and biopsy;
4. Determine the stage of disease in patients with cancer of the lip and tongue;
5. Identify complications of cancer of the lip and tongue;
6. The indications for surgery, radiation, chemotherapy and combined treatments;
7. Assess the condition of the patient in the early postoperative period.
4.3. Content of the topic
Lip cancer
Lip cancer occurs in lips and affects many important activities of the victim. Lips are
the main opening of the mouth and play an important role in the food intake. They also
enable a person to speak and pronounce the words correctly and make different sounds
through his mouth. They are soft, flexible and the lower lip is generally larger than the
upper lip.
Development of cancerous cells in the lips can be damaging as it will impact the
ability to intake food and will also affect a person's speaking abilities. Lips also play an
important role in presenting important gestures like frown, smile, etc. It is also one of the
most sensitive organs of the body and plays a crucial role in sexual activities. Hence,
presence of cancerous cells in the lips may put restriction on many basic but important
activities of a person.
Lip cancer develops mostly in the lower lip and spreads to other areas gradually. The
cancerous cells initially attack the cell layer present on the surface of the lips and penetrate
further as the intensity of the disease increase. In most of the cases, the cancerous or
malignant cells develop in the squamous cells (squamous cells are the cells forming the
layer of the lips). Hence, squamous cell carcinoma is the most common form of this
cancer. The malignant cells spread rapidly and form cancerous tumors. Basal cell cancer is
another type of cancer of the lips. The infected cells are less harmful as compared to those
in the squamous cell carcinoma and do not spread to other areas.
Tumors formed by the infected cells can be benign or cancerous. Benign tumors
usually do not invade the healthy tissues. They are less destructive and do not spread to
other parts of the body. Benign tumors are completely curable and the chance of their
recurrence is very less. On the contrary, cancerous tumors are highly destructive and cause
the maximum damage possible. Their primary targets are the live and healthy tissues
present on the surface of the lips and obstruct their functioning. They also attack live cells
present in the adjacent areas and replace them by the infected malignant cells. A tumor is
formed when an excess number of malignant cells accumulate in a particular area. The
tumor can also spread to other parts of the body through the lymph nodes or the
bloodstream. It is quite difficult to eliminate the malignant cells as they may recur after a
certain period.
The main lip cancer causes are:
1.
Tobacco: This is largely considered as the primary reason for the development of
oral cancer and also of lip cancer. Smoking of cigarettes, pipes, cigars and consumption of
tobacco on a regular basis is a major cause of this ailment. Chain smokers and the people
who consume tobacco at a regular interval in the whole day are considered at the highest
risk of lip cancer.
2.
Alcohol: Alcohol too is considered as one of the most common cause of lip cancer.
Consumption of excessive alcohol or drinking alcohol on a daily basis is a habit that can
cause other problems as well as lip or oral cancer. If the individual is consuming alcohol
with tobacco, the risk of lip cancer is very high.
3.
Sun: Excessive exposure to sun is also a major cause of lip cancer. This risk can be
reduced by using a proper lip balm or a lotion to protect the lips from ultra-violets rays of
the sun. One should always protect the face and tender parts of the face such as the lips,
with the help of a hat or an umbrella from the sun.
4.
Genetics or Hereditary: Most of the times, when a person has had neck or head
cancer, one can develop oral cancer or lip cancer easily. This can be termed as metastasis
of the cancer. This cancer can spread to other parts of the face as well.
5.
Chewing betel nut: This is a very famous practice in various parts of India and
other nations of South Asia. This causes a lot of cancer developments in many of the
organs of the face, especially the mouth and the lips. Mucosa carcinoma is the cancer
which develops in the cheeks and can spread to the lips as well.
6.
Human papillomavirus (HPV): This is the infection which is associated with the
cervix, vagina, vulva and the penis. Even after this cancer being associated with the
reproductive organs of the body, it has a strong connection in causing lip and mouth
cancer.
7.
Age: As an individual advances in age, the risk of developing this cancer will rise. It
is believed that this cancer arises in an individual after the age of 45 years.
8.
Gender: This cancer is more common in men than in women. This cancer is more
common in men because the consumption of liquor and tobacco is higher in that gender.
9.
Poor oral cleanliness: Poor oral hygiene is also considered as a very common cause
of this cancer. This is also a cause of spread of this cancer to other parts of the face, like
the jaw and mouth. Generally this cancer is developed in the inner surface of the lip.
10.
Deficiencies in the diet: Deficiencies in the food such as low intake of iron, folic
acid, vitamins such as A, C and E are also a lip cancer cause or they may increase the level
of this cancer.
11.
Weak immune system: The individual who have other illnesses such as HIV or
other major issues, are prone to this cancer on a larger extent, because the immunity level
is very low because of the intake of heavy medicines.
These are a few very common lip cancer causes which can be avoided by an individual
very easily, except age. This cancer mostly rises when continuous smoking and alcohol
consumption is observed in an individual. If the intake of these things is reduced, the risk
of developing this cancer is also reduced.
The ways by the lip cancer diagnosis can take place are as follows:

Physical Examination: Generally, the first step to detect this type of cancer is a
normal physical screening of the lips. The doctor or a dentist will inspect the lip cancer
stage by inserting gloved fingers into the mouth, and feel if there is any abnormal growth
inside the mouth or on the lips. This will also determine if there is any oral cavity in the
mouth. A mirror and light is used to check the inner portion of the mouth and the sides of
the lips. This physical exam not only checks the lips, but also the other organs of the body
such as cheeks, gums, floor of the mouth etc, to see if the cancer has spread anywhere else
than lips.

Endoscopy: Endoscopy is a process which is used for detection of various organs
including the organ where cancer has spread. An opening is made in the body and an
endoscope is inserted into the body via that particular opening, to have a look at the organs.
This instrument is in a shape of tube. It has a lens attached to it so that a clear picture can
be seen. The lens is very clear to even detect the cancerous developments in the tissue or
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the nodes. The tissue which is removed with the help of an endoscope is checked under the
microscope to detect any signs of cancer.
X-Rays: This is a very common test as well. An x-ray is a beam which can go
through the body to detect if there is any growth in the organ. An x-ray of the mouth will
be done to check if there is any tumor in the lips of an individual.
Biopsy: This is a process which is done by a pathologist. In this, cells which are
removed from the infected area are checked minutely under a microscope. If there is any
indication of Leukoplakia, then cells from other parts of the body are taken and checked
for the metastasis of the cancer.
MRI: MRI stands for Magnetic Resonance Imaging. This is a test which uses
magnets, radio active waves and a computer to check the organs of the body. This is a test
which will give out a detailed summary with the help of pictures of the organ which needs
to be detected. This test is also called as nuclear magnetic resonance imaging (NMRI)
CT scan: This is a test which involves capturing the images of various organs in
different angles. This is a scan which helps in detecting even the smallest problem in the
body. While conducting this test, a dye is either injected into the veins of the body or is
swallowed by the patient; this helps the doctor to have a better look at the tissue which has
an abnormality. This process is known as computed tomography.
Barium Swallow: This is a test which has a series of X-ray conducted of the
targeted area. This is a test in which the patient consumes barium, which is a metallic silver
liquid which helps in exfoliating the area which is carrying the ailment. The other name for
this process is also known as upper GI series.
Exfoliating Cytology: This is a test which is targeted to take the cells from the lip.
This is done with the help of cotton, or a wooden stick. These things are used to scrape out
the cells gently from the layers of the lips. The next step is it to view these cells under the
microscope to check for any signs of malignancy.
Lip cancer Stages
Stage 0
This is considered as the initial stage of the cancer
The other name of this cancer is called as Carcinoma Situ
Abnormal cells are found on the lining of the lips
This is a stage where these abnormal cells may become cancerous at a later
stage if the treatment does not start soon
If the cells are not treated then, they may spread in the nearby tissues as well
Stage 1:
This is the stage where in the cells have developed as cancer
The size of the cancer is close to 2cm or many a times smaller than that
The cancer is not very big and can still be treated with proper medications
This cancer has not reached the lymph nodes
Stage 2:
In this stage, the size of the cancer is more than 2 cm but smaller than 4 cm
This is the stage where in the cancer is growing and the treatment should start
as soon as the detection takes place
o
This is the cancerous stage where in the cancer has reached a higher state but
not the lymph nodes
o
One must treat this cancer soon, or else the treatment method of lip cancer
operation will be the only option that one will remain with
Stage 3
o
In this lip cancer stage, the tumor has become big and in most of the cases is
visible
o
This is the stage where in the size of the cancer has reached a minimum of 3
cm
o
The cancer has also spread on to the lymph nodes
o
The side where the cancer has spread, on the same side and the neck tissue is
also beginning to get damaged
o
If this is the case, then the size of the cancer is almost 4 cm
Stage 4
o
Stage 4 of the cancer is divided into 3 categories:
a.
Stage 4A
b.
Stage 4B and
c.
Stage 4 C
Stage 4A:

This is the stage which states that cancer has covered maximum of the tissue of the
lip

In this stage, the cancer in most of the cases has reached the nearby tissues or the
nearby bone. This would include the jaw, tongue, floor of the mouth etc

Most of the times, the skin of the cheeks and chin are also affected by this cancer

If the cancer has spread to the lymph nodes, of any side the length if the cancer is
almost 3cm. This is a cancerous growth which is observed very close to the neck

Many a times, it also spreads in the tissue of the bone which is very to the lips. This
can be the jaw or the tongue (primarily)

When this cancer spreads to other parts of the mouth or in some cases body, it is of
minimum 3 cm but not more than 6 cm in length
Stage 4B:

In this stage, the cancer may spread to one or more lymph nodes

The cancer will spread to the nodes which are larger than 6 cm

The cancer has also spread to the other muscles or the bones extensively

This cancer may have also spread in the lower part of the skull and or the carotid
artery
Stage 4C:

In this stage, the cancer has gone and spread beyond the lip and other parts of the
mouth
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The first organ that this cancer would affect is the lungs
o
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The size of the tumor is not defined in this stage and can spread anywhere in the
body
Treatment options for lip cancer can include one or more of the following:
Surgery
Surgery to remove the tumor is a common treatment for lip cancer. Depending on
the size of the cancer on the lip, part of the tongue, jaw and palate also may be removed.
This can affect the way many talk, swallow or chew, so reconstructive surgery is usually
takes place to help rebuild these sections of the mouth that were removed.
Radiation Therapy
An option for very small tumors on the lip or people who cannot tolerate surgery,
radiation therapy can be given internally or externally. It also is used prior to surgery to
reduce the size of the tumor as well as after surgery to destroy any remaining cancer cells
in the area.
Chemotherapy
Typically given at the same time as radiation therapy to treat lip cancer, the use of
chemotherapy can result in infection and pain in the mouth and gum area. Commonly used
chemotherapeutic drugs include 5-fluorouracil, bleomycin, carboplatin, cisplatin,
docetaxel, ifosfamide, methotrexate and paclitaxel.
Targeted Therapy
A targeted anticancer therapy called Erbitux also can be used to treat lip cancer. It is
usually is given in combination with radiation or chemotherapy. Designed to bind to a
substance called epidermal growth factor receptor (EGFR) that is found on the surface of
lip cancer cells, targeted therapies can cause less harsh side effects as compared to
chemotherapy.
Tongue Cancer
Important Indicants of Tongue Cancer
Among all the symptoms, the first one that is noticed is a red or white spot on the
tongue. This spot may vary in size from being small to medium, and can also be found on
the lining of the mouth or gums. The spot turns into a firm spot and develops raised edges.
This indicates that the cancer is progressing.
Experiencing throat pain or having difficulty while chewing or swallowing food is
also a common symptom of the condition. It is known as dysphagia. Note that, the same is
also a common symptom of strep throat (sore throat). However, if it is accompanied by the
symptoms mentioned above or below, then it is most likely an indication of a tongue
cancer.
Bleeding is a usual symptom seen in people with cancer of the tongue. The cancer
spots are too tender to tolerate pressure of any kind, and break open due to friction caused
by chewing, swallowing or drinking, etc. thus, they bleed. Apart from bleeding, patients
may also develop ulcers that show no signs of healing.
The voice of the person may also seem a little different from the usual tone,
accompanied by an ache localized in the middle or inner ear. The breath and taste of the
mouth goes from bad to worse. This is because tongue cancer is like an infection. It
produces a foul breath in the mouth, and the tongue has a disgusting taste. This foul smell
due to the cancer is different from typical bad breath.
Other tongue cancer symptoms include:
Loose teeth or tooth for no obvious reasons
Neck pain, jaw ache
Reduced movement of the tongue
A lump that develops at the back of the throat or in the lining of the mouth
Abnormal weight loss
A feeling of something stuck in the throat
Abnormal changes in the taste
As mentioned, if the cancer is detected when it is still localized, then using a
combination of surgery, radiotherapy and chemotherapy the condition could be completely
cured. The treatment procedures highly depend on the location of the cancer, and the extent
of its spread. If it is localized and small, then it could be removed through minor surgery.
Extensive surgical procedure could be required for larger tumors. For a cancer that has
spread to the neck, the treatment comprises getting rid of the cancerous lymph nodes and
other tissues. Most people may require to undergo a reconstructive surgery after the
surgery to remove the cancer. This is to help them regain their ability to talk and eat.
To conclude, the best way to deal with cancer is not letting it develop in the first
place. Although, there is no assured way to prevent tongue cancer, there are some measures
that may reduce the risk of developing the condition. These include avoiding using
tobacco, drinking alcohol in moderation, and having a diet rich in fruits and vegetables.
Equally important is to make regular visits to your dentist so that you can rule out any
precancerous changes.
TNM Stages of Tongue Cancer
The terms TNM stand for Tumor, Node and Metastasis of the cancer. They help
explain the size of primary tumor (T), if the cancer has spread to the lymph nodes (N) and
if the cancer has spread to other parts of the body (M). Let us have a look at each stage
separately.
Tumor Stage
The tumor stage is divided into 4 stages. The T1 stage means the tumor is still
present in the tongue tissues and is about 2 cm in size. The T2 stage means the tumor is
larger than 2 cm in size, but it is smaller than 4 cm. When the tumor is said to be in the T3
stage, it means it is larger than 4 cm in size. The T4a tumor means it has spread from the
tongue to the nearby tissues of the sinuses and skin. When the tumor spreads to the spaces
behind the jaws, upper jaw muscles, base of the skull, etc.
Node Stage
The node stage is also broken down into 4 stages. The N0 stage means there are no
cancer cells present in the lymph nodes. The N1 stage means there are cancer cells present
in one lymph node on the same side of the cancer. However, the lymph node is no more
than 3 cm away from the cancer. N2a stage is when 1 lymph node on the same side of the
cancer is affected, but is more than 3 cm away, but less than 6 cm across. The N2b stage
means there is more than just one lymph node affected by the cancer, but these lymph
nodes are not more than 6cm away. Also, these lymph nodes are present on the same side
of the neck. In case of N2c stage, cancer has spread to lymph nodes on both sides of the
cancer, but are not more than 6 cm away. The N3 stage means there is at least one lymph
node affected by the cancer and present more than 6 cm away from the site of cancer.
Metastasize Stage
The 'M' stage is divided into just two parts. The M0 stage means the cancer has not
spread to any other part of the body. M1 stage means the cancer has spread to other distant
parts of the body, like the lungs.
Surgery treatment
Surgical removal of the tumor is usually the first option in the treatment. The size,
location and depth of the tumor influences the surgery. An early initiative for the treatment
helps in removing small cancers through the mouth, using laser cautery. This ensures the
removal of the entire tumor without affecting the normal function of the tongue. In cases,
where in, the depth of the tumor has increased, removal of the nearby neck lymph nodes
may be included in the surgery. For tumors that are larger than normal, surgeons utilize the
latest of the techniques, without ill aftermath of the surgery.
Radiation Therapy
After conducting surgery, radiation treatment may follow. There may remain some
possibilities of untreated cancer cells in the tongue, even after the surgery. To remove these
cells, radiation therapy involves exposure of high-energy X-rays to kill the remainder
cancer cells. The therapy also uses radioisotopes or electronic beams for the same purpose.
The therapy is a localized treatment; it deals with cancer cells only in the treated area. The
patient may receive two kinds of this therapy; internal and external radiation. Common
side effects of radiation therapy comes up in the forms of skin reactions, tiredness, loss of
appetite, etc. However, these and other side effects can be easily controlled and treated.
Chemotherapy
Chemotherapy may be required in extreme cases, where in, the tongue cancer may
have extended itself to the nearby lymph nodes in the neck or other areas. In short, this
type of treatment is required when the cancer is no more localized and has spread
elsewhere. Medical oncologists may administer chemotherapy orally in the form of
medication or it can be given through a vein. This treatment basically involves the use of
drugs to destroy cancer cells.
Reconstructive Surgery
This surgery is often required to retain functions of the tongue (speech, swallowing,
eating) after its surgical excision. It is a procedure to restore the normal surface
architecture of the tongue, which might have been changed after surgical removal of the
tongue tissue. This surgery is basically performed to improve the facial appearance of the
patient.
Rehabilitation
Professionals who specialize in dietetics, speech therapy, swallowing therapy,
physical therapy and occupational therapy are the responsible persons in rehabilitation.
This step marks the last phase in the treatment of tongue cancer. The number of sessions
required by the patient depends upon the extent of the cancer and also the degree of the
after-effects of the surgery on the tongue. People going for such sessions, are taught how to
swallow, eat, speak and retain all the normal functions of their tongue.
People undergoing the various treatment methods for tongue cancer must be mentally
prepared for everything that follows once the treatment is initiated. However, as we can
see, the procedures that are undertaken by the professionals, ensure complete safety and
positive results post-treatment depending upon the stage of the disease.
5. Tests for self evaluation.
A. Tests for self evaluation (test problem)
1. What size of tumour is characterized T1 of the tongue carcinoma?
1). The diameter of the tumour to 1 cm
2). *The diameter of the tumour to 2 cm
3). The diameter of the tumour to 2 cm
4). The tumor within the competence of tongue
5). The diameter of the tumour to 4 cm
Correct answer: 2.
2. What is the histological method for research the cancer of mucous membrane oral
cavity?
1). The scrape
2). The smear preparation
3). The aspiration biopsy
4). *The incisional biopsy
5). The needle biopsy
Correct answer: 4.
3. What is the optional productive preneoplastic disease of lower lip ?
1) Erythroplacia
2) *Atrofical heilitis
3) Leicoplacia
4) Papilloma
Correct answer: 2.
4. The very often histological form of the mucous cover mouth cavity tumour is?
1) Adenocarcinoma
2) *Planocellular cancer
3) Melanoma
4) clear-cell carcinoma
5) Basal cellular cancer
Correct answer: 2.
5. The main method of treatment planocellular cancer of oral cavity on early stage?
1.
Telegammatherapy
2.
*short-distance radiation therapy
3.
chemotherapy
4.
hormonotherapy
5.
laserotherapy
Correct answer: 2.
B. Situation tasks for self-control:
Task 1.
The man of 52 y.o address to the surgical cabinet with a complaints on lower lip’s ulcer
at left. Ulcer have irregular shape and margin, app. 1.5 cm in diameter. The margin of ulcer
is above the skin level, everted and infiltrated. By palpation infiltrate around ulcer
movable, size app 4 cm. The submandibular lympho node at left is increase to 2 cm. By
cytology – cell of malignant growth.
1. Provisional diagnosis
2. Prescribe additional examinations
3. Prescribe treatment
Task 2.
The man 47 years, has addressed to the dentist with complaints to presence of an
painful ulcer of tongue on the right.
Objectively: the ulcer with soft edges in the size 1,0 cm. at the lateral surface of tongue.
The bottom is covered by grey-yellow scurf. Submandibular lymph nodes are enlarged
from both parts, painful. The doctor supposes a malignant tumour.
1. What basis methods of diagnostics it is possible to verify the diagnosis?
2. What are the diseases and what methods should be differentiated with tongue cancer?
3. How to treat the cancer of tongue?
6. Literature.
Basic.
1. Sorcin V, Popovich A, Dumanskiy Yu, et al. Clinical oncology. Simferopol,
2008; 192 p.
2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.
Additional.
1. National Comprehensive Cancer Network. NCCN Practice Guidelines in
Oncology: Lip Cancer Screening. v. 2012.
2. National Comprehensive Cancer Network. NCCN Practice Guidelines in
Oncology: Tongue Cancer Screening. v. 2012.
3. Posner M. Head and neck cancer. In: Goldman L, Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: 200 p.
4. Wein RO, Malone JP, Weber RS. Malignant neoplasms of the oral cavity. In: Flint
PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology Head and Neck
Surgery. 5th ed. St. Louis, Mo: Mosby Elsevier; 2010: 96 p.
Tumours of salivary glands.
Risk factors. Classification by TNM. Methods of diagnosis. Clinics. Treatment: surgery,
radiotherapy, chemotherapy, combined.
1. Background.
The salivary glands are located around the mouth. They produce saliva, which
moistens food to help with chewing and swallowing.
Saliva contains enzymes that begin the digestion process, and help cleanse the
mouth by washing away bacteria and food particles. By keeping the mouth moist, saliva
helps to keep dentures, retainers, or other orthodontic appliances in place.
2. Specific goals.
1. To know the etiology of tumors of salivary glands and the role of endocrine
pathology in the development of these diseases, their prevalence among different groups of
the population, the overall results of a special treatment ( = I)
2. To know the main cause of tumors of salivary glands, histologic classification and
classification system for TNM, clinical manifestations, depending on the stage of the main
methods of diagnosis and principles of radical and symptomatic treatment. (  = II)
3. To be able to examine patients with tumors of salivary glands, registering patients
at the dispensary into the registration Form 30. (=III)
4. To be able to interpret the exfoliating cytology and biopsy in patients with tumors
of salivary glands.
5. To be able to define a differentiated treatment policy in patients with different
stages of tumors of salivary glands. ( = III)
6. To acquire a deontological view when working with patients with tumors of
salivary glands and those who have complications which is the manifestation of the
underlying disease.
7. Develop a sense of responsibility for the timeliness proper medical diagnosis and
the correct choice of treatment tactics in this pathology.
3. Basic knowledge, skills, abilities, necessary for studying the topic (interdisciplinary integration).
Preceding Subject
Normal anatomy
To know
To be able
Operative
surgery
and Featuring a look of
topographic anatomy of the salivary glands and his
external and internal anatomy parts.
of
salivary
glands,
the
characteristic features of their
structure, blood supply (both
arterial and venous flow
characteristics) innervation.
Normal physiology
Humoral and neuro-endocrine
regulation. The role of the
lymphoid tissue of salivary
glands was normal.
Biochemistry
The major classes of oral
hormones, their synthesis and
degradation.
Physiopathology
Pathogenesis of endocrine
disorders in patients with
tumors of salivary glands.
Morbid anatomy
Macroscopic forms of tumors
of salivary glands. Histological
classification of tumors of
salivary glands.
General Surgery
Methods of examination of
patients with tumors of salivary
glands: a survey, physical
examination.
Additional studies: endoscopy,
CT-scan, MRI, exfoliating
cytology and biopsy.
Operative Surgery and The main types of surgery in
topographical anatomy
patients with tumors of salivary
glands.
Diathermocoagulation,
indications and techniques of
conducting.
Resection of lip: indications,
contraindications,
technique
execution.
Tonguectomy:
indications,
technique execution.
Determine the stage of
tumors of
salivary
glands according to the
histological
classification
and
classification TNM.
Conduct a focused and
systematic collection of
complaints and medical
history of patients with
suspected tumors of
salivary
glands.
Conduct
physical
examination
patients
with tumors of salivary
glands.
Surgical approaches to
define the line of the
face and oral wall
during these operations.
Interdisciplinary
Intergation
Lymphodysection: indications,
contraindications,
technique
execution.
Key diagnostic symptoms of Identify
specific
tumors of salivary glands field. manifestations
in
patients with tumors of
salivary
glands,
interpretable additional
methods of examination
in these diseases.
4. Tasks for independent work in preparation for the occupation.
4.1. Theoretical issues to employment:
1. The spread of tumors of salivary glands.
2. Histological classification and TNM classification system of tumors of salivary
glands.
3. Mandatory and special methods of examination.
4. Differential diagnosis of tumors of salivary glands.
5. Surgical treatment of tumors of salivary glands.
6. Indications and contraindications for surgery.
7. Technique of radical surgery in patients with tumors of salivary glands.
8. Palliative surgery.
9. Preoperative preparation of patients, post-operative treatment and postoperative
complications.
10. Long-term results of treatment of tumors of salivary glands.
11. Combined treatment of tumors of salivary glands. Forecast.
12. Question dispensary patients on tumors of salivary glands.
4.2. Practical work (jobs) that need to perform in class:
1. Carefully collect history. Determine the history of symptoms of tumors of salivary
glands;
2. Physical examination the patient: palpation and assessment of lymph nodes,
including regional of the neck, palpation of the abdomen, liver;
3. Determine the methods of investigation: Ultrasound, chest radiography, laboratory
tests of blood and urine, endoscopy, CT-scan, MRI, exfoliating cytology and biopsy;
4. Determine the stage of disease in patients with tumors of salivary glands;
5. Identify complications of tumors of salivary glands;
6. The indications for surgery, radiation, chemotherapy and combined treatments;
7. Assess the condition of the patient in the early postoperative period.
4.3. Content of the topic
Salivary gland tumors are abnormal cells growing in the ducts that drain the salivary
glands.
Causes
There are three pairs of major salivary glands. The largest are the parotid glands,
located in each cheek over the jaw in front of the ears. Two submandibular glands are at
the back of the mouth on both sides of the jaw. Two sublingual glands are under the floor
of the mouth. There are also thousands of minor salivary glands around the rest of the
mouth.
All of the salivary glands empty saliva into the mouth through ducts that open at
various locations in the mouth.
Salivary gland tumors are rare, especially in children. Swelling of the salivary glands is
most commonly due to:

Abdominal surgery

Cirrhosis of the liver

Infections

Other cancers

Salivary duct stones

Salivary gland infections

Sarcoidosis

Sjogren syndrome
The most common type of salivary gland tumor is a slow-growing noncancerous
(benign) tumor of the parotid gland that gradually increases the size of the gland. However,
some of these tumors can be cancerous (malignant).
Malignant salivary gland tumors are usually carcinomas.
Symptoms

A firm, usually painless swelling in one of the salivary glands (in front of the ears,
under the chin, or on the floor of the mouth); the size of the swelling gradually increases.

Difficulty moving one side of the face, known as facial nerve palsy
Exams and Tests
An examination by a health care provider or dentist shows a larger than normal
salivary gland, usually one of the parotid glands.
Tests may include:

X-rays of the salivary gland (called a ptyalogram or sialogram) to look for a tumor

CT scan or MRI to confirm that there is a growth, and to see if the cancer has spread
to lymph nodes in the neck

Salivary gland biopsy or fine needle aspiration to determine whether the tumor is
benign or malignant
Treatment
The recommended treatment is usually surgery to remove the affected salivary
gland. If the tumor is benign, no other treatment is usually needed.
Radiation therapy or extensive surgery may be needed if the tumor is cancerous.
Chemotherapy is sometimes used in patients who are considered high risk, or when
the disease has spread beyond the salivary glands.
Outlook (Prognosis)
Most salivary gland tumors are noncancerous and slow growing. Removing the
tumor with surgery usually cures the condition. In rare cases, the tumor is cancerous and
further treatment is needed.
Possible Complications

Cancerous tumors may cause further complications, including spread to other organs
(metastasis).

Rarely, surgery to remove the tumor can injure the nerve that controls movement of
the face.
When to Contact a Medical Professional
Call your health care provider if:

You have pain when eating or chewing

You notice a lump in the mouth, under the jaw, or in the neck that does not go away
in 2 - 3 weeks or is getting larger
5. Tests for self evaluation.
A. Tests for self evaluation (test problem)
1. What size of tumour is characterized T1 of the tongue carcinoma?
1). The diameter of the tumour to 1 cm
2). *The diameter of the tumour to 2 cm
3). The diameter of the tumour to 2 cm
4). The tumor within the competence of tongue
5). The diameter of the tumour to 4 cm
Correct answer: 2.
2. What is the histological method for research the cancer of mucous membrane oral
cavity?
1). The scrape
2). The smear preparation
3). The aspiration biopsy
4). *The incisional biopsy
5). The needle biopsy
Correct answer: 4.
3. What is the optional productive preneoplastic disease of lower lip ?
1) Erythroplacia
2) *Atrofical heilitis
3) Leicoplacia
4) Papilloma
Correct answer: 2.
4. The very often histological form of the mucous cover mouth cavity tumour is?
1) Adenocarcinoma
2) *Planocellular cancer
3) Melanoma
4) clear-cell carcinoma
5) Basal cellular cancer
Correct answer: 2.
5. The main method of treatment planocellular cancer of oral cavity on early stage?
6.
Telegammatherapy
7.
*short-distance radiation therapy
8.
chemotherapy
9.
hormonotherapy
10.
laserotherapy
Correct answer: 2.
B. Situation tasks for self-control:
Task 1.
The man of 52 y.o address to the surgical cabinet with a complaints on lower lip’s ulcer
at left. Ulcer have irregular shape and margin, app. 1.5 cm in diameter. The margin of ulcer
is above the skin level, everted and infiltrated. By palpation infiltrate around ulcer
movable, size app 4 cm. The submandibular lympho node at left is increase to 2 cm. By
cytology – cell of malignant growth.
4. Provisional diagnosis
5. Prescribe additional examinations
6. Prescribe treatment
Task 2.
The man 47 years, has addressed to the dentist with complaints to presence of an
painful ulcer of tongue on the right.
Objectively: the ulcer with soft edges in the size 1,0 cm. at the lateral surface of tongue.
The bottom is covered by grey-yellow scurf. Submandibular lymph nodes are enlarged
from both parts, painful. The doctor supposes a malignant tumour.
1. What basis methods of diagnostics it is possible to verify the diagnosis?
2. What are the diseases and what methods should be differentiated with tongue cancer?
3. How to treat the cancer of tongue?
6. Literature.
Basic.
1. Sorcin V, Popovich A, Dumanskiy Yu, et al. Clinical oncology. Simferopol,
2008; 192 p.
2. Schepotin IB, Evans SRT. Oncology. Kiev, 2008; 235 p.
Additional.
1. National Comprehensive Cancer Network. NCCN Practice Guidelines in
Oncology: Tumors of salivary glands Screening. v. 2012.
3. Posner M. Head and neck cancer. In: Goldman L, Ausiello D, eds. Cecil
Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007: 200 p.
4. Wein RO, Malone JP, Weber RS. Malignant neoplasms of the oral cavity. In: Flint
PW, Haughey BH, Lund VJ, et al, eds. Cummings Otolaryngology Head and Neck
Surgery. 5th ed. St. Louis, Mo: Mosby Elsevier; 2010: 96 p.
Methodical guidelines written
by Assistant oncology department
PhD. Lysenko S.A.