Download ORAL CAVITY MASS

38 y/o Male
 Chief complaint: Oral ulcer

6 months
PTC
2x2cm ulcer in the left
lower gingiva
2 months
PTC
firm mass in the
submandibular area
1 month
PTC
another mass appeared at the
left lateral neck at the level of
the lower third of the SCM
Review of Systems (-)
 Past Medical History (-)

10 pack year smoking history
 (+) alcoholic beverage drinker


Oral cavity:
2x2cm
ulcer, lower
gingiva
near the
retromolar
trigone

Neck: 4x4cm firm well-delineated, slightly
movable mass at the left jugulo-digastric area
-3x3cm firm, well-delineated, movable
mass at the lower third of the SCM

Thyroid gland: Negative for masses
38 y/o Male
 10 pack year smoking history
 (+) alcoholic beverage drinker
 2x2cm ulcer, lower gingiva near the retromolar
trigone
 4x4cm firm well-delineated, slightly movable mass
at the (L) jugulo-digastric area
 3x3cm firm, well-delineated, movable mass at the
lower third of the SCM
 thyroid gland: (-) mass

TB adenopathy
 Metastatic carcinoma from oral cavity
cancer
 Lymphoma
 Lymphadenitis from aphthous ulcer


SCC is the most common type (>90%)

Risk factors: alcohol and tobacco use,


Symptoms: non healing wound, pain, “on
and off” bleeding , pain in swallowing, ear
pain, a change in speech, uncoordinated
swallowing, or a lump in the neck
sores in the mouth, whether they are related to trauma or to
a variation of canker sores, should fully heal within three
weeks
http://www.headandneckcancer.org/patienteducation/docs/oralcavity.php
80 % of unilateral neck mass are cervical
metastasis from HNSCC
 Oral cavity CA metastasize to the nodes
in the ff levels:

› Level 1 -submental,submandibular nodes
› Level 2 –upper jugular chain nodes
› Level 3 –middle jugular chain nodes
Schwartz’s Manual of Surgery 8th Ed.

Aphthous ulcer
› Also referred to as canker sore, painful, open
sore in the mouth; white or yellow and
surrounded by a bright red area
› they are benign
› inner surface of the cheeks and lips, tongue, soft
palate, and the base of the gums
› emotional stress, dietary deficiencies (especially
iron, folic acid, or vitamin B-12), menstrual
periods, hormonal changes, food allergies, most
commonly with viral infections

may also be linked to problems with the
body's immune system, mouth injury due to
dental work, aggressive tooth cleaning, or
biting the tongue or cheek

SYMPTOMS: tingling or burning sensation,
pain, less common symptoms are fever,
malaise, swollen lymph nodes
complete healing in 1 to 3 weeks
 large ulcers (>1 cm) take 2 to 4 weeks to
heal
 may recur monthly or several times a
year

http://www.nlm.nih.gov/medlineplus/ency/article/000998.htm
 Ulcers
in the gingiva, tongue, palate,
and tonsillar area
 Clinical features: Elevated,ulcerated
area that may proliferate rapidly,
giving the appearance of traumatic
inflammation

underlying HIV infection
Harisson’s Principles of Internal Medicine 17th ed. Vol 1 p217
TB adenopathy
 Metastatic carcinoma from oral cavity
cancer
 Lymphoma
 Lymphadenitis from aphthous ulcer

Metastatic Carcinoma
from Oral Cavity CA

visual inspection of the oral and nasal
cavities, neck, throat, and tongue using
a small mirror and/or lights

also feel for lumps on the neck, lips,
gums, and cheeks

complete head and neck examination
with indirect nasopharyngeal and
laryngopharyngeal mirror examination
use a thin, lighted tube called an
endoscope to examine areas inside the
body
 type of endoscope to be used will
depend on the area being examined

 Laryngoscope - inserted through the mouth to
view the larynx;
 Esophagoscope - inserted through the mouth
to examine the esophagus
 Nasopharyngoscope - inserted through the
nose so the doctor can see the nasal cavity
and nasopharynx




TOLUIDINE BLUE- recommended for early detection
as a guide for optimal biopsy. It clinically stains
malignant lesions dark blue but does not stain normal
mucosa. Dye is absorbed by the nuclei of malignant
cells with increased DNA synthesis.
Follow with FNAB for cytology or excisional biopsy
If the diagnosis of carcinoma is made, endoscopic
examination should proceed under general
anesthesia with random biopsies of Waldeyer ring,
the hypopharynx, nasopharynx, and other common
sites of metastasis and any suspicious lesions
Subglottis, esophagus, and tracheobronchial tree are
routinely evaluated to rule out synchronous primaries,
which may have an incidence of 20%.

assess overall medical condition and
possibility of spread to distant organs

Anemia may be detected with a CBC
with platelet count

Liver function test determines hepatic
spread
Nasopharyngolaryngoscopy (-)
Biopsy of ulcer: Well-differentiated
Squamous Cell Carcinoma
Fine needle Biopsy of the neck mass:
Chronic Lymphadenitis
makes a cut in the skin and removes the
lymph node
 If more than one lymph node is taken, the
biopsy is called a lymph node dissection
 Open biopsy and lymph node dissection
takes a bigger sample than a needle biopsy
 Done to check to see if a known cancer has
spread to the lymph nodes (staging) and to
plan cancer treatment


Chest radiograph PA and Lateral




Panoramic view (Panorex) of the mandible
and/or dental X-rays.
When necessary to adequately assess the status
of the patient's dentition
RULE OUT (1) A synchronous pulmonary tumor, (2)
Acute or chronic pulmonary disease (3)
Metastatic tumor.
Abnormal findings on chest x-ray or suspicious
lesions need further imaging including a chest CT.

CT and MRI of the head, neck and superior
mediastinum
› assess the presence and extent of nodal
metastases, their relationship to the carotid and
other adjacent structures, and to evaluate the
superior mediastinum
› also useful to identify abnormalities in the base of
tongue and nasopharynx that may suggest the
location of the primary tumor, and to rule out
parapharyngeal or paratracheal adenopathy

should also include the lung fields and liver for
assessment of distant spread

Overall accuracy of nodal staging with CT (9095%) appears superior to the accuracy
obtained by clinical nodal staging (75-80%).
Thus, more metastases are detected when CT
is incorporated into the staging protocol of
patients with primary head and neck
squamous cell carcinoma

MRI of the head and neck with or without
Gadolinium
– Including the nasopharynx, skull base, and neck,
to attempt to locate the primary tumor within
the nasopharynx and, if present, assess invasion
of adjacent structures, such as the paraspinal
muscles, infratemporal fossa, temporal bone,
sphenoid sinus, bone marrow of the clivus,
carotid artery, cranial nerves, and intracranial
structures
– overall accuracy in staging LN same with CT
– preferred method for staging SCC of the oral
cavity and oropharynx
•
Panoramic x-ray (Panorex) of the mandible
and/or dental X-rays.
– When necessary to adequately assess the status of
the patient's dentition in anticipation of radiation
therapy.
•
PET scanning
– additional diagnostic tool to improve the accuracy
of CT
– In early radiologic studies, combination of CT and
PET has resulted in improved accuracy of staging,
but this is not yet the standard of care
Standard for treatment of head and
neck cancer
 literature reports radiation therapy for
patients with N0 or N1 necks and
concludes that radiation or surgery can
treat them equally well

•
•
•
•
Nearly all patients with advanced disease
require adjuvant radiotherapy, preoperatively or
postoperatively
Preoperative radiotherapy has the risk of
increased complications of surgery
Radiation dosage in excess of 6000 cGy is
recommended with a boost to areas of high risk
Indications:
– include a bulky tumor with significant risk of
recurrence (T3 and T4)
– histologically positive margins
– perineural or perivascular invasion of tumor

INDICATIONS FOR NECK:
› elective treatment of the N0 neck not treated
surgically where risk of micrometastasis is high
› gross residual tumor in the neck following neck
dissection
› multiple positive lymph nodes
› extranodal extension of tumor
Head and neck examinations: (-)
Chest X-ray: (-)
Panoramic x-ray of mandible:
lytic lesion of the body of the
mandible near the angle
3 x 2 cm ulcer of the lower gingiva with
invasion into the mandible
• 5 x 4 cm well-encapsulated firm mass
located at the submandibular triangle
(level 1 to level 2 )
• Multiple pinkish-red, firm, grossly enlarged
nodes (1-2 cm) along the jugular chain
(levels 2 to 4)
• 4 x 3 cm well encapsulated firm mass at the
subclavicular area
•
T
N
M
Stage IVC

Wide excision of the ulcer with
segmental mandibulectomy with
modified radical neck dissection, left: the
defect was reconstructed using titanium
plates.
removes an entire segment of the
mandible, disrupting continuity of the
bone. This is performed when tumor
invades bone.
 may be performed in the setting of a
composite resection,

› resection of a segment of mandible in
continuity with a cancer of the oral cavity or
oropharynx or a primary cancer of the
alveolar ridge.
http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4u1.0-B978-1-4160-2445-3..50037-6&isbn=978-1-4160-2445-3

Advantages
› Adequate margins of resection
› Excellent exposure
› Ease of exposure
Disadvantages
 Cosmetic and functional consequences


Well differentiated squamous cell
carcinoma with metastasis to 5/20 lymph
nodes, the largest measures 2 cm with
extracapsular invasion; margins clear;
with bony invasion

Pre and post-op radiation
› Improves local/regional control in HNSCC
› within 6 weeks of surgery
› 50 to 70 Gy over 5 to 7 weeks

Adverse reactions:
› acute: mucositis, skin erythema
› Late: fibrosis, xerostomia, altered state

No survival advantage compared to
surgery and/or radiation
› Cisplatin, carboplatin, 5-FU

Palliation of recurrent or unresectable
disease, combined with radiation