oral cancer

Oral Cancer

Anatomy

Lymphatic drainage of Head and Neck

levels of cervical lymph nodes


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

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 candidisis Conditions associated with an increased risk of malignant transformation Lichen planus Oral submucous fibrosis syphilitic glossitis


Clinical finding Radiograph Biopsy Blood investigations
Diagnosis of oral cancer

Malignant Tumors

CLINICAL DIAGNOSIS OF ORAL CANCERSymptoms vary according to the site of the lesionpainless in the early stagespainful and tender when secondarily infected or involves a sensory nervepainless lump or ulcer on the lipPosteriorly no symptom until it reach a size of 2‑3 cm swelling,pain and difficulty in deglutitionabsence 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 involvementexcessive salivationdifficulty in deglutition, speech haemorrhageWithin bone:painless swelling involving the buccal and lingual or palatal sulci teeth become loose and painful ‑acute alveolar abscessedentulous pt. the denture does not fit denture hyperplasiaanaesthesia 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 teethirritation.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 tongueAnterior 2/3, affect males Posterior 1/3 equal in both sexes. Age over 60 years. Predisposing factors:Bad oral hygieneHeavy alcoholic with element of Vit.B deficiency. Producing precancerous mucosal atrophySyphilitic 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. ulcerative2. fissured malignant3. papillary4. flat nodules5. scirrhous or atrophic type


Diagnosis
History of the disease (signs and symptoms)Investigations:Plain radiography(orthopantomogram “OPG” , occipito-mental, chest radiograph) Contrast radiographySialography, carotid angiography, Barium swallowCross sectional imagingComputerized tomography (CT)Magnetic resonance imaging (MRI)Nuclear medicine Bone scinitigraphyPosition emission tomography (PET)UltrasonographyBiopsyFine needle Aspirsation for cytology or biopsy

Biopsy

Incisional biopsy Excisional biopsy Fine needle aspiration biopsy Fine needle Core biopsy


Alkaline phosphatase: Found to be elevated in bone and liver disease. Amylase: Found to be elevated in diseases of the pancreas. Bilirubin: 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.
Nonspecific Blood Tests

Clinical staging of oral cancer

TNM classification of head and Neck Tumour
TISTumour in situT10.1- 2.0 cmT22.1 – 4.0 cmT34.1 – 6.0 cmT4>6.1 cmor invading adjacent structuresN 0No regional adenopathyN 1Ipsilateral adenopathyN 2single Ipsilateral node node 3-6 cm or multiple Ipsilateral nodes < 6.0 cmN 3Massive Ipsilateral or contralateral nodesM 0No evidence of MetastasesM 1Metastases beyond the cervical lymph nodesM xMetastases not assessed

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 mandibulotomyB- A ‘’ pull through’’ technique via the neckC- For maxillary tumours, an upper lip and para-nasal incision (lateral infra-orbital 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

Classical neck dissection decribed by Crile, which involves resection of the lymph nodes in level I-V of the neck together with sacrifice of: Sternocleidomastoid muscle Spinal accessory nerve Internal jugular vein All other neck dissections are selective and best described by the levels of lymph nodes resected and which of the vital structures have been sacrificed, e.g. Level I-IV with resection of internal jugular vein. This avoids confusion regarding the meaning of term such as modified radical neck dissection, functional, comprehensive, supra-omohyoid and extended. Elective neck dissection (in N0) or therapeutic neck dissection (in clinically or radiologically N disease ). Where there is no clinical or radiological evidence of nodal involvement, elective neck dissection may be indicated because up to 30% of pattern with tumours of the floor of mouth or tongue will have occult micrometastases.

Neck dissection

The following structures are preserved in neck dissection unless they are directly invaded by tumour: Sternocleidomastoid muscle Carotid artery Internal jugular vein Spinal accessory nerve Vagus Laryngeal nerve Sympathetic chain Phrenic nerve Cervical plexus Hypoglossal nerve Mandibular branch of the facial nerve
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

Late complications Recurrence Altered sensation shoulder and neck problems Hypertrophic scars Lymphoedema Fatigue Depression
Surgical complications

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 multi-organ 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

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.
Surface illumination photodynamic therapy for tongue squamous cell carcinoma using a microlens fiber.

Nutritional support

Speech and language therapy swallowing assessment Psychosocial aspects quality of life assessment