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OROPHARYNGEAL CANCER

Dr Tareq Gharaibeh, BDS, M.Med.Sc, FDS RCS

Assistant professor,Faculty of DentistryConsultant in Oral & Maxillofacial Surgery,

King Abdullah Teaching Hospital

ORPHARYNGEAL CANCER

• Introduction• Epidemiology• Aetiology• Clinical presentation• Workup and staging• Treatment modalities• Prognosis

Introduction

• The 6th most common malignancy within the EC ailthough the 3rd in men (4th in women) of developing countries

• The most common malignant tumour in south east asia.

• 40% of all malignancies in parts of India

• Commoner in males

Introduction

• The prognosis for cure improves the earlier the diagnosis is made and appropriate treatment started

• treatment for a small early lesion is likely to be less mutilating and have a lower morbidity than treatment for a large advanced lesion

Introduction

•Unlike many malignant lesions occurring elsewhere in the body oral scc can be readily observed in its‘ early stages. There are few places in the oral cavity that a lesion can genuinely progress unnoticed by patient and clinician.

Introduction

•The fact that so many patients still continue to present late with advanced disease is a sad indictment of the state of medical and dental care in Jordan and even the UK

Epidemiology

Squamous cell carcinoma (scc) accounts for about 90% of all oral malignancy the remainder include salivary gland neoplasms, lymphomas and sarcomas.

Epidemiology

The rate of new oral cancers would appear to be falling from its' peak in 1920 to the present levels. However, there is disturbing evidence that cancers of all types including oral cancer are on the increase.

Epidemiology

• there is a strong clinical impression as yet unsubstantiated that we are seeing a rise in incidence of aggressive oral scc in young patients with no accepted risk factors

Aetiology

• Actinic Radiation• Epithelial atrophy• Viruses• Immunosuppressio

n• Candida infection

• Smoking• Chewing habits• Alcohol• Poor diet• Industrial hazards• Dental factors

Aetiology

• Smoking:Cigar and pipe smoking Vs cigarette smokingReverse smoking

• Chewing habits:Pan chewing → Leukoplakia → SCC

• Alcohol:Unclear mechanismType and quality more important than quantity

Aetiology

Smoking and Alcohol synergism• Smoking alone: 9 times greater risk• Alcohol alone: 8 times greater risk• Smoking and alcohol consumption:

9+8=40!!

Aetiology

• Industrial hazards:Higher incidence in textile workers

• Dental factors• Actinic Radiation:

SCC more common in lower lip than upper lipLip cancer is rare in dark-skinned people

• Epithelial atrophy:May enhance the absorption of carcinogens

Aetiology

• Viruses:HSV-2 implicated in carcinoma of uterine cervix

• Immunosuppression:Increased incidence of certain cancers in patients with renal transplants or HIV

• Candidal infection:Chronic hyperplastic candidosis is premalignant

Jordan

Your average Mo• Male with carious teeth• Smokes 40-60 since Tany e3dady!!• Drinks cheap local spirits• Eats shawerma or falafel on the

road while Ferrarying in his Kia mini-van

Indications for urgent referral

• Any unhealed ulcer for more than two weeks

• Any unexplained oral bleeding• Any area of induration• Any unexplained white patch• All-red or red/white patches• Cervical nodes

Clinical presentation

• Can affect any part of the oral mucosa

• Sites particularly at risk vary according to aetiological factors:Europe: Tongue and lip

India: Buccal mucosa

SCC of lower lip

SCC on alveolar ridge

SCC in the FOM

Clinical presentation

• Early lesions are usually asymptomatic

• May present as:a white patch

a red patchan ulceran exophytic growth

Clinical presentation

• Pain may be a late feature• Advanced lesions have a very variable

presentation• Bone destruction may be evident on

radiographs• Teeth may become mobile• There may be altered sensation

Role of the medics

• Patient education• Elimination of risk factors• Thorough examination• Be safe.. refer if in doubt

Pre-malignant conditions

Leukoplakia

• Idiopathic white patch that cannot be wiped off the mucosa

• Up to 4% risk of malignant change in 5 years• Very variable clinical presentation

(homogeneous, speckled, verrucous, nodular,..etc)

• Management include biopsy, conservative treatment, excision, and laser ablation

Erythroplasia (erythroplakia)

• Red velvety pathches• Idiopathic• Very high risk of

malignant change• 70% are carcinomas

in situ on first biopsy• Same management as leukoplakias

Candidal leukoplakia

• Rough adherent white plaque

• Typical site is buccalmucosa behind the commissures

• Variable risk of malignant change• Management is with vigorous

systemic antifungals

Lichen planus

• Chronic inflammatory mucocutaneous disease

• Unclear pathogenesis• Two distinctive clinical types (non-

erosive and erosive)

• Usually bilateral distribution• Only erosive type is premalignant• Management includes biopsy and

steroids

Prognosis of oral cancer

• STNMP system:SiteTumour sizeNode involvementMetastasisPathology

Staging• T1 <2cm. T2 >2cm<4cm. T3 >4cm.

T4 massive tumour with invasion

• N0: No nodes• N1: ipsilateral <3cm• N2a: ipsilateral >3cm<6cm• N2b: ipsilateral multiple <6cm• N2c: Bilateral/Contralateral: <6cm• N3: any node >6cm

Investigation

• Surgical biopsy, Incisional• FNA, for neck and parotid lumps• Radiographs• CT• Ultrasound esp for abdomen and

liver mets.

Treatment

• CURATIVE

• LOCAL DISEASE CONTROL

• PALIATIVE ONLY

Team Approach

• Maxillofacial Surgeon• Plastic/Neuro surgery• Chemotherapist• Radiotherapist• Nutritionist• Speech therapist• Dentist• Maxillofacial prosthodontist

Treatment

Treatment modalities:• Surgical excision• Radiotherapy• Chemotherapy??• Surgery and radiotherapy

Surgery

• Excision of the tumour with a safety margin

• 1-2cm 3D margin for SCC• Intra-bony lesions require bigger

margin• Partial mandibulectomy or

maxillectomy with soft tissue and L.Ns

Management of the neck

• Neck divides into seven levels• Only levels I to V need

consideration

Management of the neck

• Therapeutic neck dissection: When disease is obviously present in the neck and the dissection is undertaken to ablate the disease

• Elective neck dissection; No obvious clinical disease in the neck but a high chance of occult disease or neck opened for access

Management of the neck

• Many confusing terms for dissection in use: ‘Functional’, ‘Supra-omohyoid’, ‘Lateral’, ‘Radical’, ‘Extended radical’ and ‘Modified radical’

Management of the neck

Two simpler terms:

• Comprehensive neck dissection, if all 5 levels are removed

• Selective neck dissection, anything less 5 levels

Management of the neck

Controversy regarding the (No) neck