management of the mandible in cancer of the oral...
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Management of the Mandible in cancer of the Oral Cavity
Professor Alexander D. Rapidis MD DDS PhD FACS
Chairman Dept. of Maxillofacial / Head and Neck Surgery
Greek Anticancer Institute, Saint Savvas Hospital
Athens Greece
Cancer of the mandible refers to mucosal squamous cell carcinoma of the alveolar process of the mandible that invades the underlying mandibular bone.According to several statistics, it represents the second in frequency site after
carcinoma of the tongue.
has the highest local recurrence rate
No Bone Invasion
T 1
Invasion within Alveolar Bone
T 1 T 2
Invasion beyond alveolar bone Invasion including the LMC
but above the LMC
T 3
Invasion including the LMC
T 4
LMC: Level of Mandibular Canal
Classification
Histological Patterns of Tumor Invasion
• Invasive pattern (infiltrative pattern)• Invasive pattern – (infiltrative pattern)– Islands of tumor infiltrate cancellous spaces– Little osteoclatic activity– Little osteoclatic activity– No intervening connective tissue
• Erosive pattern – (compressive patterns)• Erosive pattern – (compressive patterns)– Tumor advances as a broad front– Active osteoclasts separating tumor from boneActive osteoclasts separating tumor from bone– Connective tissue layer separating tumor/bone
Carter RL et al Patterns and mechanisms of bone invasion by squamous carcinomas of the head and neck Am J Surg 146:451, 1983
Patterns of invasion in the invasive front
Erosive
Solid border /solid cords
Patterns of invasion in the invasive front
InvasiveInfiltrating small groupsInfiltrating small groups
and single cells
Patterns of Mandibular InvasionRoutes of Entry into Mandibley
• Direct penetration through occulsal surfaceDirect penetration through occulsal surface
•Through periodontal membrane (interdental)
F th tt h d i i•From the attached gingiva
Patterns of Mandibular InvasionRoutes of Entry into Mandibley
• Through mental or mandibular foramena
• From metastatic neck tumor through lower gborder of mandible
• Cortical bone defects in edentulous alveolarCortical bone defects in edentulous alveolar ridge
How to detect mandibular invasionHow to detect mandibular invasion
• Clinical examination
• Radiographs (plain OPG)
• CT – DentaScan
• MRIMRI
• Bone scans
• Ultrasound
• PET CT
• Ultimate proof: histology
DentaScan as an accurate method of predicting mandibular invasion with squamous cell carcinoma of the oral cavity, Brockenbrough J, Petruzzelli GJ,
Lomasney L, Arch Otolaryngol Head Neck Surg 2003;129:113-117
Marginal resection
Anterior Marginal Mandibulectomyg y
Marginal resection
Take home message
Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma
• Clinical examination
• OPGOPG
• Denta Scan
• Bone Scan (Tc 99 – SPECT)( )
Take home message
Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma
• Clinical examination
• OPGOPG
• Denta Scan
• Bone Scan (Tc 99 – SPECT)( )
When negative:
M i l dib lMarginal mandibulectomy
Take home message
Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma
• Clinical examination
• OPGOPG
• Denta Scan
• Bone Scan (Tc 99 – SPECT)( )
When positive:
S l dib l i d iSegmental mandibular resection and reconstruction
Take home message
Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma
• Clinical examination
• OPGOPG
• Denta Scan
• Bone Scan (Tc 99 – SPECT)( )
When equivocal:
I i i l i iIntraoperative periosteal stripping
Take home message
Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma
• Clinical examination
• OPGOPG
• Denta Scan
• Bone Scan (Tc 99 – SPECT)( )
When equivocal:
I i i l i iIntraoperative periosteal stripping
When positive:When positive:Segmental mandibular resection and reconstruction
Take home message
Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma
• Clinical examination
• OPGOPG
• Denta Scan
• Bone Scan (Tc 99 – SPECT)( )
When equivocal:
I i i l i iIntraoperative periosteal stripping
When positive:When positive:Segmental mandibular resection and reconstruction
When negative:Marginal mandibulectomy
Second World Congress of the gInternational Academy of Oral Oncology
(IAOO)( )
July 8 – 11, 2009
Sheraton Centre Toronto
Invitation to Toronto!
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