case 3 72 y/o female. 1. a. what is your clinical impression?

Case 372 y/o female

1. a. What is your clinical

impression?

Clinical Impression• Squamous Cell Carcinoma of the

buccal mucosa with possible facial and submandibular lymph nodes metastases

Etiology: Squamous Cell Carcinoma

• SCC is an epithelial malignancy with morphologic features of squamous cell differentiation without additional features suggestive of other differentiated tissues.

• On initial presentation, 90% of cancers of the head and neck are SCCs

• A number of etiologic agents are associated with various degrees of risk in the development of SCC of the head and neck.

Etiology: Squamous Cell Carcinoma

• These risk factors include:

- use of tobacco or alcohol

- age

- genetic predisposition

- nutritional status

- chronic irritation

- exposure to industrial products or heavy metals, viruses, or ionizing radiation

Tobacco use

• tobacco inhaled as smoke and the smokeless products, such as snuff and chewing tobacco, and reverse smoking.

• association is strong and dose related• smokers are likely to have other risk factors or

etiologic agents in addition to their tobacco use. Factors such as poor dentition, ethanol use, and poor nutrition are associated with tobacco use.

Age

• Age-related patterns: rising rates of occurrence closely linked to increasing age.

• In the United States, the medial age at which patients present with oral cancers is 63 years.

Nutritional Status

• Diet is often associated with numerous confounders, such as tobacco exposure, lifestyle-related viral exposure, alcohol use, and oral hygiene.

Chronic Irritation

• The role of poor dentition and poor oral hygiene appear to increase the risk of oral SCC.

Location: Buccal Mucosa

• This includes all of the mucosal lining from the inner surface of the lips to the line of attachment of mucosa of the alveolar ridges and pterygomandibular raphe.

• Etiology: lichen planus, chronic dental trauma, and the use of tobacco and alcohol.

Location: Buccal Mucosa

• Propensity to spread locally and to metastasize to regional lymphatics

• Lymphatic drainage is to the facial and the submandibular nodes.

• Deep invasion may occur into the cheek, requiring resection.

Current concepts In the Management of oral cancer A short scientific

communication by Dr. Rehan A. Kazi M.S. (ENT), Fc.Oncology Dept. of Oncology,

Masina Hospital, Bombay, India.

1. b. What are the differential diagnosis?

Differential Diagnosis

• Oral Leukoplakia• Oral Lichen Planus• Mucosal Melanoma• Salivary Gland Tumors

Oral Leukoplakia• A whitish patch or plaque that cannot be

characterized clinically or pathologically as any other disease, and is not associated with any physical or chemical causative agent, except the use of tobacco.

• Most common potentially malignant disorders.– Highest risk of developing cancer– 4-17% had malignant transformation of the lesions in

less than 20 years. – The risk of developing malignancies at lesion sites is 5

times greater in patients with leukoplakia than in patients without leukoplakia.

Oral Leukoplakia• Most leukoplakias occur on the lip, the buccal

mucosae, or the gingivae.• Characteristics:

– Homogenous leukoplakia: smooth, white plaques – Verrucous leukoplakia : white and warty– Erythroleukoplakias/Speckled leukoplakias: mixed white

and red lesions • Dysplastic lesions: no specific clinical appearance

– Erythroplasia: dysplasia, carcinoma in situ, and frank carcinomas

– The site of the lesion is relevant: floor of the mouth or ventrum of the tongue and the lip

– The size of the lesion appears to be irrelevant

Oral Lichen Planus

• A chronic inflammatory disease that causes bilateral white striations, papules, or plaques on the buccal mucosa, tongue, and gingivae.

• T-cell–mediated autoimmune disease in which autocytotoxic CD8+ T cells trigger apoptosis of oral epithelial cells.

• Oral squamous cell carcinoma (SCC) developed in fewer than 5% of patients.

Oral Lichen Planus• Insidious onset: patients are unaware of their oral

condition• Roughness of the lining of the mouth, sensitivity of the oral

mucosa to hot or spicy foods or oral hygiene products, painful oral mucosa, sore gums, red or white patches on the oral mucosa, red gums, or oral ulcerations.

• Oral discomfort, especially in association with atrophic and erosive lesions, in 2/3 of patients– Erythematous and erosive lesions are often sensitive or painful.– Symptoms vary from mucosal sensitivity to continuous

debilitating pain.

Mucosal Melanoma

• Relatively rare condition; 8-15% of all malignant melanomas of the head and neck region, less than 1% of all melanomas.

• Shows far more aggressive behavior as compared with skin melanomas and are more inclined to metastasize into regional and distant sites or recur locally, regionally, or in distant locations, resulting in a high rate of cause-specific death.

• 5-year survival rate of 10-15%.

• Peak incidence: 60-80 years• Usually diagnosed as an advanced clinical

stage, with a rate of 5-48% of regional and 4-14% of distant dissemination.

• The nasal cavity is the most common location within the head and neck area.

• Mucosal melanoma, particularly in the oral cavity, is relatively common in Japan

Mucosal Melanoma

• Exposure to sunlight is not an etiologic factor • Irritants and carcinogenic compounds in the air, such as tobacco

smoke, have been implicated in the development of this malignancy

• The most prevalent clinical presentation of tumors within the oral cavity is a painless mass.

• Difficult to determine whether lesion is primary or metastatic because cutaneous melanoma may metastasize widely, including to the mucous membranes. – Patients with a history of cutaneous or ocular melanoma or nevi that

have regressed should be considered to have metastatic melanoma rather than primary mucosal melanoma.

– The most important features in defining a primary lesion from a metastatic lesion are site of involvement, presence or absence of pigment, overlying mucosal ulceration, extension along salivary gland ducts, and vascular and perineuralinvasion.

Mucosal Melanoma

Salivary Gland Tumors

• Salivary gland neoplasms make up 1% of all head and neck tumors.

• Most commonly appear in the sixth decade of life. – After age 60: Patients present with malignant lesions– After age 40: Patients present with benign lesions

• Benign neoplasms occur more frequently in women than in men, but malignant tumors are distributed equally between the sexes.

• Origin:– Parotid glands: 80% – Submandibular glands: 10-15% – Sublingual and minor salivary glands.

• About 80% of parotid neoplasms are benign, with the relative proportion of malignancy increasing in the smaller glands. – 25/50/75 rule: As the size of the gland decreases, the incidence of

malignancy of a tumor in the gland increases in approximately these proportions.

• The most common tumor of the parotid gland is the pleomorphic adenoma, which represents about 60% of all parotid neoplasms.

• Almost half of all submandibular gland neoplasms and most sublingual and minor salivary gland tumors are malignant.

Salivary Gland Tumors

1. c. Give the clinical stage of

the disease

TNM Staging for Oral Cavity Carcinoma

Primary Tumor

TX = Unable to assess primary tumor

T0 = No evidence of primary tumor Tis = Carcinoma in situ T1 = Tumor is <2 cm in greatest dimension T2 = Tumor >2 cm and <4 cm in greatest dimension T3 = Tumor >4 cm in greatest dimension T4 (lip) = Primary tumor invading cortical bone, inferior alveolar nerve,

floor of mouth, or skin of face (e.g., nose or chin) T4a (oral) = Tumor invades adjacent structures (e.g., cortical bone,

into deep tongue musculature, maxillary sinus) or skin of face T4b (oral) = Tumor invades masticator space, pterygoid plates, or skull

base and/or encases the internal carotid artery

8 x 6 cm ulcerating mass extending from the L buccal

mucosa externally to

the skin of the cheek


Regional lymphadenopathyNX = Unable to assess regional lymph nodesN0 = No evidence of regional metastasisN1= Metastasis in a single ipsilateral lymph node, 3 cm or less in

greatest dimensionN2a = Metastasis in single ipsilateral lymph node, >3 cm and <6

cmN2b = Metastasis in multiple ipsilateral lymph nodes, all

nodes <6 cmN2c = Metastasis in bilateral or contralateral lymph nodes, all

nodes <6 cmN3 = Metastasis in a lymph node >6 cm in greatest dimension

(2) palpable movable hard cervical

nodes at the left Submandibular

spacemeasuring 2 X 1.5 cm

and 1.5 X 1.2 cm


Distant metastases

MX = Unable to assess for distant metastases

M0 = No distant metastases

M1 = Distant metastases


Stage IVa T4a(oral)N2bM0

WORK UP• History and PE• Comprehensive head and neck examination

– Direct Laryngoscope, esophagoscopy and bronchoscopy is mandatory

• 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

• Imaging– CT scan is useful in evaluating the extent of the primary

tumor and nodal involvement. – include the lung fields and liver for assessment of distant

spread. – Overall accuracy of nodal staging with CT (90-95%) – 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 is the preferred method for staging squamous cell carcinoma of the oral cavity and oropharynx.

• Positron emission tomography (PET) – additional diagnostic tool to improve the accuracy

of CT scan. – 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.

• Tumor Evaluation on extent of cervical lymph node

• 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%.

3. What are the treatment options for this patient? How would you manage the patient?

SURGICAL TREATMENT

• Principal means of achieving the cure of an oral squamous cell carcinoma.

• Two distinctive phases– resection of the tumor – reconstruction of the defect

• may be immediate or delayed.

Current concepts In the Management of oral cancerA short scientific communication by Dr. Rehan A. Kazi M.S. (ENT), Fc.Oncology

Dept. of Oncology, Masina Hospital, Bombay, India.

SURGICAL TREATMENT

• Patients with advanced, or disseminated disease where cure is unlikely

• Potential to remove the pain and discomfort of the destructive tumor mass

• The improved ability to eat, speak, and breathe can make the last months of such patients much more tolerable.

.Current concepts In the Management of oral cancer

A short scientific communication by Dr. Rehan A. Kazi M.S. (ENT), Fc.OncologyDept. of Oncology, Masina Hospital, Bombay, India.

LOCAL RESECTION• Confined by the dimensions of the mouth. • A transpolar approach - severe limitations

– small lesions are located in the anterior portion of the mouth.

• Skin incisions - to gain sufficient access to larger lesions.

• Along anatomical planes• Splitting of the lower lip and osteotomy of the

mandible– good exposure of more posteriorly placed lesions.



LOCAL RESECTION

• Cosmetic result is less acceptable• The anterior floor of mouth - submental incision• Radical neck dissection with the resection of the

primary lesion– the neck surgery is completed first – the incision - provide access for a continuous en bloc

removal of the oral lesion. • Surgery of the maxilla cheek flap - Weber-

Ferguson incision.Current concepts In the Management of oral cancer


LOCAL RESECTION

• Extent of the resection is determined by the margins of the carcinoma

• Potentially involved tissue is not spared • The design of the resection must also consider

the possibility of spread along local structures.



LOCAL RESECTION• Clinical experience over recent years has

allowed the development of a more conservative approach to mandibular resection.

• Hemimandibulectomy – only for cases of significant bony invasion.– condylar process can some times be spared.

•



LOCAL RESECTION

• Must include the lingual to allow examination of the inferior alveolar nerve.

• If the periosteum is involved, but the bone has not obviously been disrupted– a partial thickness segment of the mandible will

need to be sacrificed. – If the area in question is above the mylohyoid line

the lower border can be left intact.



NECK DISSECTION• Presence of non-fixed cervical lymph node

metastasizes • Examination of the neck is always necessary

– cervical lymphadenopathy is not pathognomonic with metastatic carcinoma.

• Confirmation of the presence of malignant cells is needed– fine needle aspiration - before proceeding with

the neck dissection.



NECK DISSECTION

• Ideally carried out in continuity with the primary resection.

• Bilateral metastases – may be managed by simultaneous neck

dissections.

• The airway is secured by tracheotomy.



SURGICAL RECONSTRUCTION• To repair the cosmetic defect• To re-establish the functions of the lost tissues.• Should commence immediately following the

removal of the carcinoma• Should also be immediate even if the resection is

only designed to be palliative• Age or expectations of some patients may dictate

the need for only limited attempts at reconstruction.



SURGICAL RECONSTRUCTION• For more extensive soft tissue deficiencies

– flaps from the region of the head and neck• Favored method of reconstruction of larger defects in the

head and neck region. • Two types of flaps have been used - based on different

forms of blood supply. – Cutaneous flaps depend on direct axial arterialization– myocutaneous flaps have a non-axial, perforating

musculocutaneous blood supply.• Cutaneous chest flaps

– deltopectoral flap – anterior superior oblique chest flap.



SURGICAL RECONSTRUCTION• Myocutaneous flaps is dependent on the

presence of blood vessels between muscle and skin

• Sternocleidomastoid • Platysma • Trapezius myocutaneous

– provides an ideal color match for facial tissues.

• Pectoralis major flapCurrent concepts In the Management of oral cancer


MAXILLOFACIAL PROSTHODONTICS• The return of functions - speech and

mastication, and optimal cosmetic repair• Two phases of prosthodontic care may be

necessary.• The initial need is for the provision of surgical

splints. • Arch bars are of value of secure inter-dental

fixation following mandibular resection. Current concepts In the Management of oral cancer


RADIOTHERAPY• Exophytic, well-oxygenated tumours tend to

respond better than endophytic, hypoxic ones– larger lesions tend to be more hypoxic and hence are

less curable • Bone and muscle involvement adversely affect

the change of cure by radiation– Bone, being denser than soft tissues, absorbs more

radiation– The likelihood of necrosis of bone following

radiotherapy to lesions involving bone or adjacent to bone must be considered



• Anaplastic tumours are often better treated by radiotherapy– their high mitotic rate makes them more

radiosensitive



RADIOTHERAPY• Interstital Radiotherapy

– Interstitial radioactive implants are used to treat oral cancers

– Radium and Iridium 192 are more commonly used– These isotopes can only be placed on a temporary

basis– There is a risk of exposure for visitors while therapy is

ongoing– Typically, 10 rad/hour are emitted on implantation,

for a total dose of 12000 rad over 1 yearCurrent concepts In the Management of oral cancer


RADIOTHERAPY

• External irradiation– delivered in the form of protons or electrons

produced by megavoltage equipment– curative doses range from 5000 to 7000 rad,

typically spread over 5-7 weeks



COMPLICATIONS OF RADIOTHERAPY

• Exposure of the salivary glands results in destruction of the acini– May lead to xerostomia / dry mouth

• Radiation caries may also present– The teeth may be temporarily protected with acrylic splints– Intensive topical fluoride therapy combined with meticulous

oral hygiene limits the development and progression of caries– Dental infection or extractions following a course of

radiotherapy to the jaws carry a risk of osteoradionecrosis• This destructive disease is difficult to treat and often follows

a slowly progressive course leading to severe bone loss in the mandible.



CHEMOTHERAPY

• Cetuximab (Erbitux)– a monoclonal antibody– used to treat metastatic head and neck cancer– Side effect:

• A possibly severe, debilitating, acne-like rash occurs in more than 30% of patients



CHEMOTHERAPY

• Other prescribed medications include:– Cisplatin– Fluorouracil– Paclitaxel– Docetaxel



PATIENT AFTER-CARE• The critical period are the first years. Most recurrences

occur in this initial period.– Patients who are disease-free in this time will have a markedly

improved prognosis– Recurrence or metastasis of oral carcinoma carries a very poor

prognosis and in many cases palliation is the only possible course of management

– Review appointments should be scheduled monthly for the first post-treatment year, graduating to 6-monthly check-ups after 2 years.

– There is a great propensity for these patients to develop second malignant lesions in adjacent sites, or in other parts of the respiratory and digestive tracts, routine examinations should continue for life.



PATIENT AFTER-CARE• Immune-suppressed patients appear to have an

increased susceptibiity to Oral Cancer.• Precursors to Oral Carcinoma include:

– Rare Conditions such as• Xeroderma pigmentosum• Plummer-Vinson syndrome• Fanconi’s anemia

– Modifiable Lifestyle-related risk factors are• Smoking Tobacco• Alcohol



case 3 72 y/o female. 1. a. what is your clinical impression?

Documents

use of tobacco

tobacco exposure

risk of oral scc

alcohol use

oral cancers

poor oral hygiene

ethanol use

management of oral cancer