InduKrishna

3rd Year OMR

Work Up

• INTRODUCTION

• ORAL CANCER

• INCIDENCE

• CLASSIFICATION

• ETIOPATHOGENESIS

• CLINICAL FEATURES

• TNM STAGING

• INVESTIGATIONS

NOMENCLATURE & DEFINITION

• A TUMOR is a commonly used, but non-specific, term for a neoplasm. The word tumor simply refers to a mass.

• This is a general term that can refer to benign or malignant growths.

NEOPLASIA

NEO “new” PLASMA “formation”

R. A WILLIS

"A neoplasm is an abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissues, and persists in the same excessive manner after cessation of the stimulus which evoked the change."

• Cancer is a general term for malignant neoplasm CARCINOS

• CARCINOMA SARCOMA LYMPHOMA LEUKEMIA

CELL CYCLE

CHARACTERISTICS OF CANCER

CELLS• Unrestricted cellular

proliferation

• Transformation ability to invade

• Metastasis

• Suppression of apoptosis

• Angiogenesis

ORAL CAVITY AND OROPHARYNX

Incidence

• 6th most common malignancy

• India –upto 40% of all malignancies

• M>F -2:1

• AGE : 60 yrs

• 5 year survival rate

• 90% is SCC

• Most common site – lateral border of tongue

CLASSIFICATION

• Malignant epithelial tumours Squamous cell carcinoma Verrucous carcinoma Basaloid squamous cell carcinoma Papillary squamous cell carcinoma Spindle cell carcinoma Acantholytic squamous cell carcinoma

Adenosquamous carcinoma Carcinoma cuniculatumLymphoepithelial carcinoma

• Salivary gland tumours • Salivary gland carcinomas • Acinic cell carcinoma • Mucoepidermoid carcinoma • Adenoid cystic carcinoma • Polymorphous low-grade adenocarcinoma • Basal cell adenocarcinoma • Epithelial-myoepithelial carcinoma• Clear cell carcinoma, not otherwise specified

Cystadenocarcinoma• Mucinous adenocarcinoma • Oncocytic carcinoma • Salivary duct carcinoma • Myoepithelial carcinoma • Carcinoma ex pleomorphic adenoma

• Soft tissue tumours

• Kaposi sarcoma

• Lymphangioma

• Ectomesenchymal chondromyxoid tumour

• Haematolymphoid tumours • Diffuse large B-cell lymphoma (DLBCL) • Mantle cell lymphoma • Follicular lymphoma • Extranodal marginal zone B-cell lymphoma of MALT type • Burkitt lymphoma • T-cell lymphoma (including anaplastic large cell lymphoma) • Extramedullary plasmacytoma• Langerhans cell histiocytosis• Extramedullary myeloid sarcoma • Follicular dendritic cell sarcoma / tumour

• Mucosal malignant melanoma

• Secondary tumours

ETIOLOGY

• Tobacco with or without Betel Nut: About 90% of people with oral cavity and oropharyngeal cancer use tobacco

• Alcohol: Drinking alcohol strongly increases a smoker's risk of developing oral cavity and oropharyngeal cancer.

• Ultraviolet light: More than 30% of patients with cancers of the lip have outdoor occupations associated with prolonged exposure to sunlight.

• Irritation: Long-term irritation to the lining of the mouth caused by poorly fitting dentures

• Poor nutrition: A diet low in fruits and vegetables is associated with an increased risk

• Mouthwash: Some studies have suggested that mouthwash with a high alcohol content

• Human papillomavirus (HPV) infection:• Immune system suppression:• Age: The likelihood of developing oral and

oropharyngeal cancer increases with age, especially after age 35.

• Gender: Oral and oropharyngeal cancer is twice as common in men as in women

WHO has listed several conditions

having potential to transform into OC• Lichen planus

• Erythroplakia

• Actinic chelitis

• OSMF

• Leukoplakia ( verrucous)

• SYPHILIS

• DLE

• Sideropenic Dysphagia

Inherited Risk Factors

A review of inherited cancer syndromes and their relevance to oral squamous cell carcinoma (Prime SS, Thakker NS, et.al. Oral oncology 2001 Jan;37(1):1-16: examined genetic defects associated with inherited cancer syndromes and their relevance to oral cancer.

Defective DNA repair mechanism: xerodermapigmentosa, bloom syndrome, fanconi anemia, cowden syndrome,dyskeratosis congenita

• Tumor suppressor gene(p53) defect: Li Fraumeni syndrome.

• Relationship between ABO blood groups and oral cancer (Jaleel BF, et. al. Indian J Dental Research 2012 Jan;23(1):7-10:

found that people with blood group A had

1.46 times higher risk of developing oral cancer as compared with other blood group.

Molecular Basis of Cancer

• Tumor suppressor genes : p16,p21,p53,RB gene.

• Proto-oncogene : bcl1 , cyclin D1,bcl2 erb-b, ras.

• Telomeres, telomerase, cell senescence

• Tumor invasion and metastasis:: loss of 9p21 chromosome region

Patient workup

History

Clinical examination

Investigations

Early Detection is Critical !!!

• Tongue : 35%

• Floor of mouth: 30%

• Lower alveolus: 15%

• Buccal mucosa: 10%

• Upper alveolus/hard palate: 8%

• RMT: 2% followed by

• Lips: lower-93%, upper-5%, commissure- 2%

Clinical Examination : 8 step examination

Examination of Lymph Nodes

DIAGNOSTIC AIDS IN DETECTION OF CANCER

VITAL TISSUE STAINING

Brush BIOPSY

BIOPSY

CHEMILUMINESCENCE

NARROW EMISSION TISSUE

FLUORESCENCE• VELscope

COLPOSCOPY

• SALIVARY BIOMARKERS

• ELASTOGRAPHY

• BIO NANOCHIP( LAB ON A CHIP)

IMAGING MODALITIES

• Conventional modalities – 2D imaging

• Ultrasonography with FNAC

• CBCT

• CT- Multi Detector Row CT

• MRI

• PET .. PET CT

MUST Do’s… Patient work up

• Investigations :

Primary:

Photographs

Incisional biopsy

FNAC

Orthopantogram

CXR

ECG

Routine blood investigations

Investigations: for staging

- CT head + neck ± CT chest

- MRI

- USG of neck or primary ± USG guided

FNAC of suspicious lymphadenopathy

- PET

SOME COMMON ORAL CANCER THAT

WE ENCOUNTER are

SQUAMOUS CELL CARCINOMA

Basal cell CA

Verrucous Carcinoma

MALIGNANT MELANOMA

NASOPHARYNGEAL CARCINOMA

SPINDLE CELL CARCINOMA

OSTEOSARCOMA

REFERENCE

Oral and Maxillofacial Medicine: The Basis of Diagnosis and Treatment C Scully

Burket's Oral Medicine 12th edition M Glick

Oral Pathology: Clinical Pathologic CorrelationsRegezi ,Sciubba, Jordan

The Washington Manual of Oncology R Govindan

JOURNALS

• Basis of Carcinogenesis P Uma Devi Health administrator

• Oral field cancerization : update on current concepts M Mohan Oncology Reviews

• Diagnostic aids in detection of Oral Cancer : An update G Sharma WJS