1. Mangubat, Mary Love Joy Mansukhani, Sujata May Manzana, Apple
ORAL CAVITY MASS
Mangubat, Mary Love Joy
Mansukhani, Sujata May
Manzana, Apple

2. 38 y/o Male
Chief complaint: Oral ulcer

3. History of Present Illness
6 months PTC
2x2cm ulcer in the left lower gingiva
2 months PTC
firm mass in the submandibular area
1 month PTC
another mass appeared at the left lateral neck at the level of the lower third of the SCM

4. Review of Systems (-)
Past Medical History (-)

5. Personal and Social History
10 pack year smoking history
(+) alcoholic beverage drinker

6. Physical Examination
Oral cavity: 2x2cm ulcer, lower gingiva near the retromolar trigone

7. Physical Examination
Neck: 4x4cm firm well-delineated, slightly movable mass at the left jugulo-digastric area
-3x3cm firm, well-delineated, movable mass at the lower third of the SCM

8. Physical Examination
Thyroid gland: Negative for masses

9. Salient Features 38 y/o Male 10 pack year smoking history
(+) alcoholic beverage drinker
2x2cm ulcer, lower gingiva near the retromolar trigone
4x4cm firm well-delineated, slightly movable mass at the (L) jugulo-digastric area
3x3cm firm, well-delineated, movable mass at the lower third of the SCM
thyroid gland: (-) mass

10. What is your Clinical Impression?

11. Differential Diagnosis
TB adenopathy
Metastatic carcinoma from oral cavity cancer
Lymphoma
Lymphadenitis from aphthous ulcer

12. Metastatic CA from ORAL CAVITY CA
SCC is the most common type (>90%)
Risk factors: alcohol and tobacco use,
Symptoms: non healing wound, pain, “on and off” bleeding , pain in swallowing, ear pain, a change in speech, uncoordinated swallowing, or a lump in the neck
sores in the mouth, whether they are related to trauma or to a variation of canker sores, should fully heal within three weeks

13. Metastatic CA from ORAL CAVITY CA
80 % of unilateral neck mass are cervical metastasis from HNSCC
Oral cavity CA metastasize to the nodes in the ff levels:
Level 1 -submental,submandibular nodes
Level 2 –upper jugular chain nodes
Level 3 –middle jugular chain nodes
Schwartz’s Manual of Surgery 8th Ed.

14. Lymphadenitis from Aphthous ulcer
Also referred to as canker sore, painful, open sore in the mouth; white or yellow and surrounded by a bright red area
they are benign
inner surface of the cheeks and lips, tongue, soft palate, and the base of the gums
emotional stress, dietary deficiencies (especially iron, folic acid, or vitamin B-12), menstrual periods, hormonal changes, food allergies, most commonly with viral infections

15. Lymphadenitis from Aphthous ulcer
may also be linked to problems with the body's immune system, mouth injury due to dental work, aggressive tooth cleaning, or biting the tongue or cheek
SYMPTOMS: tingling or burning sensation, pain, less common symptoms are fever, malaise, swollen lymph nodes

16. Lymphadenitis from Aphthous ulcer
complete healing in 1 to 3 weeks
large ulcers (>1 cm) take 2 to 4 weeks to heal
may recur monthly or several times a year

17. Lymphoma Ulcers in the gingiva, tongue, palate, and tonsillar area
Clinical features: Elevated,ulcerated area that may proliferate rapidly, giving the appearance of traumatic inflammation
underlying HIV infection
Harisson’s Principles of Internal Medicine 17th ed. Vol 1 p217

18. Metastatic Carcinoma from Oral Cavity CA
TB adenopathy
Metastatic carcinoma from oral cavity cancer
Lymphoma
Lymphadenitis from aphthous ulcer
Metastatic Carcinoma from Oral Cavity CA

19. What is your next plan of action?

20. Thorough Physical Examination
visual inspection of the oral and nasal cavities, neck, throat, and tongue using a small mirror and/or lights
also feel for lumps on the neck, lips, gums, and cheeks
complete head and neck examination with indirect nasopharyngeal and laryngopharyngeal mirror examination

21. Endoscopy
use a thin, lighted tube called an endoscope to examine areas inside the body
type of endoscope to be used will depend on the area being examined
Laryngoscope - inserted through the mouth to view the larynx;
Esophagoscope - inserted through the mouth to examine the esophagus
Nasopharyngoscope - inserted through the nose so the doctor can see the nasal cavity and nasopharynx

22. Biopsy
TOLUIDINE BLUE- recommended for early detection as a guide for optimal biopsy. It clinically stains malignant lesions dark blue but does not stain normal mucosa. Dye is absorbed by the nuclei of malignant cells with increased DNA synthesis.
Follow with 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
Subglottis, esophagus, and tracheobronchial tree are routinely evaluated to rule out synchronous primaries, which may have an incidence of 20%.

23. Routine hematologic examination
assess overall medical condition and possibility of spread to distant organs
Anemia may be detected with a CBC with platelet count
Liver function test determines hepatic spread

24. FINDINGS Nasopharyngolaryngoscopy (-)
Biopsy of ulcer: Well-differentiated Squamous Cell Carcinoma
Fine needle Biopsy of the neck mass: Chronic Lymphadenitis

25. What will you do next?

26. Open Lymph node Biopsy
makes a cut in the skin and removes the lymph node
If more than one lymph node is taken, the biopsy is called a lymph node dissection
Open biopsy and lymph node dissection takes a bigger sample than a needle biopsy
Done to check to see if a known cancer has spread to the lymph nodes (staging) and to plan cancer treatment

27. Metastatic work ups, Imaging of oral cavity and neck to determine resectability
Chest radiograph PA and Lateral
Panoramic view (Panorex) of the mandible and/or dental X-rays.
When necessary to adequately assess the status of the patient's dentition
RULE OUT (1) A synchronous pulmonary tumor, (2) Acute or chronic pulmonary disease (3) Metastatic tumor.
Abnormal findings on chest x-ray or suspicious lesions need further imaging including a chest CT.

28. Metastatic work ups, Imaging of oral cavity and neck to determine resectability
CT and MRI of the head, neck and superior mediastinum
assess the presence and extent of nodal metastases, their relationship to the carotid and other adjacent structures, and to evaluate the superior mediastinum
also useful to identify abnormalities in the base of tongue and nasopharynx that may suggest the location of the primary tumor, and to rule out parapharyngeal or paratracheal adenopathy

29. Metastatic work ups, Imaging of oral cavity and neck to determine resectability
should also 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

30. Metastatic work ups, Imaging of oral cavity and neck to determine resectability
MRI of the head and neck with or without Gadolinium
Including the nasopharynx, skull base, and neck, to attempt to locate the primary tumor within the nasopharynx and, if present, assess invasion of adjacent structures, such as the paraspinal muscles, infratemporal fossa, temporal bone, sphenoid sinus, bone marrow of the clivus, carotid artery, cranial nerves, and intracranial structures
overall accuracy in staging LN same with CT
preferred method for staging SCC of the oral cavity and oropharynx

31. Metastatic work ups, Imaging of oral cavity and neck to determine resectability
Panoramic x-ray (Panorex) of the mandible and/or dental X-rays.
When necessary to adequately assess the status of the patient's dentition in anticipation of radiation therapy.
PET scanning
additional diagnostic tool to improve the accuracy of CT
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

32. Proceed with Surgery Standard for treatment of head and neck cancer
literature reports radiation therapy for patients with N0 or N1 necks and concludes that radiation or surgery can treat them equally well

33. Refer for radiation therapy
Nearly all patients with advanced disease require adjuvant radiotherapy, preoperatively or postoperatively
Preoperative radiotherapy has the risk of increased complications of surgery
Radiation dosage in excess of 6000 cGy is recommended with a boost to areas of high risk
Indications:
include a bulky tumor with significant risk of recurrence (T3 and T4)
histologically positive margins
perineural or perivascular invasion of tumor

34. Refer for radiation therapy
INDICATIONS FOR NECK:
elective treatment of the N0 neck not treated surgically where risk of micrometastasis is high
gross residual tumor in the neck following neck dissection
multiple positive lymph nodes
extranodal extension of tumor

35. FINDINGS Head and neck examinations: (-) Chest X-ray: (-)
Panoramic x-ray of mandible:
lytic lesion of the body of the mandible near the angle

36. What type of surgery is indicated?

37. Operative findings:
3 x 2 cm ulcer of the lower gingiva with invasion into the mandible
5 x 4 cm well-encapsulated firm mass located at the submandibular triangle (level 1 to level 2 )
Multiple pinkish-red, firm, grossly enlarged nodes (1-2 cm) along the jugular chain (levels 2 to 4)
4 x 3 cm well encapsulated firm mass at the subclavicular area

39. TNM Staging T N
Source: American Joint Committee on Cancer Staging Manual, 6th ed. M

40. Stage IVC

41. Operation done
Wide excision of the ulcer with segmental mandibulectomy with modified radical neck dissection, left: the defect was reconstructed using titanium plates.
Segmental mandibulectomy:  removes an entire segment of the mandible, disrupting continuity of the bone.  This is performed when tumor invades bone.
Modified/functional/Bocca radical neck:  cervical lymph nodes, submandibular gland.

42. Segmental Mandibulectomy
removes an entire segment of the mandible, disrupting continuity of the bone.  This is performed when tumor invades bone.
may be performed in the setting of a composite resection,
resection of a segment of mandible in continuity with a cancer of the oral cavity or oropharynx or a primary cancer of the alveolar ridge.

43. Cosmetic and functional consequences
Advantages
Adequate margins of resection
Excellent exposure
Ease of exposure
Disadvantages
Cosmetic and functional consequences

44. Final histopath:
Well differentiated squamous cell carcinoma with metastasis to 5/20 lymph nodes, the largest measures 2 cm with extracapsular invasion; margins clear; with bony invasion

45. What adjuvant treatment is required?

46. Radiation Pre and post-op radiation Adverse reactions:
Improves local/regional control in HNSCC
within 6 weeks of surgery
50 to 70 Gy over 5 to 7 weeks
Adverse reactions:
acute: mucositis, skin erythema
Late: fibrosis, xerostomia, altered state

47. Chemotherapy
No survival advantage compared to surgery and/or radiation
Cisplatin, carboplatin, 5-FU
Palliation of recurrent or unresectable disease, combined with radiation

48. THANK YOU!