3 History of Present Illness 6 months PTC2x2cm ulcer in the left lower gingiva2 months PTCfirm mass in the submandibular area1 month PTCanother mass appeared at the left lateral neck at the level of the lower third of the SCM
5 Personal and Social History 10 pack year smoking history(+) alcoholic beverage drinker
6 Physical ExaminationOral cavity: 2x2cm ulcer, lower gingiva near the retromolar trigone
7 Physical ExaminationNeck: 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 ExaminationThyroid gland: Negative for masses
9 Salient Features 38 y/o Male 10 pack year smoking history (+) alcoholic beverage drinker2x2cm ulcer, lower gingiva near the retromolar trigone4x4cm firm well-delineated, slightly movable mass at the (L) jugulo-digastric area3x3cm firm, well-delineated, movable mass at the lower third of the SCMthyroid gland: (-) mass
11 Differential Diagnosis TB adenopathyMetastatic carcinoma from oral cavity cancerLymphomaLymphadenitis 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 necksores 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 HNSCCOral cavity CA metastasize to the nodes in the ff levels:Level 1 -submental,submandibular nodesLevel 2 –upper jugular chain nodesLevel 3 –middle jugular chain nodesSchwartz’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 areathey are benigninner surface of the cheeks and lips, tongue, soft palate, and the base of the gumsemotional 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 cheekSYMPTOMS: 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 weekslarge ulcers (>1 cm) take 2 to 4 weeks to healmay 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 inflammationunderlying HIV infectionHarisson’s Principles of Internal Medicine 17th ed. Vol 1 p217
18 Metastatic Carcinoma from Oral Cavity CA TB adenopathyMetastatic carcinoma from oral cavity cancerLymphomaLymphadenitis from aphthous ulcerMetastatic Carcinoma from Oral Cavity CA
20 Thorough Physical Examination visual inspection of the oral and nasal cavities, neck, throat, and tongue using a small mirror and/or lightsalso feel for lumps on the neck, lips, gums, and cheekscomplete head and neck examination with indirect nasopharyngeal and laryngopharyngeal mirror examination
21 Endoscopyuse a thin, lighted tube called an endoscope to examine areas inside the bodytype of endoscope to be used will depend on the area being examinedLaryngoscope - inserted through the mouth to view the larynx;Esophagoscope - inserted through the mouth to examine the esophagusNasopharyngoscope - inserted through the nose so the doctor can see the nasal cavity and nasopharynx
22 BiopsyTOLUIDINE 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 biopsyIf 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 lesionsSubglottis, 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 organsAnemia may be detected with a CBC with platelet countLiver function test determines hepatic spread
24 FINDINGS Nasopharyngolaryngoscopy (-) Biopsy of ulcer: Well-differentiated Squamous Cell CarcinomaFine needle Biopsy of the neck mass: Chronic Lymphadenitis
26 Open Lymph node Biopsymakes a cut in the skin and removes the lymph nodeIf more than one lymph node is taken, the biopsy is called a lymph node dissectionOpen biopsy and lymph node dissection takes a bigger sample than a needle biopsyDone 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 LateralPanoramic view (Panorex) of the mandible and/or dental X-rays.When necessary to adequately assess the status of the patient's dentitionRULE 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 mediastinumassess the presence and extent of nodal metastases, their relationship to the carotid and other adjacent structures, and to evaluate the superior mediastinumalso 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 spreadOverall 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 GadoliniumIncluding 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 structuresoverall accuracy in staging LN same with CTpreferred 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 scanningadditional diagnostic tool to improve the accuracy of CTIn 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 postoperativelyPreoperative radiotherapy has the risk of increased complications of surgeryRadiation dosage in excess of 6000 cGy is recommended with a boost to areas of high riskIndications:include a bulky tumor with significant risk of recurrence (T3 and T4)histologically positive marginsperineural 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 highgross residual tumor in the neck following neck dissectionmultiple positive lymph nodesextranodal 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
37 Operative findings:3 x 2 cm ulcer of the lower gingiva with invasion into the mandible5 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
41 Operation doneWide 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 AdvantagesAdequate margins of resectionExcellent exposureEase of exposureDisadvantagesCosmetic 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
46 Radiation Pre and post-op radiation Adverse reactions: Improves local/regional control in HNSCCwithin 6 weeks of surgery50 to 70 Gy over 5 to 7 weeksAdverse reactions:acute: mucositis, skin erythemaLate: fibrosis, xerostomia, altered state
47 ChemotherapyNo survival advantage compared to surgery and/or radiationCisplatin, carboplatin, 5-FUPalliation of recurrent or unresectable disease, combined with radiation