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

38 y/o Male Chief complaint: Oral ulcer

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

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

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

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

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

Physical Examination Thyroid gland: Negative for masses

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

What is your Clinical Impression?

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

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 http://www.headandneckcancer.org/patienteducation/docs/oralcavity.php

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.

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

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

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 http://www.nlm.nih.gov/medlineplus/ency/article/000998.htm

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

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

What is your next plan of action?

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

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

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%.

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

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

What will you do next?

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

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.

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

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

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

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

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

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

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

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

What type of surgery is indicated?

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

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

Stage IVC

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.

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. http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-1-4160-2445-3..50037-6&isbn=978-1-4160-2445-3

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

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

What adjuvant treatment is required?

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

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

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