Oral Cancer

Anatomy

Lymphatic drainage of Head and Neck

levels of cervical lymph nodes

Tumor: Is a mass of cells, tissues or organs resembling those normally present but arranged atypically and behave abnormally. Is a mass of cells, tissues or organs resembling those normally present but arranged atypically and behave abnormally. Behavior is very essential and is of great importance. Behavior is very essential and is of great importance. Oral cancer

Classification: Histogenetic: Histogenetic: Epithelial originEpithelial origin connective tissue originconnective tissue origin Histological: Histological: Degree of differentiation.Degree of differentiation. Well Well moderate moderate poorly differentiated poorly differentiated

Clinical behavior: Clinical behavior: Benign:Benign: slowly growing and expanding causing pressure atrophy but remain within the capsule. slowly growing and expanding causing pressure atrophy but remain within the capsule. Very few mitosis could be seen. Very few mitosis could be seen. Malignant:Malignant: Invade surrounding tissues and locally invasive. Invade surrounding tissues and locally invasive. Progressive growth and metastasize to distant organs, embolic spread due to lack of cell adhesion Progressive growth and metastasize to distant organs, embolic spread due to lack of cell adhesion Mitosis. Mitosis. Intermediate:Intermediate: Locally invasive, no metastasis. Basal cell carcinoma and Ameloblastoma Locally invasive, no metastasis. Basal cell carcinoma and Ameloblastoma

Pathways of cancer spread (Metastasis) Invasion into local stroma Invasion into local stroma Lymphatic spread Lymphatic spread Vascular system (Hematogenous spread) Vascular system (Hematogenous spread) Neural spread Neural spread Circulation of the tumor and arrest at the distant site Circulation of the tumor and arrest at the distant site

Epidemiology Oral cavity and oropharyngeal tumours comprise 40% of cancers Oral cavity and oropharyngeal tumours comprise 40% of cancers Greater in men than women Greater in men than women It is most common in the 6 th and 7 th decades, although there is evidence that it is increasing in young adults It is most common in the 6 th and 7 th decades, although there is evidence that it is increasing in young adults

Aetiology smoking and consumption of alcohol smoking and consumption of alcohol diet containing high proportions of vegetables and fruit might modulate carcinogenic effect diet containing high proportions of vegetables and fruit might modulate carcinogenic effect Human papilloma virus (HPV) considers as a risk factor in oropharyngeal squamous cell carcinoma Human papilloma virus (HPV) considers as a risk factor in oropharyngeal squamous cell carcinoma Betel quid chewing is related to the high incidence of oral cancer in India Betel quid chewing is related to the high incidence of oral cancer in India

Roles of the dentist with patients in oral cancer Recognition of Cancer and Medical Considerations Recognition of Cancer and Medical Considerations Treatment Planning Modifications Treatment Planning Modifications Dental treatment planning for the patient with cancer begins with establishment of the diagnosis. Planning involves the following: 1- Pre-treatment evaluation and preparation of the patient 2- Oral health care during cancer therapy, which includes hospital and outpatient care 3- Post-treatment management of the patient, including long-term considerations Reference: Dental Management. CHAPTER 26 - Cancer and Oral Care of the Patient

Premalignant conditions Conditions of definite premalignant potential Leukoplakia Leukoplakia Erythroplakia Erythroplakia Chronic hyperplastic candidisis Chronic hyperplastic candidisis Conditions associated with an increased risk of malignant transformation Lichen planus Lichen planus Oral submucous fibrosis Oral submucous fibrosis syphilitic glossitis syphilitic glossitis

Clinical finding Clinical finding Radiograph Radiograph Biopsy Biopsy Blood investigations Blood investigations Diagnosis of oral cancer

Malignant Tumors  CLINICAL DIAGNOSIS OF ORAL CANCER Symptoms vary according to the site of the lesion Symptoms vary according to the site of the lesion painless in the early stagespainless in the early stages painful and tender when secondarily infected or involves a sensory nervepainful and tender when secondarily infected or involves a sensory nerve painless lump or ulcer on the lippainless lump or ulcer on the lip Posteriorly no symptom until it reach a size of 2 ‑ 3 cm swelling,Posteriorly no symptom until it reach a size of 2 ‑ 3 cm swelling, pain and difficulty in deglutition pain and difficulty in deglutition absence of symptoms until the tumor metastasize to regional lymph nodesabsence of symptoms until the tumor metastasize to regional lymph nodes hard lump on the neck hard lump on the neck

Malignant Tumors late symptoms:late symptoms: pain due to secondary infection or nerve involvement pain due to secondary infection or nerve involvement excessive salivation excessive salivation difficulty in deglutition, speech difficulty in deglutition, speech haemorrhage haemorrhage Within bone :Within bone : painless swelling involving the buccal and lingual or palatal sulci painless swelling involving the buccal and lingual or palatal sulci teeth become loose and painful ‑ acute alveolar abscess teeth become loose and painful ‑ acute alveolar abscess edentulous pt. the denture does not fit edentulous pt. the denture does not fit denture hyperplasia denture hyperplasia anaesthesia of the upper or lower lip and the cheek. anaesthesia of the upper or lower lip and the cheek.

Lip Cancer Carcinoma of lip: Carcinoma of lip: age 50 ‑ 70 years. Male lower class.age 50 ‑ 70 years. Male lower class. Predisposition factor: Predisposition factor: dirty, jagged and stained teethdirty, jagged and stained teeth irritation.irritation. tobacco smokertobacco smoker leukoplakia.leukoplakia. intense solar radiation ‑ blistering cheilitis due to sunshine.intense solar radiation ‑ blistering cheilitis due to sunshine.

Lip Cancer Lower lip affected in 93%Lower lip affected in 93% Upper lip affected in 5%Upper lip affected in 5% Angle of mouth affected in 2%Angle of mouth affected in 2% Metastases within a year ‑ submental, submandibular and upper jugular.Metastases within a year ‑ submental, submandibular and upper jugular. Death due to infection and bronchopneumonia. Death due to infection and bronchopneumonia.

Tongue cancer Carcinoma of tongue Carcinoma of tongue Anterior 2/3, affect malesAnterior 2/3, affect males Posterior 1/3 equal in both sexes.Posterior 1/3 equal in both sexes. Age over 60 years.Age over 60 years. Predisposing factors: Predisposing factors: Bad oral hygieneBad oral hygiene Heavy alcoholic with element of Vit.B deficiency. Producing precancerous mucosal atrophyHeavy alcoholic with element of Vit.B deficiency. Producing precancerous mucosal atrophy Syphilitic and leukoplakia. 25% and 5%.Syphilitic and leukoplakia. 25% and 5%. Superficial glossitis, papilloma, fissures and non ‑ specific ulcers.Superficial glossitis, papilloma, fissures and non ‑ specific ulcers.

Malignant Tumors Site & Types: Site & Types: 1. lateral edge of tongue 58% 1. lateral edge of tongue 58% 2. tip of tongue 2 ‑ 4% 2. tip of tongue 2 ‑ 4% 3. dorsum. of tongue 7 ‑ 15% 3. dorsum. of tongue 7 ‑ 15% 4. posterior 1/3 21 ‑ 33% 4. posterior 1/3 21 ‑ 33% 1. ulcerative1. ulcerative 2. fissured malignant2. fissured malignant 3. papillary3. papillary 4. flat nodules4. flat nodules 5. scirrhous or atrophic type5. scirrhous or atrophic type

Diagnosis History of the disease (signs and symptoms) History of the disease (signs and symptoms) Investigations: Investigations: Plain radiography (orthopantomogram “OPG”, occipito-mental, chest radiograph) Contrast radiography Sialography, carotid angiography, Barium swallow Cross sectional imaging Computerized tomography (CT) Magnetic resonance imaging (MRI) Nuclear medicine Bone scinitigraphy Position emission tomography (PET) Ultrasonography Biopsy Biopsy Fine needle Aspirsation for cytology or biopsy

Biopsy Incisional biopsy Incisional biopsy Excisional biopsy Excisional biopsy Fine needle aspiration biopsy Fine needle aspiration biopsy Fine needle Core biopsy Fine needle Core biopsy

 Alkaline phosphatase: Found to be elevated in bone and liver disease. Found to be elevated in bone and liver disease.  Amylase: Found to be elevated in diseases of the pancreas. Found to be elevated in diseases of the pancreas.  Bilirubin: Found to be elevated in Liver disease Found to be elevated in Liver disease  Calcium: Found to be elevated in cancer of the bone, parathyroid, Found to be elevated in cancer of the bone, parathyroid, multiple myeloma and other diseases.  Creatinine: to be elevated in kidney disease. to be elevated in kidney disease. Nonspecific Blood Tests

Clinical staging of oral cancer

TNM classification of head and Neck Tumour  TISTumour in situ  T cm  T22.1 – 4.0 cm  T34.1 – 6.0 cm  T4>6.1 cmor invading adjacent structures  N 0No regional adenopathy  N 1Ipsilateral adenopathy  N 2single Ipsilateral node node 3-6 cm or multiple Ipsilateral nodes < 6.0 cm  N 3Massive Ipsilateral or contralateral nodes  M 0No evidence of Metastases  M 1Metastases beyond the cervical lymph nodes  M xMetastases not assessed

Multidisciplinary Team (MDT)  Oral and maxillofacial surgeons  ENT surgeons  specialist anaesthetists  clinical / medical Oncologists  specialist nurses  specialist pathologists  Specialist radiologists  Speech and language therapists  Dieticians  Restorative dentists  Dental hygienists  Psychologists

Therapeutic options of oral cancer Surgery Surgery Radiotherapy Radiotherapy Systemic anti-cancer therapies Systemic anti-cancer therapies Factors have a bearing on the choice of treatment: Site of primary tumour Site of primary tumour Stage of disease Stage of disease Proximity or involvement of bone Proximity or involvement of bone Physical status of patient Physical status of patient Patient performance Patient performance

Surgery Conventional excision Conventional excision Laser surgery Laser surgery Thermal surgery Thermal surgery

Access to the primary tumour Trans-oral route: anterior part of the oral cavity Trans-oral route: anterior part of the oral cavity When the tumour increase in size and becomes more posterior, three main alternative approaches can be applied: When the tumour increase in size and becomes more posterior, three main alternative approaches can be applied: A- Lip split and mandibulotomy B- A ‘’ pull through’’ technique via the neck C- For maxillary tumours, an upper lip and para-nasal incision (lateral infra-orbital extension is rarely required and has a high complication rate)

Tracheostomy

Neck dissection Radical neck dissection: Refers to the removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible to the clavicle, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the diagastric muscle medially, to the anterior border of the trapezius. Included are levels I through V. This entails the removal of three important nonlymphatic structures—the internal jugular vein, the sternocleidomastoid muscle, and the spinal accessory nerve. Modified radical neck dissection: Modified radical neck dissection: Refers to removal of the same lymph node levels (I through V) as the radical neck dissection, but with preservation of the spinal accessory nerve, the internal jugular vein, or the sternocleidomastoid muscle.

Neck dissection Classical neck dissection decribed by Crile, which involves resection of the lymph nodes in level I-V of the neck together with sacrifice of: Classical neck dissection decribed by Crile, which involves resection of the lymph nodes in level I-V of the neck together with sacrifice of: Sternocleidomastoid muscle Spinal accessory nerve Internal jugular vein All other neck dissections are selective and best described by the levels of lymph nodes resected and which of the vital structures have been sacrificed, e.g. Level I-IV with resection of internal jugular vein. This avoids confusion regarding the meaning of term such as modified radical neck dissection, functional, comprehensive, supra- omohyoid and extended. All other neck dissections are selective and best described by the levels of lymph nodes resected and which of the vital structures have been sacrificed, e.g. Level I-IV with resection of internal jugular vein. This avoids confusion regarding the meaning of term such as modified radical neck dissection, functional, comprehensive, supra- omohyoid and extended. Elective neck dissection (in N0) or therapeutic neck dissection (in clinically or radiologically N disease ). Where there is no clinical or radiological evidence of nodal involvement, elective neck dissection may be indicated because up to 30% of pattern with tumours of the floor of mouth or tongue will have occult micrometastases. Elective neck dissection (in N0) or therapeutic neck dissection (in clinically or radiologically N disease ). Where there is no clinical or radiological evidence of nodal involvement, elective neck dissection may be indicated because up to 30% of pattern with tumours of the floor of mouth or tongue will have occult micrometastases.

Neck dissection The following structures are preserved in neck dissection unless they are directly invaded by tumour: The following structures are preserved in neck dissection unless they are directly invaded by tumour: Sternocleidomastoid muscle Carotid artery Internal jugular vein Spinal accessory nerve Vagus Laryngeal nerve Sympathetic chain Phrenic nerve Cervical plexus Hypoglossal nerve Mandibular branch of the facial nerve Neck Access: Apron incision H incision MacFee incision

Reconstruction Speech Speech Swallowing Swallowing Eating Eating Chewing Chewing Sensation Sensation Cosmesis Cosmesis Reconstruction techniques: 1- Open wound (in case of laser) 2- Primary closure 3- Graft (it gains a new blood supply from the wound bed): Autogenous (same individual), Allograft (same species but different individual), Xenograft (different species). Mucosa graft: split thickness skin graft (epidermis and part of dermis), full thickness skin graft Bone grafts Cartilage grafts (ear, nose and rib) 4- Flaps (retaining its attached vascular supply) Local, Regional and Distant flaps 5- Developments (tissue expansion and tissue engineering), it has limited roles in cancer patients 6- Implants 7- Prosthetic rehabilitation

Surgical complications Immediate/ early complications Bleeding Bleeding Airway obstruction an tracheostomy problems Airway obstruction an tracheostomy problems Seroma and salivary collection Seroma and salivary collection Infection Infection Dehiscence/ failure of wound healing/ fistula Dehiscence/ failure of wound healing/ fistula Nerve injuries Nerve injuries Flap failure Flap failure Donor site morbidity Donor site morbidity

Late complications Recurrence Recurrence Altered sensation Altered sensation shoulder and neck problems shoulder and neck problems Hypertrophic scars Hypertrophic scars Lymphoedema Lymphoedema Fatigue Fatigue Depression Depression Surgical complications

Radiotherapy External beam radiotherapy External beam radiotherapy Interstitial radiotherapy (brachytherapy) Interstitial radiotherapy (brachytherapy)

Systemic anticancer therapies  chemotherapy  Gene therapy  photodynamic therapy

Chemotherapy Timing of administration of chemotherapy Timing of administration of chemotherapy Neoadjuvant/ induction: prior to radiotherapy or surgery Concurrent: administered during the radiotherapy treatment schedule (treatment for tonsil, base of tongue and nasopharynx) Adjuvant: Given after radiotherapy or surgery Complications of chemotherapy: Early complications: severe mucositis, nausea and vomiting, weight loss, diarrhoea, bleeding, hair loss, neurotoxicity, immunosuppression, neutropaenia, thrombocytopaenia and multi-organ failure. Late complications: Nephropathy, cardiomyopathy, pulmonary fibrosis and peripheral neuropathy

Photodynamic therapy Killing of cancer cells (by singlet oxygen) through administration of a photosensitiser followed by non thermal laser light application Killing of cancer cells (by singlet oxygen) through administration of a photosensitiser followed by non thermal laser light application Photosensitiser, light and oxygen Photosensitiser, light and oxygen Photosensitisers either topical or systemic Photosensitisers either topical or systemic light illumination either surface illumination or interstitial illumination light illumination either surface illumination or interstitial illumination

Interstitial photodynamic therapy for base of tongue tumour. Illumination with 652nm red laser light using fine optic fibers. US scan was used as a guidance for fibers insertion. Surface illumination photodynamic therapy for tongue squamous cell carcinoma using a microlens fiber.

Nutritional support

Speech and language therapy swallowing assessment Psychosocial aspects quality of life assessment