1. ORAL CANCER
Submitted By:
Kanika Singhal

2. CONTENTS Acknowledgement Introduction Epidemiology
Etiology and Risk factors
Clinical features
Diagnosis
Treatment
Prevention

3. ACKNOWLEDGEMENT
I am grateful acknowledging the valuable contributions of community department staff for skillful and generous support in the presentation of the content.

4. INTRODUCTION
Oral Cancer is a part of a cancer group called HEAD AND NECK CANCERS , and is defined as an uncontrollable growth of cancerous cells and invade the mouth (called oral cavity ) and the part of the throat behind the mouth (called oropharynx).
It most commonly involves the tissue of lips or tongue. It may also occur on-cheek lining, floor of mouth, gums, palate.

5. EPIDEMIOLOGY One of the 10 leading cancers About 2-5 lakh new cases
It accounts for 2% of cancer deaths in males and 1% of cancer deaths in females.
Majority of oral cancers are squamous cell cancers.
Average age – 40 to 60 years.

6. ETIOLOGY & RISK FACTORS
7 ETIOLOGY S OF ORAL CANCER
1) Smoking
2) Spirit
3) Spices
4) Sepsis
5) Sunlight
6) Sharp tooth
7) Syphillis

7. RISK FACTORS : AGE :men over the age greater than 40 years
GENDER : men are at higher risk than women.
LOCATION : cancer of lip is rare and cancer of buccal mucosa and tongue constitute the bulk of oral cancer.
GENETIC PREDISPOSITION :genetic studies have shown that neoplasm tend to occur in families .
Individuals with GSTM1 male genotype may be at higher risk of oral cancer development .
POOR ORAL CAVITY HYGIENE AND ILL FITTING DENTURES : these 2 factors can increase the risk for developing oral cancer when associated with tobacco use and alcohol consumption ,offering a perfect location for tumour 2 develop .
PRE CANCEROUS ORAL LESIONS: leukoplakia is the most common pre malignant lesion. The rate of transformation to malignant lesion varies 1- 3 %
INFECTIOUS AGENTS: bacteria- syphillis:tertiary stage, virus-HSV type 1, HIV
ENVIRONMENTAL FACTORS : tobacco , alcohol, dietary factors, physical agents such as – sunlight,trauma,heat,radiation.

8. CLINICAL FEATURES
Patches inside the mouth or on lips that are white (leukoplakia), a mixture of red and white (Erythro leukoplakia) or red (Erythroplakia).
A sore on lip and in the mouth that won't heal.
Bleeding in the mouth.
Loose teeth.
Difficulty or pain when swallowing.
Difficulty wearing dentures.
A lump in the neck.
Ear ache.

9. DIAGNOSIS DIAGNOSTIC AIDS :
VITAL TISSUE STAINING WITH TOLUIDINE BLUE: tld. Blue can be applied directly to suspicious lesions or used as an oral rinse .
The assesment of dye uptake depends upon clinical judgement and experience
Positive retention of tld.blue (mainly in areas of leukoplakia, erythroplakia and uptake in a peripheral pattern of an ulcer ) may indicate the need for biopsy.
False positive dye retension may occur in inflammatory and ulcerative lesions but false negetive retension is uncommon.

10. COMPUTER-ASSISTED CYTOLOGY-OF ORAL BRUSH BIOPSY SPECIMENS: it is done on pap-stained exfoliated cells and then scanned by computer for abnormal cell morphology and keratinization and then final diagnosis is done on the basis of standard histomorphologic criteria.
Exfoliative oral epithelial cells have the same genetic changes associated with dysplasia and cancer as did paired biopsy specimens.

11. LIGHT TECHNOLOGIES : vizilite is a disposable chemiluminescent light sourse , used in conjunction with a standard visual examination and tld. Blue
It enhance the visibility of lesions by increasing the brightness, texture, sharpness.

12. IMAGING TECHNOLOGIES: ROUTINE RADIOLOGY, COMPUTED TOMOGRAPHY (CT) NUCLEAR, SCINTISCANING ,MAGNETIC RESONANCE IMAGING, AND ULTRASONOGRAPHY – provide evidence of bone involvment and indicate the extent of some soft tissue lesions .
POSITRON EMISSION THEREPY (PET) – using the radiolabeled glucose analog 18-FLUORODEOXY GLUCOSE (FDG) offers the functional imaging approach for the entire body.
PET fused with COMPUTED TOMOGRAPHY(PET-CET) – provide information for staging and in evaluation of patients with suspected recurrent squamous cell carcinoma of head and neck , in whom anatomic imaging is inconclusive .

13. TREATMENT SURGERY: - Tumors involving bone.
- When the side effects of sugery are less significant then those with radiations.
- For tumors that lack sensetivity to radiations
- For recurrent tumors in areas that have previously received radio therepy.
RECENT ADVANCES; reconstruction, neurological anastmosis of free grafts.

14. RADIATION THERAPY :
It may be administered with intent to cure, as part of a combined radiation surgery or chemotherepy, or for palliation
Biologic effect of radiation depends on the dose per fraction , no.of fractions per day , total t/t time , total dose of radiation.
It has an advantage of t/t the d/s in situ and avoiding the need for removal of tissue , and may be the t/t of choice for t1 and t2 tumors .

15. CHEMOTHERAPY:
It is used as induction therapy prior to local therapies, simultaneous chemoradiotherapy, and adjuvant chemo therapy after local t/t.
Toxic effects – mucositis ,nausea, vomiting , bone marrow suppression
Agents – methotrexate, bleomycin, cisplatin.

16. COMBINED RADIATION AND SUGERY
Combined therapy can result in improved survival in cases of advanced tumors and tumors that show aggressive biologic behavior.
Radiations can be used pre operatively, post operatively or with a planned split-course approach.
Post operative chemoradiotherapy can be used to treat cells that remain at the margin of resection and to control sub clinical disease.

17. CANCER VACCINES
Form of biological therapy.
Vaccines for infectious diseases like measles, mumps, tetanus are injected into a person before diseases develops.
They expose a body immune cells to weakenend forms of the disease antigens that are present on the surface of the infectious agent.

18. GENE THERAPY
It is an experimental treatment that involves introducing genetic material into a person's cells to fight diseases.
A gene may be inserted into an immune system cell to inhances it's ability to recognize and attact cancer cells.
Cancer cells with genes can be injected that cause the cancer cells to produce cytukines and stimulate the immune system.

19. CANCER IMMUNOTHERAPY
It is use of immune system to reject cancer.
This can be either –
a) through immunization of the patient in which case the patient own's immune system is trained to recognize tumor cells as targets to be destroyed.
b) through the administration of therapeutic antibody as drugs in which case the patient's immune system is recruited to destroy tumor cells by the therapeutic antibodies.

20. TNM- STAGING :
T – TUMOR
TX -size cannot be assessed .
T0 – no evidence.
TIS – carcinoma in situ .
T1 – tumor 2cm or less.
T2 - tumor > 2cm but < 4cm.
T3 - tumor > 4cm .
T4 – lip : tumor invade adjt. Structures eg. Through cortical bone, tongue , skin pof neck.
Oral cavity : tumor invades adjt. Structures eg . Through cortical bone , into deep muscle of tongue, max. sinus, skin .

21. N – NODAL INVOLVMENT
NX – lymphnode cannot be assessed.
NO - no lymphnode meta stasis.
N1 - metastasis in a single ipsilateral lymphnode 3cm or <
N2a- metastasis in a single ipsilateral lymphnode >3cm but < 6cm.
N2b - metastasis in multiple ipsilateral lymphnode <6cm .
N2c - metastasis in bilateral or contralateral lymphnode <6cm .
N3 – metastasis in a lymphnode >6cm.
M – DISTANT METASTASIS
MX – distant metastasis cannot be assesed.
MO – no distant metastasis.
M1 – distant metastasis .

22. STAGING STAGE T N M Stage 0 Tis N0 M0 Stage I T1 Stage II T2 Stage III
N0, N1
Stage IV T4
Any T
N2, N3
Any N M1

23. PREVENTION 4 LEVELS * tertiary prevention
* primordial prevention --> healthy lifestyles, exercise, no adverse habits, healthy eating habits
*primary prevention --> prohibit sale of tobacco
--> prohibit advertising of tobacco products
--> restrict use of tobacco products
--> increase tax on tobacco products
--> celebrating days like NO TOBACCO DAY
* tertiary prevention

24. *secondary prevention --> screening
--> oral self examination
--> use of nicotine replacement therapy
*tertiary prevention --> surgery
--> radiotherapy
--> chemotherapy
--> removable and fixed prosthesis,
maxillofacial prosthesis