1 The Principles of Oral Cancer ManagementKingket Agsornwong DDS, Diplomate Thai Board in Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery Unit Department of Dentistry, Maharaj Nakhon Si Thammarat Hospital

2 Oral Cavity BoundariesUpper anterior : skin and vermillion junction of upper lip Lower anterior : skin and vermillion junction of lower lip Upper posterior : junction of hard and soft palate Lower posterior : line of circumvallate papillae on the tongue

3 Oral Cavity Components of Oral cavity Lip Buccal mucosaLower alveolar ridge Upper alveolar ridge Retromolar trigone Floor of mouth Anterior part of tongue Tip of tongue Lateral borders of tongue Dorsum of tongue Ventral of tongue

4 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

5 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

6 Pathology Pathological types can occur : Mucosa Minor salivary gland- SCCA - Malignant melanoma Minor salivary gland - Mucoepidermoid tumor - Adenoid cystic carcinoma - Other adenocarcinoma

7 Pathology Pathological types can occur : Bone Other neoplasm- Osteogenic sarcoma Other neoplasm - Malignant lymphoma - Soft tissue sarcoma - Kaposi’s sarcoma - Carcinosarcoma Metastatic tumor

8 Pathology Vast majority of primary tumor of oral cavity is squamous cell carcinoma (SCCA) SCCA presents as many features Obvious exophytic, ulcerated lesion with a greyish necrotic base Associated margin of induration Flat superficial type

9 Pathology Endophytic type that infiltrated deeplyVerrucous type covered with filiform projection

10 Pathology squamous cell carcinoma (SCCA)

11 Pathology Histologically consist of irregular nestscolumn or strand of malignant epithelial cell infiltrating subepithelially

12 Pathology Site Distribution25% in alveolar, lingual area – corresponding to the posterior floor of mouth and adjacent lateral border of tongue 25% in anterior floor of mouth 25% in the rest of mouth

13 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

14 Etiological Factor Smoking and alcoholic drinking : major risk factorin caucasians Betel nut and tobacco consumption : major risk factor in asian people

15 Etiological Factor Tobacco - reverse smoking- increased incidence of cancer of hard palate Chewing “paan” - increased incidence of alveolobuccal cancer Alcohol - act synergistic with tobacco - topical effect and mucosal exposed to prolong contact with alcohol

16 Etiological Factor Ultraviolet radiation- increased risk of lower lip cancer Human virus - Herpes simplex virus (HSV) -> sensitized mucosa to the carcinogen in tobacco - Human papilloma virus (HPV) type 2, 11, 16 - HIV infected Pt with AIDS -> Kaposi’s sarcoma -> Non-Hodgkin’s lymphoma -> SCCA

17 Etiological Factor Premalignant lesion 1. Homogeneous leukoplakia- leukoplakia : white patch or plaque that cannot be characterised clinically or pathologically as any other disease - most common variety - appear as homogeneous, sharply circumscribed, thickened whitish area broken up by longitudinal fissure - generally hyperorthokeratotic (less hyperparakeratotic) - 2-5% of Pt with dysplastic change D clinically or pathologically

18 Homogeneous leukoplakiaEtiological Factor D clinically or pathologically Homogeneous leukoplakia

19 Etiological Factor Premalignant lesion 2. Non-homogeneous leukoplakia- Can be nodular, speckle or verrucous - Microscopic features : hyperkeratosis, acanthosis, parakeratosis, widening of rete peg, dyskeratosis, carcinoma in situ - Can develop into SCCA or verrucous carcinoma D clinically or pathologically

20 Non-homogeneous leukoplakiaEtiological Factor D clinically or pathologically Non-homogeneous leukoplakia

21 Etiological Factor Premalignant lesion 3. Erythroplakia- Erythroplakia : bright red velvety patch that cannot be characterised clinically or pathologically as being caused by any other condition - Commonly associated with underlying epithelial dysplasia and carcinoma in situ - 40% of Pt will develop frank malignancy - 17 times more common than leukoplakia to become malignancy D clinically or pathologically

22 Etiological Factor D clinically or pathologically Erythroplakia

23 Etiological Factor Others - poor oral hygiene- chronic use of mouth wash - marijuana smoking - diet and nutrition deficiency of iron, Vitamin C, E, A, riboflavin D clinically or pathologically

24 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

25 Epidemiology 2-6% of all cancer diagnosed annually in the US30% of all cancer of H&N Incidence increase with age 85% of cases (in Britain) occur after 5th decade M:F ~ 2-3:1 Trend : increased incidence and mortality in younger male D clinically or pathologically

26 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

27 Metastases I. Regional metastases (Nodal metastases)Lymphatic spread of tumor from oral cavity into the neck follow a step-wise, orderly and predictable fasion D clinically or pathologically The Memorial Sloan-Kettering Classification

28 Metastases I. Regional metastases (Nodal metastases)Pt with cervical metastases reduced 5 YSR ~ 50% Worse prognosis in : - multiple level of nodal involvement - extracapsular spread Pt with clinically negative neck % risk of metastases to level I-III Pt with clinically positive neck risk of metastases to level I-IV D clinically or pathologically

29 Metastases I. Regional metastases (Nodal metastases)Skip to level IV do occur ( with missing out level II, III) commonly associated with CA of anterior of tongue Metastases to level V - only 1% of Pt with clinically palpable node at other level - never seen as skip metastases D clinically or pathologically

30 Metastases I. Regional metastases (Nodal metastases)Risk of cervical nodal metastases : depend on primary site and stage of disease - Oral cavity : ~30% of initial evaluation - Lip : ~10% - Oral commissure : ~ 20% - FOM : 25-50% occult metastatic nodal disease - Alveolar ridge : 15% occult metastatic nodal disease D clinically or pathologically

31 Metastases I. Regional metastases (Nodal metastases)Risk of cervical nodal metastases : - Buccal mucosa : 10-20% occult metastatic nodal disease - RMT : 10-20% occult metastatic nodal disease - Tongue : % of Pt present occult metastases 20-50% of Pt with cervical LN metastases more frequent than other site - Contralateral metastases is common from the lesion closed to midline D clinically or pathologically

32 Metastases II. Distant metastasesMost common sites of distant metastases 1. Lung 66% 2. Bone 22% 3. Liver 9.5% Disease stage correlated with the rate of distant metastases Stage I : 1% Stage II : 14% Stage III : 15% Stage IV : 20% D clinically or pathologically

33 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

34 Staging Clinical staging of a particular tumor consist of1. Size of the primary tumor (T) 2. Status and size of the cervical LN (N) 3. Presence or absence of distant metastases (M) Concluded to TNM stage grouping for the tumor D clinically or pathologically

35 Staging D clinically or pathologically

36 Staging D clinically or pathologically

37 Staging D clinically or pathologically

38 Staging Stage 0 Tis N0 M0 Stage 1 T1 N0 M0 Stage 2 T2 N0 M0Stage 4a Any T N2 M0 Stage 4b Any T N3 M0 Stage 4c Any T Any N M1 D clinically or pathologically

39 Staging Stage I, II : confined to the primary site Stage III: present large primary tumor or those who with ipsilateral cervical metastases Stage IV : massive primary tumor or extensive regional or distant metastases D clinically or pathologically

40 Staging TNM Staging : aid clinician in 1. Planning of the therapy2. To provide the prognosis of the Pt 3. To assist in the evaluation of Rx results 4. Exchange of information among the center D clinically or pathologically

41 Staging Limitation : no presentation of Pt’s performance statusComorbidity Nutritional status Immune status Fixation of the node Level of nodal disease Pathologic features : depth of invasion, ECS, perineural invasion D clinically or pathologically

42 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

43 Diagnosis and evaluationPrinciples 1. History taking 2. Physical examination 3. Dental assessment 4. Radiographic evaluation 5. Tissue biopsy 6. Intra-operative visualization D clinically or pathologically

44 Diagnosis and evaluationCommon signs and symptoms Painful lesion in the mouth Persistent or bleeding ulcer Loose teeth Ill-fitting denture Pain in the mandible Trismus Hypoesthesia (due to perineural involvement) Malnutrition, weight loss D clinically or pathologically

45 Diagnosis and evaluationExtended tumor into the posterior portion Dysphagia Dehydration due to dysphagia Drooling Voice change Otalgia (involved CN IX, X) Respiratory distress D clinically or pathologically

46 Diagnosis and evaluationPhysical Examination Inspection, palpation, percussion, auscultation Visual inspection Oral cavity Size, location, appearance of the primary lesion Mobility of the tongue Elevation of the soft palate Trismus Indirect or fiberoptic laryngoscopy D clinically or pathologically

47 Diagnosis and evaluationPhysical Examination Palpation Bimanual palpation : used to evaluate the depth of invasion of the musculature of the tongue and the floor of mouth Palpation of the neck for nodal disease assessment D clinically or pathologically

48 Oral Cavity Components of Oral cavity Lip Buccal mucosaLower alveolar ridge Upper alveolar ridge Retromolar trigone Floor of mouth Anterior part of tongue Tip of tongue Lateral borders of tongue Dorsum of tongue Ventral of tongue

49 Diagnosis and evaluationD clinically or pathologically Oral Examination

50 Diagnosis and evaluationD clinically or pathologically Oral Examination

51 Diagnosis and evaluationD clinically or pathologically Oral Examination

52 Diagnosis and evaluationD clinically or pathologically Oral Examination

53 Diagnosis and evaluationRadiographic Evaluation For visualization of primary tumor and any nodal disease Chest x-ray Routine examination Assess for metastases and second primary cancer D clinically or pathologically

54 Diagnosis and evaluationRadiographic Evaluation Orthopanography Assessment of mandibular invasion D clinically or pathologically

55 Diagnosis and evaluationRadiographic Evaluation Computered tomography scan Most often used modality in CA of oral cavity Assess of soft tissue and bony involvement Deep tongue musculature Floor of mouth Mandible Palate Pterygomaxillary fossa D clinically or pathologically

56 Diagnosis and evaluationRadiographic Evaluation Magnetic resonance imaging (MRI) More accurate evaluation of soft tissue than CT scan eg. Base of tongue, perineural invasion Superior in cases where dental amalgam can result in CT artefacts D clinically or pathologically

57 Diagnosis and evaluationRadiographic Evaluation Ultrasound Screen for nodal disease that is not otherwise palpable clinically Not exposed the Pt to additional therapy Combined with FNA : specificity of U/S guided cytology ~ 90% D clinically or pathologically

58 Diagnosis and evaluationRadiographic Evaluation Positron emission tomography (PET) Newer techniques Use to identify nodal metastases and recurrent disease Sensitivity and specificity equal or superior to CT and MRI especially in case of previous XRT or chemotherapy D clinically or pathologically

59 Diagnosis and evaluationTissue Biopsy Should be obtained at the time of initial evaluation Techniques : knife, punch Bx forceps, trucut needle or fine-needle aspiration Submucasal mass, LN : FNA > open Bx Many lesion of the oral cavity are amenable to do Bx ~LA D clinically or pathologically

60 Diagnosis and evaluationTissue Biopsy Open neck node Biopsy May compromised an adequate node dissection in definitive management Last resort when 1. No primary can be found after examination of the entire upper aerodigestive tract ~GA 2. FNA cytology has proven unhelpful 3. For Dx of lymphoma when FNA cytology suggests that the Dx is possible D clinically or pathologically

61 Diagnosis and evaluationIntra-operative Evaluation Necessary in some Pt with inadequate examination from pain, trismus or extensive disease Complete visualization, palpation of the oral cavity and neck ~GA D clinically or pathologically

62 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

63 Treatment General principle Surgical management RadiotherapyChemotherapy Combined therapy D clinically or pathologically

64 Treatment General Principle The choice of best therapy dependson multiple factors D clinically or pathologically

65 Treatment General PrincipleRisk of treatment should be assessed base on - Intercurrent condition - cardiopulmonary status - Pt’s enthusiasm and acceptance of aparticular plan of management - Pt’s lifestyle, socioeconomic status D clinically or pathologically

66 Treatment General Principle I. Early lesionEffective Rx : Radiation, surgery Surgery local resection require less Rx time than full course of XRT Faster rehabilitation Holding to other modality for the Rx of a second primary tumor of the upper aerodigestive tract D clinically or pathologically

67 Treatment General Principle I. Early lesion XRTProper for Pt with significant risk associated with GA Pt with surgical refusion Functional disability (speech, deglutition) present even in small lesion D clinically or pathologically

68 Treatment General Principle II. Advanced lesion Primary surgeryFollow by post-operative radiation therapy D clinically or pathologically

69 Treatment Surgical Management Access to the oral cavityManagement of the mandible Management of the maxilla Management of the neck Reconstructive surgery D clinically or pathologically

70 Treatment Surgical Management Access to the oral cavityManagement of the mandible Management of the maxilla Management of the neck Reconstructive surgery D clinically or pathologically

71 Treatment Access to the oral cavity I. Transoral excisionII. Cheek flap III. mandibulotomy D clinically or pathologically

72 Treatment I. Transoral excision D clinically or pathologically

73 Treatment II. Cheek flap D clinically or pathologically

74 Treatment III. Mandibulotomy D clinically or pathologically

75 Treatment III. Mandibulotomy D clinically or pathologically

76 Treatment Surgical Management Access to the oral cavityManagement of the mandible Management of the maxilla Management of the neck Reconstructive surgery D clinically or pathologically

77 Treatment Resection of the mandible D clinically or pathologically

78 Treatment Resection of the mandible D clinically or pathologically

79 Treatment Surgical Management Access to the oral cavityManagement of the mandible Management of the maxilla Management of the neck Reconstructive surgery D clinically or pathologically

80 Treatment Resection of the maxilla D clinically or pathologically

81 Treatment Resection of the maxilla D clinically or pathologically

82 Treatment Surgical Management Access to the oral cavityManagement of the mandible Management of the maxilla Management of the neck Reconstructive surgery D clinically or pathologically

83 Treatment Neck dissectionRemoval of cervical LN, lymphatic duct and adjacent organs including primary lesion into one piece 2 types 1. Therapeutic neck dissection 2. Elective neck dissection / Prophylactic neck dissection D clinically or pathologically

84 Treatment Surgical Management Access to the oral cavityManagement of the mandible Management of the maxilla Management of the neck Reconstructive surgery D clinically or pathologically

85 Treatment Reconstructive Surgery Primary closureFree skin graft or dermal graft Tongue flap Regional cutaneous flap Myocutaneous flap Free flap with microvascular anastomosis D clinically or pathologically

86 Treatment Reconstructive Surgery D clinically or pathologically

87 Treatment RadiotherapyGenerally SCCA are vascularized and well oxygenated tend to be most radiosensitive XRT alone is effective for Early limited cancer Lack of an experience of surgeon or inadequate facilities for Sx Pt is physically or emotionally unable to undergo extensive Sx For palliation in extremely advanced case When survival and morbidity rate is better or equal to Sx but the functional or cosmetic result is likely to be better D clinically or pathologically

88 Treatment Indication for post-operative XRT to the neckFeature of the primary tumor Advanced T-stage Bulky tumor Involvement of bone, nerve or skin High histological grade Positive surgical resection margins Lymphatic permeation Vascular invasion Perineural spread D clinically or pathologically

89 Treatment Indication for post-operative XRT to the neckFeature of the cervical LN Single pathologically involved node in high risk Patient and/or unfavorable primary tumor More than 2 pathologically involved node Involved at more than 1 LN level in the neck LN > 3 cm in diameter (N2 or N3 stage) Presence of ECS Microscopic or gross residual disease in the neck D clinically or pathologically

90 Treatment ChemotherapyUes of chemotherapy as a single modality dismal result Use as an adjunctive agent Reported to improve the rate of organ preservation with no change in overall survival Statistically significant improvement is seen un disease-free survival with the use of adjuvant chemotherapy Often employed in the palliative setting : Pt with recurrence, unresectable, distant disease D clinically or pathologically

91 The Principles of Oral Cancer ManagementPathology Etiological Factors Epidemiology Metastases Staging Diagnosis and Evaluation Treatment Rehabilitation

92 Rehabilitation Surgeon, speech therapist, physical therapist, social worker, occupational therapist, prosthodontist, nurse, dietician, Pt’s family Cosmetic appearance Speech Deglutition Mastication Psycosocial functioning D clinically or pathologically

93 Questions ??? D clinically or pathologically