جراحة \ خامس اسنان د. وفاء (م8) 27 \ 12 \ 2016 Oral Cancer

Anatomy

Lymphatic drainage of Head and Neck

levels of cervical lymph nodes

Oral cancer Tumor: 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.

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

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

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

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

Aetiology smoking and consumption of alcohol 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 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 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 Erythroplakia Chronic hyperplastic candidiasis Conditions associated with an increased risk of malignant transformation Lichen planus Oral submucous fibrosis syphilitic glossitis

Diagnosis of oral cancer Clinical finding Radiograph Biopsy Blood investigations

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

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

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

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

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

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

Diagnosis History of the disease (signs and symptoms) 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 Fine needle Aspirsation for cytology or biopsy

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

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

Clinical staging of oral cancer

TNM classification of head and Neck Tumour TIS Tumour in situ T1 0.1- 2.0 cm T2 2.1 – 4.0 cm T3 4.1 – 6.0 cm T4 >6.1 cm or invading adjacent structures N 0 No regional adenopathy N 1 Ipsilateral adenopathy N 2 single Ipsilateral node 3-6 cm or multiple Ipsilateral nodes < 6.0 cm N 3 Massive Ipsilateral or contralateral nodes M 0 No evidence of Metastases M 1 Metastases beyond the cervical lymph nodes M x Metastases 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 Radiotherapy Systemic anti-cancer therapies Factors have a bearing on the choice of treatment: Site of primary tumour Stage of disease Proximity or involvement of bone Physical status of patient Patient performance

Surgery Conventional excision Laser surgery Thermal surgery

Access to the primary tumour 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: 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: 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 Neck Access: Apron incision H incision MacFee incision

Reconstruction Reconstruction techniques: Speech Swallowing Eating Chewing Sensation 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 Airway obstruction an tracheostomy problems Seroma and salivary collection Infection Dehiscence/ failure of wound healing/ fistula Nerve injuries Flap failure Donor site morbidity

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

Radiotherapy External beam radiotherapy Interstitial radiotherapy (brachytherapy)

Systemic anticancer therapies chemotherapy Gene therapy photodynamic therapy

Chemotherapy Complications 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 Photosensitiser, light and oxygen Photosensitisers either topical or systemic light illumination either surface illumination or interstitial illumination

Interstitial photodynamic therapy for base of tongue tumour 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