Oral CancerOral Cancer

Anatomy

Lymphatic drainage of Head and NeckLymphatic drainage of Head and Neck

levels of cervical lymph nodeslevels of cervical lymph nodes

Tumor:Tumor: Is a mass of cells, Is a mass of cells,

tissues or organs tissues or organs resembling those resembling those normally present normally present but arranged but arranged atypically and atypically and behave behave abnormally. abnormally.

Behavior is very Behavior is very essential and is of essential and is of great importance.great importance.

Oral cancerOral cancer

Oral cancerOral cancer

Classification:Classification: HistogeneticHistogenetic::

• Epithelial originEpithelial origin• connective tissue connective tissue

originorigin

HistologicalHistological: : • Degree of Degree of

differentiation. differentiation. Well Well moderate moderate poorly differentiatedpoorly differentiated

Clinical behavior: Clinical behavior: • BenignBenign: :

slowly growing and expanding causing pressure atrophy slowly growing and expanding causing pressure atrophy but remain within the capsule. 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, Progressive growth and metastasize to distant organs,

embolic spread due to lack of cell adhesion embolic spread due to lack of cell adhesion Mitosis.Mitosis.

• Intermediate:Intermediate: Locally invasive, no metastasis. Basal cell carcinoma Locally invasive, no metastasis. Basal cell carcinoma

and Ameloblastomaand Ameloblastoma

Pathways of cancer spread (Metastasis)Pathways of cancer spread (Metastasis)

• Invasion into local stroma Invasion into local stroma • Lymphatic spreadLymphatic spread• Vascular system (Vascular system (Hematogenous spread)Hematogenous spread)• Neural spreadNeural spread• Circulation of the tumor and arrest at the distant Circulation of the tumor and arrest at the distant

sitesite

EpidemiologyEpidemiology

• Oral cavity and oropharyngeal tumours Oral cavity and oropharyngeal tumours comprise 40% of cancers comprise 40% of cancers

• Greater in men than women Greater in men than women • It is most common in the 6It is most common in the 6thth and 7 and 7thth

decades, although there is evidence that it decades, although there is evidence that it is increasing in young adultsis increasing in young adults

AetiologyAetiology• smoking and consumption of alcoholsmoking and consumption of alcohol• diet containing high proportions of vegetables and fruit diet containing high proportions of vegetables and fruit

might modulate carcinogenic effectmight modulate carcinogenic effect• Human papilloma virus (HPV) considers as a risk factor Human papilloma virus (HPV) considers as a risk factor

in oropharyngeal squamous cell carcinoma in oropharyngeal squamous cell carcinoma • Betel quid chewing is related to the high incidence of oral Betel quid chewing is related to the high incidence of oral

cancer in Indiacancer in India

Roles of the dentist with patients in oral cancerRoles of the dentist with patients in oral cancer

• Recognition of Cancer and Medical ConsiderationsRecognition of Cancer and Medical Considerations

• Treatment Planning ModificationsTreatment Planning Modifications

Dental treatment planning for the patient with cancer begins with Dental treatment planning for the patient with cancer begins with establishment of the diagnosis. Planning involves the following:establishment of the diagnosis. Planning involves the following:

1- Pre-treatment evaluation and preparation of the patient1- Pre-treatment evaluation and preparation of the patient

2- Oral health care during cancer therapy, which includes hospital and outpatient care2- Oral health care during cancer therapy, which includes hospital and outpatient care

3- Post-treatment management of the patient, including long-term considerations3- Post-treatment management of the patient, including long-term considerations

Reference: Dental Management. CHAPTER 26 - Cancer and Oral Care of the PatientReference: Dental Management. CHAPTER 26 - Cancer and Oral Care of the Patient

Premalignant conditionsPremalignant conditions

Conditions of definite premalignant potentialConditions of definite premalignant potential• Leukoplakia Leukoplakia • Erythroplakia Erythroplakia • Chronic hyperplastic candidisis Chronic hyperplastic candidisis

Conditions associated with an increased risk of malignant Conditions associated with an increased risk of malignant transformationtransformation

• Lichen planus Lichen planus • Oral submucous fibrosisOral submucous fibrosis• syphilitic glossitis syphilitic glossitis

• Clinical findingClinical finding• RadiographRadiograph• BiopsyBiopsy• Blood investigationsBlood investigations

Diagnosis of oral cancerDiagnosis of oral cancer

Malignant TumorsMalignant Tumors CLINICAL DIAGNOSIS OF ORAL CANCERCLINICAL DIAGNOSIS OF ORAL CANCER

Symptoms vary according to the site of the lesionSymptoms 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 painful and tender when secondarily infected or involves a sensory nervea 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 Posteriorly no symptom until it reach a size of 2‑3 cm swelling,swelling,

pain and difficulty in deglutitionpain and difficulty in deglutition

• absence of symptoms until the tumor metastasize to absence of symptoms until the tumor metastasize to regional lymph nodes regional lymph nodes

hard lump on the neck hard lump on the neck

Malignant TumorsMalignant Tumors

• late symptoms: late symptoms: pain due to secondary infection or nerve pain due to secondary infection or nerve

involvementinvolvement excessive salivationexcessive salivation difficulty in deglutition, speech difficulty in deglutition, speech haemorrhagehaemorrhage

• Within boneWithin bone:: painless swelling involving the buccal and lingual or painless swelling involving the buccal and lingual or

palatal sulci palatal sulci teeth become loose and painful ‑acute alveolar teeth become loose and painful ‑acute alveolar

abscessabscess edentulous pt. the denture does not fit edentulous pt. the denture does not fit denture hyperplasiadenture hyperplasia anaesthesia of the upper or lower lip and the cheek.anaesthesia of the upper or lower lip and the cheek.

Lip CancerLip 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 smoker tobacco smoker • leukoplakia.leukoplakia.• intense solar radiation ‑ blistering cheilitis due to sunshine.intense solar radiation ‑ blistering cheilitis due to sunshine.

Lip CancerLip 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 Metastases within a year ‑ submental, submandibular and upper jugular. upper jugular.

• Death due to infection and bronchopneumonia.Death due to infection and bronchopneumonia.

Tongue cancerTongue cancer

• Carcinoma of Carcinoma of tonguetongue• Anterior 2/3, affect males Anterior 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 Heavy alcoholic with element of Vit.B deficiency. Producing

precancerous mucosal atrophyprecancerous mucosal atrophy• Syphilitic and leukoplakia. 25% and 5%. Syphilitic and leukoplakia. 25% and 5%. • Superficial glossitis, papilloma, fissures and non‑specific Superficial glossitis, papilloma, fissures and non‑specific

ulcers.ulcers.

Malignant TumorsMalignant Tumors

• Site & Types:Site & Types: 1. lateral edge of tongue 58%1. lateral edge of tongue 58% 2. tip of tongue2. tip of tongue 2‑4% 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

DiagnosisDiagnosis• History of the disease (signs and symptoms)History of the disease (signs and symptoms)• Investigations:Investigations:Plain radiographyPlain radiography

(orthopantomogram “OPG” , occipito-mental, chest radiograph) (orthopantomogram “OPG” , occipito-mental, chest radiograph)

Contrast radiographyContrast radiography

Sialography, carotid angiography, Barium swallowSialography, carotid angiography, Barium swallow

Cross sectional imagingCross sectional imaging

Computerized tomography (CT)Computerized tomography (CT)

Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)

Nuclear medicine Nuclear medicine

Bone scinitigraphyBone scinitigraphy

Position emission tomography (PET)Position emission tomography (PET)

UltrasonographyUltrasonography

• BiopsyBiopsy

Fine needle Aspirsation for cytology or biopsyFine needle Aspirsation for cytology or biopsy

BiopsyBiopsy

• Incisional biopsyIncisional biopsy• Excisional biopsy Excisional biopsy • Fine needle aspiration biopsyFine needle aspiration biopsy• Fine needle Core biopsyFine needle Core biopsy

Alkaline phosphatase:Alkaline phosphatase: Found to be elevated in bone and liver disease.Found to be elevated in bone and liver disease.

Amylase:Amylase: Found to be elevated in diseases of the pancreas.Found to be elevated in diseases of the pancreas.

Bilirubin: Bilirubin: Found to be elevated in Liver diseaseFound to be elevated in Liver disease

Calcium: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.multiple myeloma and other diseases.

Creatinine: Creatinine: to be elevated in kidney disease.to be elevated in kidney disease.

Nonspecific Blood TestsNonspecific Blood Tests

Clinical staging of oral cancerClinical staging of oral cancer

TNM classification of head and Neck TNM classification of head and Neck TumourTumour

TISTIS Tumour in situTumour in situ T1T1 0.1- 2.0 cm0.1- 2.0 cm T2T2 2.1 – 4.0 cm2.1 – 4.0 cm T3T3 4.1 – 6.0 cm4.1 – 6.0 cm T4T4 >6.1 cmor invading adjacent structures>6.1 cmor invading adjacent structures N 0N 0 No regional adenopathyNo regional adenopathy N 1N 1 Ipsilateral adenopathyIpsilateral adenopathy N 2N 2 single Ipsilateral node node 3-6 cm or multiple single Ipsilateral node node 3-6 cm or multiple

Ipsilateral nodes < 6.0 cmIpsilateral nodes < 6.0 cm N 3N 3 Massive Ipsilateral or contralateral nodesMassive Ipsilateral or contralateral nodes M 0M 0 No evidence of MetastasesNo evidence of Metastases M 1M 1 Metastases beyond the cervical lymph nodesMetastases beyond the cervical lymph nodes M xM x Metastases not assessedMetastases not assessed

Multidisciplinary Team (MDT)Multidisciplinary Team (MDT) Oral and maxillofacial surgeonsOral and maxillofacial surgeons ENT surgeonsENT surgeons specialist anaesthetistsspecialist anaesthetists clinical / medical Oncologists clinical / medical Oncologists specialist nursesspecialist nurses specialist pathologists specialist pathologists Specialist radiologistsSpecialist radiologists Speech and language therapists Speech and language therapists DieticiansDieticians Restorative dentistsRestorative dentists Dental hygienists Dental hygienists Psychologists Psychologists

Therapeutic options of oral cancerTherapeutic options of oral cancer

• Surgery Surgery

• Radiotherapy Radiotherapy • Systemic anti-cancer therapiesSystemic anti-cancer therapies

Factors have a bearing on the choice of treatment:Factors have a bearing on the choice of treatment:• Site of primary tumourSite of primary tumour• Stage of diseaseStage of disease• Proximity or involvement of boneProximity or involvement of bone• Physical status of patientPhysical status of patient• Patient performance Patient performance

Surgery Surgery

• Conventional excision Conventional excision • Laser surgery Laser surgery • Thermal surgery Thermal surgery

Access to the primary tumourAccess to the primary tumour• Trans-oral route: anterior part of the oral cavityTrans-oral route: anterior part of the oral cavity

• When the tumour increase in size and becomes more posterior, When the tumour increase in size and becomes more posterior, three main alternative approaches can be applied:three main alternative approaches can be applied:

A- Lip split and mandibulotomyA- Lip split and mandibulotomy

B- A ‘’ pull through’’ technique via the neckB- A ‘’ pull through’’ technique via the neck

C- For maxillary tumours, an upper lip and para-nasal incision (lateral C- For maxillary tumours, an upper lip and para-nasal incision (lateral infra-orbital extension is rarely required and has a high complication infra-orbital extension is rarely required and has a high complication rate)rate)

TracheostomyTracheostomy

Neck dissectionNeck dissection

Radical neck dissection: Radical neck dissection:

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

Neck dissectionNeck dissection

• Classical neck dissection decribed by Crile, which involves resection of the lymph Classical neck dissection decribed by Crile, which involves resection of the lymph nodes in level I-V of the neck together with sacrifice of:nodes in level I-V of the neck together with sacrifice of:

Sternocleidomastoid muscle Sternocleidomastoid muscle

Spinal accessory nerveSpinal accessory nerve

Internal jugular vein Internal jugular vein

• All other neck dissections are selective and best described by the levels of lymph 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 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 with resection of internal jugular vein. This avoids confusion regarding the meaning of term such as modified radical neck dissection, functional, comprehensive, supra-term such as modified radical neck dissection, functional, comprehensive, supra-omohyoid and extended. omohyoid and extended.

• Elective neck dissection (in N0) or therapeutic neck dissection (in clinically or 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 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 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. with tumours of the floor of mouth or tongue will have occult micrometastases.

Neck dissectionNeck dissection

• The following structures are preserved in neck dissection unless they are The following structures are preserved in neck dissection unless they are directly invaded by tumour:directly invaded by tumour:

Sternocleidomastoid muscleSternocleidomastoid muscle

Carotid artery Carotid artery

Internal jugular veinInternal jugular vein

Spinal accessory nerveSpinal accessory nerve

Vagus Vagus

Laryngeal nerveLaryngeal nerve

Sympathetic chain Sympathetic chain

Phrenic nervePhrenic nerve

Cervical plexusCervical plexus

Hypoglossal nerve Hypoglossal nerve

Mandibular branch of the facial nerveMandibular branch of the facial nerve

Neck Access:• Apron incision• H incision• MacFee incision

ReconstructionReconstruction• Speech Speech • Swallowing Swallowing • EatingEating• Chewing Chewing • Sensation Sensation • CosmesisCosmesis

Reconstruction techniques:Reconstruction techniques:1- 1- Open wound (in case of laser)Open wound (in case of laser)

2- Primary closure 2- Primary closure

3- Graft (it gains a new blood supply from the wound bed): Autogenous (same individual), Allograft 3- Graft (it gains a new blood supply from the wound bed): Autogenous (same individual), Allograft (same species but different individual) , Xenograft (different species).(same species but different individual) , Xenograft (different species).

Mucosa graftMucosa graft::

split thickness skin graft (epidermis and part of dermis), full thickness skin graftsplit thickness skin graft (epidermis and part of dermis), full thickness skin graft

Bone graftsBone grafts

Cartilage grafts (ear, nose and rib)Cartilage grafts (ear, nose and rib)

4- Flaps (retaining its attached vascular supply)4- Flaps (retaining its attached vascular supply)

Local, Regional and Distant flapsLocal, Regional and Distant flaps

5- Developments (tissue expansion and tissue engineering), it has limited roles in cancer patients5- Developments (tissue expansion and tissue engineering), it has limited roles in cancer patients

6- Implants6- Implants

7- Prosthetic rehabilitation 7- Prosthetic rehabilitation

Surgical complicationsSurgical complications

Immediate/ early complications Immediate/ early complications • BleedingBleeding• Airway obstruction an tracheostomy problemsAirway obstruction an tracheostomy problems• Seroma and salivary collectionSeroma and salivary collection• Infection Infection • Dehiscence/ failure of wound healing/ fistulaDehiscence/ failure of wound healing/ fistula• Nerve injuriesNerve injuries• Flap failureFlap failure• Donor site morbidity Donor site morbidity

Late complicationsLate complications

• Recurrence Recurrence • Altered sensation Altered sensation • shoulder and neck problemsshoulder and neck problems• Hypertrophic scarsHypertrophic scars• Lymphoedema Lymphoedema • FatigueFatigue• Depression Depression

Surgical complicationsSurgical complications

RadiotherapyRadiotherapy

• External beam radiotherapyExternal beam radiotherapy• Interstitial radiotherapy (brachytherapy) Interstitial radiotherapy (brachytherapy)

Systemic anticancer therapiesSystemic anticancer therapies

chemotherapychemotherapy Gene therapyGene therapy photodynamic therapyphotodynamic therapy

Chemotherapy Chemotherapy

• Timing of administration of chemotherapyTiming of administration of chemotherapyNeoadjuvant/ induction: Neoadjuvant/ induction: prior to radiotherapy or surgeryprior to radiotherapy or surgery

Concurrent: Concurrent: administered during the radiotherapy treatment schedule administered during the radiotherapy treatment schedule (treatment for tonsil, base of tongue and nasopharynx)(treatment for tonsil, base of tongue and nasopharynx)

Adjuvant: Adjuvant: Given after radiotherapy or surgeryGiven after radiotherapy or surgery

Complications of chemotherapy:Complications of chemotherapy:Early complications: Early complications:

severe mucositis, nausea and vomiting, weight loss, diarrhoea, bleeding, hair severe mucositis, nausea and vomiting, weight loss, diarrhoea, bleeding, hair loss, neurotoxicity, immunosuppression, neutropaenia, thrombocytopaenia loss, neurotoxicity, immunosuppression, neutropaenia, thrombocytopaenia and multi-organ failure. and multi-organ failure.

Late complications:Late complications:

Nephropathy, cardiomyopathy, pulmonary fibrosis and peripheral neuropathy Nephropathy, cardiomyopathy, pulmonary fibrosis and peripheral neuropathy

Photodynamic therapyPhotodynamic therapy

• Killing of cancer cells (by singlet oxygen) Killing of cancer cells (by singlet oxygen) through administration of a photosensitiser through administration of a photosensitiser followed by non thermal laser light followed by non thermal laser light applicationapplication

• Photosensitiser, light and oxygenPhotosensitiser, light and oxygen• Photosensitisers either topical or systemicPhotosensitisers either topical or systemic• light illumination either surface light illumination either surface

illumination or interstitial illumination 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 supportNutritional support

Speech and language therapySpeech and language therapy

swallowing assessment swallowing assessment

Psychosocial aspectsPsychosocial aspects

quality of life assessment quality of life assessment