ORAL CANCER OVERVIEW ORAL CANCER OVERVIEW AND MANAGEMENTAND MANAGEMENT

Dr V.RAMKUMARDr V.RAMKUMAR

CONSULTANT DENTAL &FACIOMAXILLARY SURGEONCONSULTANT DENTAL &FACIOMAXILLARY SURGEON

REGNO:4118-TAMILNADU –INDIA(ASIA)REGNO:4118-TAMILNADU –INDIA(ASIA)

DEFINITIONDEFINITION

Abnormal uncontrol purposeless Abnormal uncontrol purposeless proliferation of new cells that persist even proliferation of new cells that persist even after the cessation of orginal stimulusafter the cessation of orginal stimulus

CLASSIFICATIONCLASSIFICATION

BENIGNBENIGN

MALIGNANT MALIGNANT

Benign tumor is one that is slow growing Benign tumor is one that is slow growing and locally invasive , this tumor does not and locally invasive , this tumor does not metastatise eg lipoma, fibromametastatise eg lipoma, fibroma

Malignant tumor is one that is fast Malignant tumor is one that is fast spreading and higly invasive it metastatisespreading and higly invasive it metastatise

eg carcinoma ,sarcomaeg carcinoma ,sarcoma

CARCINOGENESIS CARCINOGENESIS

This is process of formation of malignant This is process of formation of malignant tumortumor

A carcinogen is an agent that induces A carcinogen is an agent that induces certain changes with in a cell and certain changes with in a cell and promotes the formation of a tumorpromotes the formation of a tumor

TYPES OF CARCINOGENSTYPES OF CARCINOGENS

ENVIRONMENTAL eg RadiationENVIRONMENTAL eg Radiation

CHEMICAL AGENTS eg Tobacco, tanninsCHEMICAL AGENTS eg Tobacco, tannins

Biological agents eg VirusBiological agents eg Virus

Miscellaneous eg vitamin Miscellaneous eg vitamin deficiencydeficiency

MECHANISM OF MECHANISM OF CARCINOGENESISCARCINOGENESIS

INITIATIONINITIATION

This is the induction of certain irreversible This is the induction of certain irreversible changes within the DNA of the cells.these changes within the DNA of the cells.these cells have the ability to promote tumor cells have the ability to promote tumor cells when stimulated by promoting cells when stimulated by promoting agents.agents.

PROMOTIONPROMOTION

chemicals which promote tumor formation chemicals which promote tumor formation in cells that have previously been initiated in cells that have previously been initiated are refferred to as promoting agents are refferred to as promoting agents prmoting agents by themselves are not prmoting agents by themselves are not capalble of causing tumors in un initiated capalble of causing tumors in un initiated cells. Their effect of cells is short lived and cells. Their effect of cells is short lived and reversible.reversible.

ONCOGENESONCOGENES

These are genes which are associated with These are genes which are associated with neoplatic transformation.neoplatic transformation.

Protooncogenes are normal oncogenes which Protooncogenes are normal oncogenes which bring about celluar differentiation and bring about celluar differentiation and growth,these can be converted into oncogenes. growth,these can be converted into oncogenes.

Antioncogenes –cells that normally suppresscell Antioncogenes –cells that normally suppresscell proliferationare known as cancer supressor proliferationare known as cancer supressor genes.genes.

CLINICAL EVALUATIONCLINICAL EVALUATION

Chief complaintChief complaintDuration of the lesionDuration of the lesionMode of onsetMode of onsetAssociated symptomsAssociated symptomsPast medical historyPast medical historyPersonal historyPersonal history

GENERAL EXAMINATIONGENERAL EXAMINATION

MalnutritionMalnutrition

PalorPalor

CachexiaCachexia

Lymphnode examinationLymphnode examination

INTRA ORAL EXAMINATIONINTRA ORAL EXAMINATION

LOOSENING OF TEETHLOOSENING OF TEETH

IMPAIRED TONGUE MOBILITYIMPAIRED TONGUE MOBILITY

FACIAL NERVE FUNCTIONFACIAL NERVE FUNCTION

CHANGE IN VOCCAL CORDSCHANGE IN VOCCAL CORDS

MODE OF SPREAD OF TUMORMODE OF SPREAD OF TUMOR

LOCAL EXTENSIONLOCAL EXTENSION

LYMPHATIC SPREADLYMPHATIC SPREAD

HEMATOGENOUS SPREADHEMATOGENOUS SPREAD

TNM CLASSIFICATIONTNM CLASSIFICATION TPrimary tumourTisPre-invasive carcinoma (carcinoma TPrimary tumourTisPre-invasive carcinoma (carcinoma

in situ)T0No evidence of primary tumourin situ)T0No evidence of primary tumour T1Tumour 2 cm or less in its greatest dimension T1Tumour 2 cm or less in its greatest dimension T2Tumour more than 2 cm but not more than 4 cm in its T2Tumour more than 2 cm but not more than 4 cm in its

greatest dimensiongreatest dimension T3Tumor more than 4cm in its greatest dimension T3Tumor more than 4cm in its greatest dimension T4Tumour with extension to bone, muscle, skin, antrum, T4Tumour with extension to bone, muscle, skin, antrum,

neck, etcneck, etc .TXThe minimum requirements to assess he primary .TXThe minimum requirements to assess he primary

tumour cannot be met. tumour cannot be met.

NRegional Lymph NodesNRegional Lymph Nodes N0No evidance of regional lymph node involvement N0No evidance of regional lymph node involvement N1Evidence of involvement of movable homolateral N1Evidence of involvement of movable homolateral

regional lymph nodes < 3cm in diameter.regional lymph nodes < 3cm in diameter. N2aInvolvement of single ipsilateral movable lymph N2aInvolvement of single ipsilateral movable lymph

nodes 3-6 cm in diameter nodes 3-6 cm in diameter N2bMultiple ipsilateral lymph nodes < 6cm in diameterN2bMultiple ipsilateral lymph nodes < 6cm in diameter N2cMultiple contralateral lymph nodes <6cm in diameterN2cMultiple contralateral lymph nodes <6cm in diameter N3aSingle or multiple fixed lymph nodes >6cm diameterN3aSingle or multiple fixed lymph nodes >6cm diameter N3bBilateral nodes stage each node separatelyN3bBilateral nodes stage each node separately N3cContralateral node(s) onlyN3cContralateral node(s) only

M-MetastasisM-MetastasisM0-No evidence of distant metastasesM0-No evidence of distant metastases M1-Evidence of distant metastasesM1-Evidence of distant metastasesMxThe minimum requirements to assess MxThe minimum requirements to assess

the presence of distant metastases cannot the presence of distant metastases cannot be met. be met.

Stage IT1NoMoStage IT1NoMoStage IIT2NoMoStage IIT2NoMoStage IIIT3NoMoT1,T2,T3N1MoStage IIIT3NoMoT1,T2,T3N1MoStage IVT4-N0,N1MoStage IVT4-N0,N1Mo Any TN2,N3MoAny TN2,N3Mo Any TAnyNM1Any TAnyNM1

INVESTIGATIONSINVESTIGATIONS

SYSTEMICSYSTEMIC HEMOGRAMHEMOGRAM ECGECG LUNG FUNCTION TESTLUNG FUNCTION TEST

LOCALLOCAL OPGOPG OCCLUSAL VIEWOCCLUSAL VIEW PNSPNS ULTRASOUNDULTRASOUND CT,MRI,PETCT,MRI,PET BIOPSYBIOPSY

TREATMENTTREATMENT

SURGERYSURGERY

RADIOTHERAPYRADIOTHERAPY

CHEMOTHERAPYCHEMOTHERAPY

RECENT ADVANCESRECENT ADVANCES

LASERLASER

CRYOSURGERYCRYOSURGERY

IMMUNOTHERAPYIMMUNOTHERAPY

GENE THERAPYGENE THERAPY

SURGERYSURGERY

NECK DISSECTIONNECK DISSECTION

SUPRA OMOHYOID NECK DISSECTIONSUPRA OMOHYOID NECK DISSECTION

LATERAL NECK DISSECTIONLATERAL NECK DISSECTION

ANTERIOR COMPARTMENT NECK ANTERIOR COMPARTMENT NECK DISSECTIONDISSECTION

POSTEROLATERAL NECK DISSECTIONPOSTEROLATERAL NECK DISSECTION

EXTENDED NECK DISSECTIONEXTENDED NECK DISSECTION

MAXILLARY MAXILLARY SURGICALPROCEDURESURGICALPROCEDURE

ALVEOLECTOMYALVEOLECTOMYSUBTOTAL MAXILLECTOMYSUBTOTAL MAXILLECTOMYTOTAL MAXILLECTOMYTOTAL MAXILLECTOMYLIMITEDMAXILLECTOMYLIMITEDMAXILLECTOMY

ALVEOLECTOMY

SUBTOTAL MAXILLECTOMY

MANDIBULAR SURGICAL MANDIBULAR SURGICAL PROCEDUREPROCEDURE

ALVEOLECTOMYALVEOLECTOMYMARGINAL MANDIBULECTOMYMARGINAL MANDIBULECTOMYSEGMENTAL RESECTIONSEGMENTAL RESECTIONHEMIMANDIBULECTOMYHEMIMANDIBULECTOMYDISARTICULATING DISARTICULATING

HEMIMANDIBULECTOMYHEMIMANDIBULECTOMY

TOTAL MAXILLECTOMY

RADICAL MAXILLECTOMY

WEBERFERGUSSON INCISIONWEBERFERGUSSON INCISION

ALVEOLECTOMYALVEOLECTOMY

MARGINAL RESECTION

SEGMENTAL RESECTIONSEGMENTAL RESECTION

HEMIMNADIBULECTOMYHEMIMNADIBULECTOMY

DISARTICULATING DISARTICULATING HEMIMANDIBULECTOMYHEMIMANDIBULECTOMY

LEVELS OF LYMPH NODELEVELS OF LYMPH NODE

SKIN INCISION

CHEMOTHERPAYCHEMOTHERPAY

Chemotherapy is the chemical modality of Chemotherapy is the chemical modality of treatment of head and neck cancer with certain treatment of head and neck cancer with certain drugs are in combination form.drugs are in combination form.

DRUGS used in chemotherapyDRUGS used in chemotherapy

MethotrexateMethotrexate

BleomycinBleomycin

CisplatinCisplatin

5-fluouracil5-fluouracil

RADIATION THERAPYRADIATION THERAPY

It is the treatment of diseaseswith ionizing It is the treatment of diseaseswith ionizing radiation.radiation.

Mechanism- breakage of double strand DNAMechanism- breakage of double strand DNA

Direct action- With in the DNA itselfDirect action- With in the DNA itself

Indirect action- Free radical release from Indirect action- Free radical release from radiation action on cell by hydrolysis. radiation action on cell by hydrolysis.

TYPES OF RADIOTHERAPYTYPES OF RADIOTHERAPY

Brachy therapyBrachy therapy

TeletherapyTeletherapy

ADVERSE EFFECTSADVERSE EFFECTS AcuteAcuteErythemaErythemaMucositisMucositisLoss of tasteLoss of tasteXerostomiaXerostomia

Late effectsLate effects fibrosisfibrosis lymphodemalymphodema delayed wound healingdelayed wound healing ostepradionecrosis ostepradionecrosis

LASER

CRYO SURGERYCRYO SURGERY

IMMUNOTHERAPYIMMUNOTHERAPY

These are new treatment that use the These are new treatment that use the body own natural defences to fight against body own natural defences to fight against cancer.cancer.

InterferonsInterferons InterleukinInterleukinMonoclonal antibodyMonoclonal antibodyVaccinesVaccinesColony stimulating factorsColony stimulating factors

Gene therapyGene therapy

Gene is inserted into immune systemto Gene is inserted into immune systemto enhance its ability to recogonize and enhance its ability to recogonize and attack cancer cells.attack cancer cells.

Cancer cells with genes are inserted that Cancer cells with genes are inserted that cause the cancercells to produce cause the cancercells to produce cytokinesand stimulate the immune cytokinesand stimulate the immune system. system.