4 Overview Oral Cancer-WayanS,DrSpB

7/31/2019 4 Overview Oral Cancer-WayanS,DrSpB

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ORAL CANCER

An Overview

Wayan SudarsaWorkshop and Hands-on Experiences

in Head and Neck Cancer Surabaya, 3-4 April 2006


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Introduction

Oral Cancer is the sixth leading cause of cancerworldwide

The survival rate was 52%.

Oral cancer generally are socially derived diseases.

Tobacco and alcohol are synergistic effect

Treatment of early oral cancer is surgery. Locallyadvanced T3/4 are best treated with combined surgeryand Radiotherapy.

High risk of second primary cancer. (Field cancerization)


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EPIDEMIOLOGY

The Oral cavity extends from vermilion border of lips to

the plane between junction of the hard palate and soft

palate.

Include: Lips and oral cavity(buccal mucosa, tongue,

ginggiva, retromolar trigone, flour of mouth, hard palate)

The incidence of oral cancer varies throughout the world.

High incidence in India, France, SE Asia. Low incidence

in Japan.

40% of HN cancer

Age onset 50 yrs. Sex ratio 3:1


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Risk factors

Heavy tobacco

Alcohol.

Syphilis Viruses (EB, HSV, HPV, HIV)

Neglect of oral dental hygiene(chronic

infection, unfit dentures) Lichen planus, Plummer Vinson sy.

Immunosuppression, malnutrition


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Molecular Biology of HNSCC

Cytogenetics (Chromosomes 3, 5, 8, 11, 17, 18.

Tumor Supressor genes in-activation : p16, p53, p21.RBgene

Proto-oncogene activation (PRADD1/cyclinD1) Growth factors & receptors over expression (EGF, EGF-

R; TGF ; HER-2/ neu; FGF, FGF-R, PDGF)

Ras family oncogene

Telomeres, Telomerase & Cell senescence

Tumor Immunology (role of TIL, CTL, IL-2/4/6)

Cancer Invasion & Metastasis (endothelial proliferation:PGE2, TGFb, FGF,VEGF), MMP


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MOLECULAR PROGRESSION MODEL OF HNSCCCARCINOGENESIS

Normal squamous mucosa

EGF, EGFR

Overexpression

Squamous hyperplasia

Telomerase activation p16 inactivation

Dysplasia

PRAD-1 amplification 3p deletion

p53 inactivation

Carcinoma in-situ

4q, 5q, 8p, 13q

deletionInvasive carcinoma

Matrix metalloproteinase

Over-expression

Metastasis


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Site of Oral cavity Cancer

Tongue (35%)

Floor of mouth (30%)

Lower alveolus (15%) Buccal mucosa (10%)

Upper alveolus/hard palate (8%)

Retromolar (2%)

Lips(lower 93%, upper 5%, commissure

2%)


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Distribution of Oral Cancer

According to Locations

Tongue

34%

Retromolar

2%Ginggiva Max

12%Ginggiva Mand

7%

Buccal24%

Lower Lip

16%

Palatum

5%


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Pathology

90% SCC:

Well/Moderate/Poorly/Undiff

Exophytic, Ulcerative, Infiltrative,verucous

Other: Adeno Ca / from malignant minorsalivary gland tumors, Melanoma, Sarcomas.

Premalignant lesions:

Leucoplakia, hyperplasia, Erythroplakia,and dysplasia

Regional Lnn meta related to size and thickness

of primary tumor


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Clinical presentation

Non healing ulcers

Induration

Verucous/cauliflower Hot potato chewing

Trismus

Lnn enlargement


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diagnosis

Clinical:HistoryDetail clinical examination (used headlamp, mirror)

Bimanual palpationCervical Lnn examination

Endoscopy (searching the second primary)(Field cancerization)

Biopsy

Staging: Panoramic photo, thorax,USG liver, orCT/MRI/PET Scan


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Components of an Oral Cancer Examination*

1. Extra oral examination

- Inspect head and neck

- Bimanually palpate lymph nodes and salivary glands

2. Lips

- Inspect and palpate outer surfaces of lip and vermilion border

- Inspect and palpate inner labial mucosa

3. Buccal mucosa

- Inspect and palpate inner cheek lining

4. Gingiva / alveolar ridge

- Inspect maxillary / mandibular gingiva and alveolar ridges on both the buccal and lingual aspects

5. Tongue

- Have patient protrude tongue and inspect the dorsal surface- Have patient lift tongue and inspect the ventral surface

- Grasping tongue with a plece of gauze and pulling it out to each side.

Inspect the lateral borders of the tongue from its tip back to the lingual tonsil region

- Palpate tongue

6. Floor of mouth

- Inspect and palpate floor of mouth

7. Hard palate- Inspect hard palate

8. Soft palate and oropharynx

- Gently depressing the patients tongue with a mouth mirror or tongue blade, inspect the soft palateand

oropharynx

* A good oral examination requires an adequate light source, protective gloves, 2x2 gauze squares,and a mouth mirror or tongue blade.


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UICC/AJCC STAGING SYSTEM FOR ORAL CANCER2002

Primary Tumor

(T)

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor 2 cm or less in greatest dimension

T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension

T3 Tumor more than 4 cm in greatest dimension

T4a (lip) Tumor invades through cortical bone, inferior alveolar nerve, floor

of mouth, or skin (chin or nose)

T4a (oral cavity) Tumor invades through cortical bone, into deep / extrinsic

muscle of tongue (genioglossus, hyoglossus, palatoglossus and

styloglossus), maxillary sinus, or skin of face

T4b (lip and oral cavity) Tumor invades masticator space, pterygoid plates,

or skull base, or encases internal carotid artery


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Regional Lymph Nodes

(N)

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension

N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than

6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more

than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes,

non more than 6 cm in greatest dimension

N2a Metastasis in single ipsilateral lymph node more than 3 cm but not

more than 6 cm in greatest dimension

N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm ingreatest dimension

N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6

cm in greatest dimension

N3 Metastasis in a lymph node more than 6 cm in greatest dimension

Distant Metastasis

(M)MX Presence of distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis


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Stage Grouping

Stage 0 Tis N0 M0Stage I T1 N0 M0

Stage II T2 N0 M0

Stage III T1, T2 N1 M0

T3 N0, N1 M0

Stage IV A T1, T2, T3 N2 M0

T4a N0, N1, N2 M0

Stage IV B Any T N3 M0

T4b Any N M0

Stage IV C Any T Any N M1


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TREATMENT

Treatment Goals:

To eradicate of the primary tumor and

LN metastasis, to maintain the

function, and cosmetic reconstruction.

Factors affecting choice of treatment:

Tumor factors

Patient factors

Resource factors


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TREATMENT

SURGERY:Early stage T1/2No tumor: Wide excision +/ - ND

High risk of locoregional recurrent (40%)

Management ofNo Neck:

High incidence of occult metastasis in the clinicallyNo Neck (15-43%)

Controversy : Observation or Surgery/RadiationDepend on primary site.

Should be have minimal morbidity

ELND if risk of occult meta >20%. (SND/SOHND).

Sentinel Lymph Node Biopsy (SLNB)?

Locally advanced tumor: Combined modality treatment


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Lymph node metastasis

Alveolar ridge cancer Cancer of floor of mouth

Oral tongue cancer


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6 Levels of Lymph-Nodes


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Selective Neck Dissection


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Classification of ND

1991 Classification:

RND

Modified RND

Selective ND:SupraomohyoidLateralPosterolateral

Anterior Extended ND

2001 Classification:

RND

Modified RND

Selective ND (SND):SND (L.I-III/IV)SND (L.II-IV)SND (L.II-V)

SND (L.VI) Extended ND

Proposed by American HN Society and AAOHNS


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Selective neck dissection Modified RND type 1,2,3.


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SURGICAL APPROACHES

Trans-oral approach

Lower cheek approach

Upper cheek approach

Swing mandibulotomy

Visor flap


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RECONSTRUCTION

Single-stage immediate reconstruction is

recommended.

The technique:

Skin grafts

Pedicle flaps

Alloplastic meterials

AutograftsFree flaps


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Adjuvant treatment

Radiothrepy (External beam/Interstitial)

Chemotherapy

Concomittant Radio+Chemotherapy(Neoadjuvant)

Palliative Chemotherapy for advanceddiseases


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PROGNOSIS

Location/thickness/depth of primary tumor

Staging

Type of histology

Grading

Presence of perineural spread

Mandibular invasion

Lnn extention (Level, size, extracaps of meta)

Molecular markers (?)


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Summary

The main problem of oral cancer is earlydetection

Surgery is still the most important modality inmanagement of oral cancer.

Better understanding of molecular biology ofHNSCC.

Bio-molecular markers can be used in the

management of SCC oral cancer. High risk of second primary cancer,

Chemoprevention?


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The ability to control oral cancer willbe depend on:

PreventionEarly diagnosis

Continuing educational campaigns


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4 Overview Oral Cancer-WayanS,DrSpB