9. Oral Cancer and Precancer Flashcards
Oral squamous cell carcinoma (OSCC) and Oropharyngeal SCC
• 51,540 new cases in 2018
- 3.0 % of all new cancers
• 10,030 deaths in 2018
- >____ death per hour every day
• Incidence rates >2x higher in ____ than women
• 1.2% of population will be diagnosed in lifetime
• 5-year survival rates (2008-2014) – Overall – Early diagnosis (Stages \_\_\_\_) – Late diagnosis (Stages \_\_\_\_) • Late diagnosis accounts for over \_\_\_\_% of all diagnoses – African-American 33% – Caucasian \_\_\_\_%
• The biggest hurdle in improving 5-year survival rates is ____ and ____!
• Posterior boundary of oral cavity > PG folds ○ From the \_\_\_\_ to the \_\_\_\_ folds • Anterior boundary of oropharynx > PP folds ○ \_\_\_\_(tonsils) are located within the oropharyngeal region • No sex predilection, but more prevalent in \_\_\_\_ • Talking about cancer - 5 yr survival rates - "what are my chances?" ○ The rates guide \_\_\_\_ and \_\_\_\_ over many patients ○ 5 years from time of finishing diagnosis - whether the cancer recurs, whether they get new cancer, or whether the patient dies/lives • 65% - in the realm of OK survival rates • Most carcinomas use the TMN staging system ○ Subcategorize into I-IV stages ○ IV - the worse the prognosis • Ethnic variations - \_\_\_\_ have worse survival rate than Caucasians • Early diagnosis and prevention is critical
1 men I & II III & IV 60 55
awareness
early diagnosis
lips
PG
adenoids
males
treatment
prognosis
AA
Age of onset Median age = ____
Age of death Median age = ____
____% - Localized to primary site
____% - Spread to regional lymph nodes
____% - Cancer has metastasized
4% - Unknown
• Oropharyngeal cancer ○ After the age of 55 - primarily an older person's disease ○ From 20-54 - 25% of patients will get cancer [???] ○ Ones who get cancer at a younger age have a better \_\_\_\_ (only 15% of the 25% will die of the disease under 55) § This applies to all cancer types • At time of diagnosis: ○ 30% cancer localized to one area (I or II) § Implies that \_\_\_\_% of all cancers will have already spread to other sites/lymph nodes ○ Most oropharyngeal cancers are diagnosed \_\_\_\_ - which is what contributes to these numbers • Oropharynx spread - not a metastasis - considered to be \_\_\_\_ primary cancer if it's a different site
63 67 30 47 19
prognosis
70
late
secondary
Epidemiology of OSCC
• >90% occur in patients >____ yrs
• Increasing incidence in ____ patients (<40 yrs) without risk factors
• Ethnic and racial variation in survival not ____
– May reflect access to healthcare, level of education, and late diagnosis
• OSCC - implying we're talking about only oral cancer ○ Very different from oropharyngeal cancer • First number - both OSCC and oropharyngeal; the second number is for \_\_\_\_ only • We assumed increasing incidence was due to \_\_\_\_ for OSCC, but it's not; IT DOES NOT CAUSE THIS TYPE OF CANCER ○ For oropharyngeal it is because of \_\_\_\_
50
younger
prevalence
OSCC
HPV
HPV
The facts • Litigation against dentists is frequently related to oral cancer – Failure to \_\_\_\_ – Misdiagnosis – Inappropriate \_\_\_\_ dentistry • Oral cancer awareness is increasing
• Ultimate goal of cancer treatment is \_\_\_\_ • Need for appropriate – \_\_\_\_ – Detection – \_\_\_\_ – Diagnosis
• Post-therapeutic needs: rampant \_\_\_\_, xerostomia - it's the dentist's responsibility to treat these manifestations, not the oncologist
diagnose post-therapeutic prevention education recognition caries
OSCC is a multifactorial disease
Extrinsic factors \_\_\_\_ / smoking / smokeless tobacco \_\_\_\_ Ultraviolet light \_\_\_\_ nut Sanguinaria Psychoactive plants
Intrinsic factors
____ / epigenetics Genomic instability Chronic immunosuppression
Previous history of OSCC
• Multifactorial - both extrinsic and intrinsic factors Extrinsic factors • Smoking and chronic alcohol usage are the most common factors for \_\_\_\_-development and involved with oropharyngeal (but the biggest factor is \_\_\_\_) ○ Smokeless tobacco to replace cigarette smoking - some forms of it may increase risk of cancer, however ○ Can suggest usage - the risk is \_\_\_\_ but not absent entirely • UV light a risk factor for the \_\_\_\_ lip • Betel nut - naturally occurring substance > addictive, reddish coloration, contains a carcinogen > increases risk of OSCC • Sanguinaria and psychoactive plants - addictive and carcinogenic
Intrinsic factors
• These apply for all ____
• Long ____ - less of a cancer risk
• ____ (chronic immunosuppression) - secondary risk for OSCC
tobacco alcohol betel genetics OSCC HPV lower lower cancers telomeres cyclosporine
≥ 80% of all OSCC caused by tobacco / alcohol
• Smoking
– Active and passive
– ____x risk
• Alcohol
– Increases risk ____x
• Synergism
– >5 drinks/day + >20 cigs/day =
>____x increased risk than either alone
– >____x risk over non-smokers and drinkers
• Field cancerization
• Do not memorize any numbers - just the trends (stages) • Smoking has the highest risk of any factors for OSCC-development ○ No evidence that second hand smoke causes OSCC, but it may for \_\_\_\_ and certainly lung cancer • \_\_\_\_ drinking can be a risk for some patients • Previous smokers can have a lower risk than a current smoker, but still have higher risk than a never smoker ○ Smoking causes damage to DNA > propagated during cell division to yield new cells that contain the same damage > eventually, so much damage in DNA in one cell > allows the cell to proliferate uncontrollably ○ Field cancerization [???] - one cell exposed is all cells exposed in organ sites - i.e. bronchioles down to your lungs will be exposed to carcinogens § All \_\_\_\_ are affected somewhat equally § Patient with cancer on buccal mucosa is equally likely to occur at another area
8-20
6
13
50
oropharyngeal
social
areas
• Sun damaged skin - ____
○ Blue stain - ____ fibers
○ Can occur in any area - field cancerization effect
solar elastosis
elastic
Ethnic customs
• Betel nut (Areca nut)
– Commonly used in South and East ____
• Bidi
– Rudimentary, hand-rolled ____
• Yerba mate
– Ilex ____
• Toombak
– ____ snuff
• Khat / Qat
– ____ plant
- Shisha / Hooka (Water pipe)
- Yerba mate - ____ cancer is common (South America)
asia cigarette paraguayensis sudanese catha edulis esophageal
Intrinsic factors
• Not everyone who smokes or drinks develops OSCC
• Young age of onset almost always associated with inherent ____
• Increased risk by 2-4 fold if positive family history
– 1 or more ____ degree relatives affected
• Intrinsic factors further modify the risk of any given patient • OSCC is not a \_\_\_\_ inherited cancer ○ There is a risk if you have a first degree relative with cancer
predisposition
first
genetically
Intrinsic factors
• Genetic \_\_\_\_ • Short \_\_\_\_ • Chronic immunosuppression – \_\_\_\_ patients on medications – Severe \_\_\_\_ deficiency
• Telomeres are inheritable
polymorphisms
telomeres
transplant
iron
Genetic diseases associated with OSCC development • Fanconi anemia • Dyskeratosis congenita • Li-Fraumeni syndrome • Ataxia telangiectasia • Bloom syndrome • Xeroderma pigmentosum • Epidermolysis bullosa
• The risk for cancer is transferrable • XP (middle patient) > has \_\_\_\_ cancer but has a risk for OSCC • EB (BR patient) ○ \_\_\_\_ why it causes OSCC • What unifies all the other diseases (1-6) - characterized by mutations in proteins that regulate response to repair \_\_\_\_ > DNA becomes genomically unstable
skin
unknown
DNA damage
Possible risk factors?? More research is needed
• Lichen planus
– WHO-recognized ____ lesion
– No definitive well-controlled studies that indicate risk
• ____
– Increasing number of studies suggest elevated risk
• Systemic sclerosis
– Increased risk for ____ cancer
• ____
– Some studies suggest possible risk
• LP - if left untreated can result in cancer
precancerous
diabetes mellitus
tongue
marijuana
What does OSCC look like? \_\_\_\_ Leukoplakia Erythroplakia \_\_\_\_
* Important slide * OSCC can look like \_\_\_\_
non-healing ulcer
mass
anything
• Leukoplakia
– White lesion that does not ____ off and cannot be characterized as other pathology
• Erythroplakia
– ____ lesion that cannot be attributed to other pathology
• Erythroplakia - not \_\_\_\_ in origin and not \_\_\_\_
rub
red
vascularized
inflamed
What does oral pre-cancer look like?
____
____
* You also treat at this \_\_\_\_ * Patients with erythroplakia - more likely to be \_\_\_\_ than leukoplakias
leukoplakia
erythroplakia
stage
cancerous
• Bottom left - mass - it’s not precancerous (or dysplastic); it is either ____, reactive or ____
benign
cancer
Pre-cancerous & cancerous lesions have NO distinctive
____ features
clinical
Treatment Options
• Complete ____
• ____ red/white lesions in high risk areas should be excised
• Long-term ____
* \_\_\_\_ tongue - higher risk - more likely to not be seen quickly * \_\_\_\_ of the mouth - higher risk * [???] * If not cancerous in high risk area > still requires \_\_\_\_
removal all follow up posterior floor excision
Definitions • Hyperplasia – Increased \_\_\_\_ of cells • Hyperkeratosis – Increased \_\_\_\_ • Dysplasia – \_\_\_\_ stage – Only applies to \_\_\_\_ • Carcinoma – Cancer of \_\_\_\_ cells
• Hyperplasia and hyperkeratosis are not \_\_\_\_ diagnoses ○ However, if in high risk area - warrants excision • Dysplasia used only in context of \_\_\_\_ (squamous, glandular, etc.)
number keratin pre-cancerous epithelium epithelial pre-cancerous epithelium
