Cancer - Thomson/Curtin Flashcards
What is the most common type of oral cancer
Squamous cell carinoma (>90%)
5 Primary tumour types of oral cancer
SCC
Minor salivary gland carcinoma
Lymphoma
Malignant Melanoma
Sarcoma
SCC
ORAL CANCER acronym
Oral ulceration (non-healing)
Red/white patches
Abnormal swellings
Loss of tongue mobility
Cauliflower-like growths
Abnormal, localised tooth mobility
Non-healing sockets
Colour change in mucosa (brown/blue)
Erosions in mucosa
Reduced / altered sensation
Why is SCC a lethal disease?
50% of patients seen with SCC will die within 5 years
- rising incidence
Aetiology of SCC (7)
Tobacco / Alc
Poor nutrition
Infections (HPV)
Poor oral health
Low SES
Immunosuppression
Genetics
What is the malignant transformation rate of oral epithelial dysplasia?
12.3%
What is an OPMD?
Morphologically altered tissue in which oral cancer is more likely to occur than its normal counterpart
Definition of leukoplakia
White patch which cannot be wiped off mucosa or ascribed to any other clinical or histo-pathological condition
- By definition, leukoplakia has a potentially malignant predisposition
What has a higher risk of malignant transformation - homogenous or non-homogenous leukoplakia?
Non-homogenous
What is the commonest type of OPMD?
Leukoplakia
Female pt aged 63
Proliferative verrucous leukoplakia
Features of Proliferative verrucous leukoplakia (5)
- Females > 60
- Not associated with tobacco or alc use
- Slow growing, progressive
- Fissured, warty-looking
- 70% malignant transformation rate
What to be mindful with erythroplakia?
high chance of malignancy
- 40% of observed erythroplakia is already invasive OSCC
Erythroleukoplakia
- White flecks or nodules on atrophic erythematous base
- More dangerous than leukoplakia, but not as likely to turn malignant as erythroplakia
- If in labial commissures, could be related to chronic hyperplastic candidosis
Erythroleukoplakia
- White flecks or nodules on atrophic erythematous base
- More dangerous than leukoplakia, but not as likely to turn malignant as erythroplakia
Oral Submucous Fibrosis
Chronic hyperplastic candidosis
How to treat chronic hyperplastic candidosis
Fluconazole (systemic antifungal)
Why dont topical antifungals work on chronic hyperplastic candidosis (nystatin, amphotericin)
They have thickened hyperplastic epithelium above the fungi
- Topical antifungal will not be able to penetrate, requires a systemic antifungual (fluconazole)
Why does chronic hyperplastic candidosis come back?
Pt keeps smoking
Discoid lupus erythematous
Actinic cheilitis
Lichen planus / lichenoid lesions
- be very mindful if its seen on the tongue
Tertiary syphillis
What locations are the most high risk for malignant change?
- Floor of mouth
- Ventro-lateral tongue
- Retromolar regions
Managment goals of OPMD (7)
- Accurate diagnosis
- Prediction of clnical behaviour
- Early recognition of malignancy
- Removal of dysplastic mucosa
- Prevention of recurrence
- Prevent malignant transformation
- Minimal patient morbidity
What does sclerous mean?
Hard / bony
What defines a malignant tumour? (3)
The appearance, behaviour & histology
What is the appearance of cancer?
- Ulcerated / non-healing
- White or red in colour
- Margins are fucked
- Cirrous / Sclerous (hard and bony)
What is the primary mode of spread of oral cancer?
Lymphatic
What is the behaviour of cancer?
- Grows locally invasively
- Spreads regionally then distantly
- “Parasitic”
- “Anarchistic”
What is the role of lymph nodes?
LN are drainage ports, packed full of lymphocytes
What is cachexia?
Extreme weight loss and muscle wasting
What happens to the basement membrane cells when cancer occurs?
Basement membrane cells switch to mesenchymal cells
What is an adenoma carcinoma?
Adenocarcinoma is a type of cancer that starts in mucus-producing glandular cells of your body
- Salivary gland tumours
- Asymptomatic
What are the principles of management for oral oncology
- Establish diagnosis
- Establish extent of disease
- Classification
- Staging
- Treatment
What are the three parameters of cancer staging?
Tumour size
Lymph node involvement
Metastasis
Why do we use staging for oncology? (5)
Standardisation
Disease progression
Prognosis
Risk stratification
Disease management
What is prognostication?
Guessing the outcome based on statistics
What is the fatality rate for small, treatable oral cancer tumours
25%
General complications of cancer
CANCER acronym
Cachexia & wasting
Anaemia
Nutritional deficiency
Cutaneous manifestations
Endocrine disorders
Rare manifestations
3 common sites for metastases from jaws
Breast
Lung
Prostate
Effects of tumour metabolites (4)
Facial flushing
Pigmentations
Amyloidosis
Oral erosions
Changes caused by functional disturbances (4)
Purpura
Bleeding
Infections
Anaemia
What complications can radiotherapy have on periodontal tissues (4)
Mucositis
Ulceration
Periodontal disease
Candidosis
What complications can radiotherapy have on teeth?
Radiation caries
Dental hypersensitivity
Loss of taste
What complications of radiotherapy can affect your tx plan? (3)
Trismus
Osteoradionecrosis
Craniofacial defects (in younger pts)
Path of radiation in radiotherapy case
Radiation caries
Osteoradionecrosis
How to manage patient during head & neck radiotherapy (5)
- Discourage smoking and alcohol
- Elimate infections
- Relieve mucositis
- Saliva substitutes
- Physiotherapy for trismus
Managment of patients after receiving head & neck radiotherapy (6)
- Continue OH/preventive care
- Antibiotics for infections
- Refer to OMFS for exo/oral surg
- Topical fluoride
- Avoid mucosal trauma
- Saliva substitutes
Saliva substitute
Biotene
Oral complications of chemotherapy
Infections
Ulcers / mucositis
Lip cracking
Bleeding
Xerostomia
Periodontal disease
Delayed / abnormal development
Management of patients befor Chemotherapy (2)
Oral and dental assessment
OH
Management of patients during chemotherapy (6)
- Folic acid to reduce ulcers
- Ice cold water / sucking ice
- CHX (diluted)
- Nystatin (for candidosis)
- Aciclovir (herpes infection)
- AB for infections
What drug interaction should wartch out for with methotrexate? (chemotherapy drug)
Methotrexate exacerbates the effect of NSAIDs and Aspirin
*Patients suffering from rheumatoid arthritis often also take methotrexate as a medication
Features of oral mucositis
Widespread erythema
Ulceration
Soreness & bleeding
WHO mucositis scale
1- Soreness / erythema
2- Erythema & ulcers / able to eat solids
3- Ulcers / requires liquid diet
4- Oral intake not possible
Management of patients with Oral Mucositis (5)
PCA / opioids
Avoid smoking, alc, spices
Good OH
Cold water / ice
Topical analgesics
Why do cancer treatments have the potential to significantly impact oral tissues?
Treatments are aimed at rapidly dividing cells (skin, mucosa, blood, etc)
Chemo - systemic
Radio - localised
Why do th things sometimes not go according to plan with cancer treatment?
Altered pt priorities
Pt capacity
Altered oral physiology
Cannot get to dentist
Financial problems
What needs to be done before cancer patient receives treatment? (6)
- Clinical exam
- Identify problem teeth
- Pulp testing
- radiography
- OPG
- Perio issues
Consideration for exos post cancer treatment
Radiotherapy damages bone permanently
If tooth needs to come out, be very careful - atraumatic resto
Oral consideration for Radiotherapy? Management?
Xerostomia
Cells of salivary glands are affected greatly
- Leads to dental, mucosal and eating issues
- Infection
- Mucosa becomes atrophic
Management: do surgery first so tissues can heal - will be permanently affected after radiotherapy
Mechanism of action radiotherapy vs chemo
Radiotherapy - locallised radiation doses stops growth of cancer cells
Chemotherapy - uses drugs to stop growth (killing or stopping cell division)
Systemic effects of chemotherapy
Myelosuppression (mucositis)
Neutropenia (infections)
Fungal (thrush)
Viral (herpes, cytomegalovirus)
Oral impacts of chemotherapy
Mucositis
Oral thrush
Sloughing of mucosa
What is involved in CO2 laser surgery? (7)
Rapid dissection
Haemostasis
Post-operative analgesia
Excision allows histopathological dx
Low morbidity
Reduced scarring
Good patient acceptance
What are the 3 surgical interventions for OPMD’s
- Scalpel excision
- Laser therapy
- Photodynamic therapy
Histopathological features of OED
Cytology features (4)
Variation in:
- Nucleus size & shape
- Cell size & shape
Hyperchromasia
Increased # and size of nucleoli
Atypical mitotic figures
Histopathological Features of OED
Tissue Architecture (IDLAK)
Irregular epithelial stratification
Drop-shaped rete ridges
Loss of polarity of basal cells
Abnormally superficial mitoses
Keratin pearls within rete ridges
What is dysplasia?
Histopathological term describing a range of tissue dysmaturation and disorganisation changes seen in biopsy specimens
Associated with an increased risk of malignant transformation
What are the 2 systems of grading OED
WHO (mild, mod, severe, carcinoma in situ)
Binary System (high/low grade/risk)
Describe the Binary System’s method of grading OED
High risk lesions
- Lesions presenting with at least 4 architectural changes and 5 cystological changes
- Low-risk lesions present with <4 architectural changes and <5 cytological changes
Describe what cancer is (features, how)
Invasive tumour from epithelial lining tissue
accumulation of multiple mutations in DNA
Disruption of cell proliferation, differentiation and development
Abnormal, uncoordinated growth
Due to Carcinogens or spontaneous mutation
Local tissue invasion and destruction
Crab-like
Metastasis
3 high risk and 3 low risk aetiology of OSCC
HIGH risk
- Tobacco/alc
- Age
- Immunodeficiency
LOW risk
- Poor OH
- Low SES
- HPV
