Diagnosis and Surgical Management of Oral Cancer Flashcards
_____ are part of a group of cancers commonly referred to as head and neck cancers,
and they comprise about 85% of that category.
Oral cancers
T/F: Oral cancer can develop in any part of the oral cavity or the oropharynx.
True
Epithelium: “ 90% of oral cancer cases is _______ and they arise in
epithelial surface layer of oral mucosa.
Squamous cell carcinoma”
What are the 2 most common areas for SCC in oral cavity?
Lips
Tongue
______: way SCC spreads
Squamous cell carcinoma of the oral cavity first grows locally by progressive infiltration,
invasion and destruction of the surrounding tissue leaving them poorly demarcated.
• Important to local extension is the anatomic location of the tumor and the adjacent tissues next to
the tumor.
• Muscle is easily invaded while periosteum offers a good barrier to invasion.
Local Invasion
_____ spread of SCC
As the tumor progresses, the oral cancer spreads to the regional lymph nodes of the neck through the
lymphatic channel.
This is the most important and most frequent pathway for the spread of oral squamous cell
carcinoma.
• The cancer invades the local lymphatic supply and travels to the regional lymph node(s) draining the site.
- Usually oral squamous cell carcinoma spreads to the ipsilateral cervical lymph nodes i.e lymph nodes on the same side of the neck as the cancer.
- The lymph node containing the tumor cells is typically firm to stony hard (Indurated), non-tender and enlarged.
- Lymph nodes are freely movable at first but as the tumor breaks through the capsule, the node becomes fixed.
- Lymphadenopathy does not indicate metastasis for certain as it can result from inflammation associated with the presence of tumor also.
Lymphatic Spread
Does lymphatic spread usually occur on the ipsilateral or contralateral side?
Ipsilateral
___ spread of SCC
• In the later stages of the disease process, the tumor spreads into the vascular channel
(hematogenous metastasis) and may seed other parenchymal sites if tumor invasion is not
controlled at the lymphatic level.
• The usual sites of secondary spread (distant metastases) include the lungs, liver, bone, brain, and
adjacent skin, as well as other sites, depending on the tumor histology.
Distant Metastasis Through Hematogenous Spread
• It is important to evaluate the medical status of the patient in detail before
finalizing a surgical treatment plan.
Health History
T/F: Lymphatic spread usually occurs first in the uppermost, then middle and finally the lower cervical lymph nodes.
True
The most commonly involved node in case of oral and pharyngeal cancer is the ________) lymph nodes.
subdigastric (juglo-digastric
It is important to be aware of the phenomena of “________” of the primary oral
cancer into the Lymph nodes of the neck.
• In this case you will not be able to detect any lymph node enlargement by routine
clinical and radiographic examination. However, there is microscopic metastasis of the
oral squamous cell carcinoma from the oral cavity into the neck.
Occult Metastasis “
Primary Site
– Lower lip
What lymph nodes are most likely to be affected?
– Submental nodes
Primary Site
– Floor of the Mouth
What lymph nodes are most likely to be affected?
– Submental nodes
Primary site
– Posterior mouth
What lymph nodes are most likely to be affected?
– Superior jugular/digastric
Primary Site
– Oropharynx
What lymph nodes are most likely to be affected?
– Jugulo-digastric chain or retropharyngeal nodes
Is MRI or CT scan more precise in identifying tumor necrosis?
CT
Can CT or MRI detect lymph nodes smaller than 1 cm with occult metastasis?
NO
• In a patient with squamous cell carcinoma of the oral cavity, it is important to determine the extent of bone
involvement of the tumor process. Bone scans are highly sensitive in detecting earlier changes in the bone.
• Bone invasion is considered positive when bone scans reveal an asymmetrical or increased activity in the
area of jaw bone which corresponded to the clinical site of the primary tumor. Thus, they help clinicians
with preoperative evaluation of any evident tumor infiltration of bone.
• Although the Bone scans lack anatomical definition, they are useful in planning treatment for a patient
with oral cancer planning treatment for a patient with oral cancer.
Bone Scan
• PET provides information about the metabolic activity of the tissues.
• Positron emission tomography (PET) has been used to assist in the diagnosis of lymph node
metastasis or spread of tumor to other parts of the body.
• A minimal amount of tumor tissue must be present for the finding to be positive. Thus,
precision of PET is limited to about 5 mm.
PET (Positron Emission Tomography) Scan
The ______ system is the most widely used cancer staging system in the world
TNM
What does T stand for in TNM system?
T - the size and depth of the primary tumor
What does N stand for in TNM system?
N - whether the cancer has spread to the lymph nodes
What does M stand for in TNM system?
M - whether the cancer has spread to another part of the body i.e distant metastases
T?
No evidence of primary tumor
T0
T?
Tumor 2 cm or less in greatest dimension (Tumor < 2cm)
T1
T?
Tumor more than 2 cm but not more than 4 cm in greatest dimension (Tumor 2 to 4 cm)
zT2
T?
Tumor more than 4 cm in greatest dimension (Tumor > 4 cm)
T3
T?
Tumor invades deep adjacent structures (e.g., through cortical bone, inferior alveolar nerve, floor of
mouth, skin of face)
T4
N?
Regional lymph nodes cannot be assessed
N0
N?
Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
— single ipsilateral node ≤ 3cm)
(N1
N?
Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest
dimension
(— single ipsilateral node 3 to 6 cm)
N2a
N?
Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
(— multiple ipsilateral nodes ≤ 6cm)
N2b
N?
Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
(— contralateral or bilateral nodes ≤ 6cm)
N2c
N?
Metastasis in a lymph node more than 6 cm in greatest dimension
( — node > 6cm)
N3
M?
No distant metastasis - Means the cancer has not spread to other parts of
the body
M0
M?
Distant metastasis - Means cancer has spread to other parts of the body
such as the lungs liver, bone, brain, adjacent skin etc.,
M1
Stage___ Cancer
This is tumor of small size (Tumor 2 cm or less in greatest dimension) that has not grown deeply
into nearby tissues and has not spread to the lymph nodes or other parts of the body.
It is often called localized or early stage cancer
5 year survival rate is 85%
Stage 1
Stage ___ Cancer
This is a operable primary tumor (2 cm to 4 cm or less in greatest dimension) that has not grown
deeply into nearby tissues and has not spread to the lymph nodes or other parts of the body.
T2, N0, M0
5 year survival rate is 66%
Stage 2 cancer
Stage ___ Cancer
T3, N0, M0 - The oral tumor is larger than 4 cm across, has not grown deeply into nearby tissues and has not
spread to the lymph nodes or other parts of the body
T1 toT3, N0, M0 - The oral tumor is any size but has not grown into nearby adjacent structures or spread to
distant sites in the body. However, cancer cells are present in one lymph node, which is located on the same
side of the head or neck as the primary tumor and is smaller than 3 cm across.
T3, N0, M0
T1, N1, M0
T2, N1, M0
T3, N1, M0 5 year survival rate is 35-45%
Stage 3 cancer
Stage ____ cancer
In this situation, the cancer has reached an advanced stage and in stage IVC has distant metastasis.
T4, N0, M0
T4, N1, M0
Any T, N2, M0
Any T, N3, M0
Any T, Any N, M1
5 year survival rate is 9%
Stage 4 cancer
T/F: Tumor grading is not the same as the TNM staging system of a cancer.
True
Tumor _____ is determining the progression or spread of tumor in the body.
Tumor Staging
tumor _______
looks at the tumor cell differentiation and rate of growth under microscopic examination.
Grading
G?
: Well differentiated (Low Grade)
G1
G?
Moderately well differentiated (intermediate grade)
G2:
G?
Poorly differentiated (High Grade)
G3:
G?
Undifferentiated (High Grade)
G4:
- Small portion of the lesion with the adjacent normal tissues to facilitate correct diagnosis.
- To visualize the transitional zone between tumor and normal tissue.- Performed at the periphery to avoid the necrotic central area.
Incisional Biopsy
Removal of the Primary tumor along with a cuff of normal tissue around it. 1-2 cm
safety margins around tumor tissue.
En bloc resection:
: Resection of a tumor without disruption of the continuity of the bone
Indication: This type of surgical procedure is performed in patients who have advanced primary tumors
adjacent to the mandible.
Marginal Resection
: Resection of a tumor by removing full-thickness portion of the jaw. In this situation, the
jaw continuity is disrupted.
Indication: This type of surgical procedure is performed in patients who have advanced tumors that frankly
invade the mandible extensively.
Partial Resection
Lymph node metastasis reduces the survival rate of patients with squamous cell carcinoma by ____
half.
INdications for ______:
• Clinically palpable or radiographic evidence of metastasic submandibular and
cervical lymph nodes.
• There is secondary involvement of the neck from squamous cell carcinoma of
anterior part of the tongue, buccal mucosa and gingiva which gives rise to cervical
lymph node metastasis in 30% to 40% of the cases,
• There is secondary involvement of the neck from squamous cell carcinoma of of the
posterior tongue and hypopharynx which gives rise to cervical lymph node metastasis
in 50% to 60% of the cases,
Neck Dissection - Indications
What is the most aggressive form of neck dissection?
Radical neck dissection
_______ Neck Dissection
- Preservation of at least one of the following:
- Cranial Nerve XI (Spinal Accessory Nerve)
- SCM (Sternocleido Mastoid Muscle)
- IJV (Internal Jugular Vein)
Modified (functional)
_______Neck Dissection
- Not all lymph node regions dissected for e.g
- Supraomohyoid neck dissection
Selective (functional)
