Diagnosis and Surgical Management of Oral Cancer

Question 1

_____ are part of a group of cancers commonly referred to as head and neck cancers,
and they comprise about 85% of that category.

Answer 1

Oral cancers

Question 2

T/F: Oral cancer can develop in any part of the oral cavity or the oropharynx.

Answer 2

True

Question 3

Epithelium: “ 90% of oral cancer cases is _______ and they arise in
epithelial surface layer of oral mucosa.

Answer 3

Squamous cell carcinoma”

Question 4

What are the 2 most common areas for SCC in oral cavity?

Answer 4

Lips

Tongue

Question 5

______: 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.

Answer 5

Local Invasion

Question 6

_____ 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.

Answer 6

Lymphatic Spread

Question 7

Does lymphatic spread usually occur on the ipsilateral or contralateral side?

Answer 7

Ipsilateral

Question 8

___ 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.

Answer 8

Distant Metastasis Through Hematogenous Spread

Question 9

• It is important to evaluate the medical status of the patient in detail before
finalizing a surgical treatment plan.

Answer 9

Health History

Question 10

T/F: Lymphatic spread usually occurs first in the uppermost, then middle and finally the lower cervical lymph nodes.

Answer 10

True

Question 11

The most commonly involved node in case of oral and pharyngeal cancer is the ________) lymph nodes.

Answer 11

subdigastric (juglo-digastric

Question 12

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.

Answer 12

Occult Metastasis “

Question 13

Primary Site
– Lower lip

What lymph nodes are most likely to be affected?

Answer 13

– Submental nodes

Question 14

Primary Site
– Floor of the Mouth

What lymph nodes are most likely to be affected?

Answer 14

– Submental nodes

Question 15

Primary site
– Posterior mouth

What lymph nodes are most likely to be affected?

Answer 15

– Superior jugular/digastric

Question 16

Primary Site
– Oropharynx

What lymph nodes are most likely to be affected?

Answer 16

– Jugulo-digastric chain or retropharyngeal nodes

Question 17

Is MRI or CT scan more precise in identifying tumor necrosis?

Answer 17

CT

Question 18

Can CT or MRI detect lymph nodes smaller than 1 cm with occult metastasis?

Answer 18

NO

Question 19

• 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.

Answer 19

Bone Scan

Question 20

• 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.

Answer 20

PET (Positron Emission Tomography) Scan

Question 21

The ______ system is the most widely used cancer staging system in the world

Answer 21

TNM

Question 22

What does T stand for in TNM system?

Answer 22

T - the size and depth of the primary tumor

Question 23

What does N stand for in TNM system?

Answer 23

N - whether the cancer has spread to the lymph nodes

Question 24

What does M stand for in TNM system?

Answer 24

M - whether the cancer has spread to another part of the body i.e distant metastases

Question 25

T? No evidence of primary tumor

Answer 25

T0

Question 26

T? Tumor 2 cm or less in greatest dimension (Tumor < 2cm)

Answer 26

T1

Question 27

T? Tumor more than 2 cm but not more than 4 cm in greatest dimension (Tumor 2 to 4 cm)

Answer 27

zT2

Question 28

T? Tumor more than 4 cm in greatest dimension (Tumor > 4 cm)

Answer 28

T3

Question 29

T? Tumor invades deep adjacent structures (e.g., through cortical bone, inferior alveolar nerve, floor of mouth, skin of face)

Answer 29

T4

Question 30

N? Regional lymph nodes cannot be assessed

Answer 30

N0

Question 31

N? Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension — single ipsilateral node ≤ 3cm)

Answer 31

(N1

Question 32

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)

Answer 32

N2a

Question 33

N? Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension (— multiple ipsilateral nodes ≤ 6cm)

Answer 33

N2b

Question 34

N? Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension (— contralateral or bilateral nodes ≤ 6cm)

Answer 34

N2c

Question 35

N? Metastasis in a lymph node more than 6 cm in greatest dimension ( — node > 6cm)

Answer 35

N3

Question 36

M? No distant metastasis - Means the cancer has not spread to other parts of the body

Answer 36

M0

Question 37

M? Distant metastasis - Means cancer has spread to other parts of the body such as the lungs liver, bone, brain, adjacent skin etc.,

Answer 37

M1

Question 38

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%

Answer 38

Stage 1

Question 39

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%

Answer 39

Stage 2 cancer

Question 40

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%

Answer 40

Stage 3 cancer

Question 41

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%

Answer 41

Stage 4 cancer

Question 42

T/F: Tumor grading is not the same as the TNM staging system of a cancer.

Answer 42

True

Question 43

Tumor _____ is determining the progression or spread of tumor in the body.

Answer 43

Tumor Staging

Question 44

tumor _______ | looks at the tumor cell differentiation and rate of growth under microscopic examination.

Answer 44

Grading

Question 45

G? : Well differentiated (Low Grade)

Answer 45

G1

Question 46

G? Moderately well differentiated (intermediate grade)

Answer 46

G2:

Question 47

G? Poorly differentiated (High Grade)

Answer 47

G3:

Question 48

G? Undifferentiated (High Grade)

Answer 48

G4:

Question 49

- 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.

Answer 49

Incisional Biopsy

Question 50

Removal of the Primary tumor along with a cuff of normal tissue around it. 1-2 cm safety margins around tumor tissue.

Answer 50

En bloc resection:

Question 51

: 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.

Answer 51

Marginal Resection

Question 52

: 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.

Answer 52

Partial Resection

Question 53

Lymph node metastasis reduces the survival rate of patients with squamous cell carcinoma by ____

Answer 53

half.

Question 54

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,

Answer 54

Neck Dissection - Indications

Question 55

What is the most aggressive form of neck dissection?

Answer 55

Radical neck dissection

Question 56

_______ Neck Dissection - Preservation of at least one of the following: - Cranial Nerve XI (Spinal Accessory Nerve) - SCM (Sternocleido Mastoid Muscle) - IJV (Internal Jugular Vein)

Answer 56

Modified (functional)‏

Question 57

_______Neck Dissection - Not all lymph node regions dissected for e.g - Supraomohyoid neck dissection

Answer 57

Selective (functional)‏