Diagnosis and Surgical Management of Oral Cancer Flashcards
Oral cancers are part of a group of cancers commonly referred to as head and neck cancers,
and they comprise about –% of that category.
85
Oral cancer can develop in
any part of the oral cavity or the oropharynx
Origin of Malignancies in the Oral Cavity
(4)
- Epithelium:
- Connective Tissue:
- Salivary Gland:
- Metastatic disease:
- Epithelium:
“90% of oral cancer cases is Squamous cell carcinoma” and they arise in
epithelial surface layer of oral mucosa.
- Connective Tissue:
Sarcomas account for 2% of oral cancer cases. For e.g. Osteosarcoma,
Chondrosarcoma, Ewings sarcoma, Kaposi’s sarcoma, Lymphoma etc.,
- Salivary Gland:
Accounts for 4 to 8% of oral cancer cases. For e.g. Mucoepidermoid carcinoma,
Adenoid cystic carcinoma, Adenocarcinoma, Acinic cell carcinoma etc.,
- Metastatic disease:
Accounts for less than 1%, of oral cancer cases. Most originate from common
primary sites including lung, kidney, skin (melanoma), prostate in men and breast in women. Metastatic to
Mandible and occasionally soft tissues i.e to gingiva or tongue.
“—” is the most common oral malignancy that accounts for –%
of all Oral cancers).
Squamous cell carcinomas
90
- Lip - –%
- Tongue - –%
- Floor of the Mouth - –%
- Palate/tonsil - –%
- Gingiva - –%
- Other - –%
38
22
17
11
6
6
The Importance of Oral Cancer Screening
- Early diagnosis, prompt referral and appropriate treatment is critical for favourable
long term prognosis and survival of patients with oral cancer
he Spread of Oral Squamous Cell Carcinoma
Local Invasion
Squamous cell carcinoma of the oral cavity first grows locally by progressive infiltration,
invasion and destruction of the surrounding tissue leaving them poorly demarcated
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 …
* Muscle is easily invaded while periosteum offers a …
anatomic location of the tumor and the adjacent tissues next to
the tumor.
good barrier to invasion.
The Spread of Oral Squamous Cell Carcinoma
Regional Spread through Lymphatic Spread
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 Spread of Oral Squamous Cell Carcinoma
Regional Spread through Lymphatic Spread
- 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.
The Spread of Oral Squamous Cell Carcinoma
Distant Metastasis Through Hematogenous Spread
* 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 (5)
lungs, liver, bone, brain, and
adjacent skin, as well as other sites, depending on the tumor histology
Oral Cancer – Diagnosis and Workup
(6)
- Health History
- Detailed Patient History
- Head and Neck examination
- Imaging Studies - Radiographs, CT Scan/MRI exam, Bone Scan, PET Scan
- Biopsy
- Staging and Grading of Oral cancer
Health History
- It is important to evaluate the medical status of the patient in detail before
finalizing a surgical treatment plan.
Detailed Patient History - Signs and Symptoms
(9)
- Painless lump or ulcer (in the early stages)
- Posteriorly no symptom until it reach a size of 2-3 cm swelling then manifests as dysphagia
- Ear pain
- Difficulty in moving the jaw or tongue
- Hoarseness
- Paraesthesia (Tongue, lip etc.,)
- Swelling
- Non healing ulcer
- Absence of symptoms until the tumor metastasize to regional lymph nodes (hard lump on the
neck)
Indirect Laryngoscopy
- As patients diagnosed with oral cancer are also at increased risk for other head and
neck cancers, it is important to examine other areas of the throat for any additional
tumor process,
Oncologic Lymph Node Levels Of The Neck
Level I -
Level II -
Level III -
Level IV -
Level V -
Submental/submandibular nodes
Upper jugular nodes
Middle jugular nodes
Lower jugular nodes
Posterior triangle nodes
The Lymphatic Spread of Tumor is Orderly and Logical
* Lymphatic spread usually occurs first in the
* The most commonly involved node in case of oral and pharyngeal cancer is the
uppermost, then middle and finally the
lower cervical lymph nodes.
subdigastric (juglo-digastric) lymph nodes.
Examination of the Lymph nodes of the Neck
(5)
*Location
*Size(< measured in cm >)
*Tenderness
*Consistency(soft, firm or Hard)
*Mobility(mobile or fixed)
Palpation of the Lymph Nodes of the Neck
* Finding a palpable lymph node is helpful in the management of the
cancer
patient but it is not diagnostic of metastatic tumor.
Occult Metastasis of Primary Tumor to Neck Lymph Nodes
* It is important to be aware of the phenomena of “Occult Metastasis “ 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 of Primary Tumor to Neck Lymph Nodes
* In patients with Oral Squamous cell carcinoma, the phenomena of occult metastasis
occurs at rate of
- –% of the floor of mouth lesions
- –% of the tongue lesions
- –% of the gingival lesions
- –% of the tongue lesions
- –% of the lesions of the hard palate
- –% of the lesions of the buccal mucosa
20-35
38-52
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38-52
22
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Therefore, in order to minimize the risk of tumor recurrence, the surgeons perform a
prophylactic neck dissection to remove some of the most commonly associated lymph
nodes in the neck along with surgical resection of the primary tumor.
Likely sites of involved cervical lymph nodes from the spread of primary
head/neck SCC
Primary Site
(2)
– Lower lip
– Floor of the Mouth
– Posterior mouth
– Oropharynx
Site of Metastasis
(4)
– Submental nodes
– Submental nodes
– Superior jugular/digastric
– Jugulo-digastric chain or retropharyngeal nodes
Radiographic Examination - Panorex
Useful in cases of
bony involvement or to rule out any bony involvement
- Panoramic views shows lytic lesions
C.T.Scan with I.V contrast (Level: From base of skull to clavicles)
C.T Scans help with
precise delineation of the tumor extent and thus provides valuable information
about the size, shape and position of any tumors.
CT Scans with contrast also help reveals
enlarged lymph nodes suggestive of metastatic adenopathy
(seen on C.T.Scan as enhancement of the nodal capsule).
C.T Scans also helps us evaluate adjacent
bony structures and erosions involving the paranasal
sinuses, base of skull and the cervical spine
Magnetic Resonance Imaging (MRI)
* MRI is less commonly used as it is less precise than CT scan in identifying tumor
necrosis and extracapsular spread, but MRI is better in assessing
enlarged lymph
nodes that do not necessarily represent metastasis.
* However, MRI gives a better resolution for soft tissue tumors.
Limitations of C.T.Scan and MRI
- Both C.T.Scan and MRI cannot detect lymph nodes smaller than 1 cm. which, on
occasion, independently of the size, are involved in metastasis (Occult Metastasis)
Management of Oral Cancer
Additional Investigations
(4)
- Bone scan
- PET (Positron Emission Tomography) Scan
- Chest X-ray; if abnormal, then CT Scan of Chest must be examined
- Liver Function test
Bone Scan
* 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.
PET (Positron Emission Tomography) Scan
* PET provides information about the
* Positron emission tomography (PET) has been used to assist in the diagnosis of
* A minimal amount of tumor tissue must be present for the finding to be positive. Thus,
precision of PET is limited to about – mm.
metabolic activity of the tissues.
lymph node
metastasis or spread of tumor to other parts of the body.
5
Purpose and Principles of
TNM Staging System of Malignant Tumors
* Once all clinical and imaging information is collected, the tumor can be accurately staged based
on
AJCC (American Joint Committee on Cancer) -TNM classification.
The — is the most widely used cancer staging system in the world
TNM system
The TNM staging is very useful in facilitating discussion about the
type of malignant tumor that
the patient has between clinicians.
Purpose and Principles of TNM Staging System
Staging looks at the size and depth of the cancer (tumor) and whether it has spread
anywhere else in the body.
As the primary tumor (T) increases in size over time, local invasion occurs followed by
Spread to the regional lymph nodes (N) draining the area of the tumor followed by
Spread to other parts of the body i.e Distant Metastasis (M)
T - the size and depth of the primary tumor
N - whether the cancer has spread to the lymph nodes
M - whether the cancer has spread to another part of the body i.e distant metastases
The TNM system is an expression of the anatomic extent of disease and is based on the
assessment of three components:
T The extent of the primary tumor.
N The absence or presence including extent of regional lymph node metastasis.
M The absence or presence of distant metastasis
The use of numerical subsets of the TNM components indicates the
progressive extent of the
malignant disease i.e to determine how early or advanced the cancer is…..
- T0, T1, T2, T3, T4,
- N0, N1, N2, N3,
- M0, M1.
Primary Tumor
Indicated by the letter “–” and the suffix — represent more advancing disease
T
1,2, 3 or 4
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 (Tumor < 2cm)
T2
Tumor more than 2 cm but not more than 4 cm in greatest dimension (Tumor 2 to 4 cm)
T3
Tumor more than 4 cm in greatest dimension (Tumor > 4 cm)
T4
Tumor invades deep adjacent structures (e.g., through cortical bone, inferior alveolar nerve, floor of
mouth, skin of face)
Regional Lymph Nodes (N)
Is used to describe
progressive lymph node involvement
N0
Regional lymph nodes cannot be assessed
(N0 - No palpable nodes)
N1
Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension
(N1 — single ipsilateral node ≤ 3cm)
N2a
Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest
dimension
(N2A— single ipsilateral node 3 to 6 cm)
N2b
Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
(N2B— multiple ipsilateral nodes ≤ 6cm)
N2c
Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
(N2C— contralateral or bilateral nodes ≤ 6cm)
N3
Metastasis in a lymph node more than 6 cm in greatest dimension
(N3 — node > 6cm)
Distant Metastasis (M)
M describes
whether the cancer has spread to a different part of the body.
MX
Distant metastasis cannot be assessed
M0
No distant metastasis - Means the cancer has not spread to other parts of
the body
M1
Distant metastasis - Means cancer has spread to other parts of the body
such as the lungs liver, bone, brain, adjacent skin etc.,
American Joint Committee on Cancer (AJCC) staging system
* The AJCC staging system is a classification system developed by the American Joint
Committee on Cancer.
* It utilizes
* It acts as a guide to appropriate treatment and prognosis.
in part the TNM scoring system and is used to describe the amount and spread of
cancer in a patient’s body.
American Joint Committee on Cancer (AJCC) Staging System
* Stage I
T1, N0, M0
American Joint Committee on Cancer (AJCC) Staging System
* Stage II
T2, N0, M0
American Joint Committee on Cancer (AJCC) Staging System
* Stage III
T3, N0, M0
T1, N1, M0
T2, N1, M0
T3, N1, M0
American Joint Committee on Cancer (AJCC) Staging System
* Stage IVA
T4, N0, M0
T4, N1, M0
Any T, N2, M0
American Joint Committee on Cancer (AJCC) Staging System
* Stage IVB
Any T, N3, M0
American Joint Committee on Cancer (AJCC) Staging System
* Stage IVC
Any T, Any N, M1
Stage I 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 locallized or early stage cancer
5 year survival rate is –% for Stage I Cancer
85
Stage II 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.
5 year survival rate is –% for Stage II Cancer
66
Stage III 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
Stage III Cancer
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.
5 year survival rate is –% for Stage III Cancer
35-45
TNM Clinical Stage IV Cancer
In this situation, the cancer has reached an advanced stage and in stage IVC has distant metastasis
5 year survival rate is –% for Stage IV Cancer
9
What is Tumor Grading?
* Tumor grading is not the same as the TNM staging system of a cancer.
* Staging is …
determining the progression or spread of tumor in the body. However, tumor Grading
looks at the tumor cell differentiation and rate of growth under microscopic examination.
- In tumor grading,
the pathologist carries out the description of a tumor based on how abnormal
the tumor cells are. Grading helps the pathologist determine if there is a degree of dysplastic
changes in the tumor and also helps us know how quickly a tumor is likely to grow and spread.
Tumor Grading of Squamous Cell Carcinoma
Histopathological Grading:
Tumors are graded as 1, 2, 3, or 4, depending on the
amount of abnormality
Gx:
G1:
G2:
G3:
G4:
Grade of differentiation cannot be assessed (undetermined grade)
Well differentiated (Low Grade)
Moderately well differentiated (intermediate grade)
Poorly differentiated (High Grade)
Undifferentiated (High Grade)
How does tumor grade affect a patient’s treatment options?
In Grade 1 tumors, the tumor cells and the organization of the tumor tissue appear close to
normal. These tumors tend to grow and spread slowly and indicates a better prognosis.
In contrast, the cells and tissue of Grade 3 and Grade 4 tumors do not look like normal cells and
tissue and tend to grow rapidly and spread faster and may require immediate or more aggressive
treatment.
Clinicians use a combination of the (4), to develop a treatment plan and to determine a patient’s prognosis
tumor grade, TNM staging and a patient’s age and general
health
Definitive Diagnosis of Oral Cancer
Biopsy
This is the mainstay of tumor diagnosis coupled with high degree of suspicion
Incisional Biopsy
(3)
- 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.
Biopsy Result
- If your clinical impression does not match the Histopathological diagnosis, then the
biopsy procedure must be repeated.
Management of Oral Cancer
(4)
- Surgery
- Radiation
- Chemotherapy
- Combination Treatment
Oral Cancer – Surgical Management
(3)
- Surgical resection of Primary tumor
- Neck dissection
- Surgical reconstruction
Surgical Management of Oral Cancer
Management of Primary Tumor
En bloc resection:
Removal of the Primary tumor along with a cuff of normal tissue around it. 1-2 cm
safety margins around tumor tissue
Surgical Management of Oral Cancer
(4)
Management of Primary Tumor
Surgical Management of The Neck Lymph Nodes
Functional reconstruction including restoration of esthetics
Concurrent Chemotherapy and radiation treatment
Surgical Management of The Neck Lymph Nodes
Neck dissection
Squamous Cell Carcinoma - Lateral border of tongue
TNM Grading
Surgical Treatment :
Partial Glossectomy + with Radical Neck Dissection
Marginal Resection
If cancer has spread into bone, surgery may include removal of the involved bone tissue of the maxilla or
mandible.
Marginal Resection:
Indication:
Resection of a tumor without disruption of the continuity of the bone
This type of surgical procedure is performed in patients who have advanced primary tumors
adjacent to the mandible.
Partial Resection
Partial Resection:
Indication:
Resection of a tumor by removing full-thickness portion of the jaw. In this situation, the
jaw continuity is disrupted.
In the mandible, this can vary from a small continuity defect to a hemimandibulectomy.
This type of surgical procedure is performed in patients who have advanced tumors that frankly
invade the mandible extensively.
Partial resection of the Mandible
Partial Resection:
Indication:
Resection of a tumor by removing full-thickness portion of the jaw. In this situation, the
jaw continuity is disrupted.
This type of surgical procedure is performed in patients who have advanced tumors that frankly
invade the mandible extensively.
Total Resection
(2)
- Resection of a tumor by removal of the involved bone.
- Eg., Hemi-Maxillectomy and Hemi-Mandibulectomy
Management of Oral Cancer
Neck Dissection
- Lymphatic metastasis to the neck is the most important mechanism of spread of Oral cavity
squamous cell carcinoma from primary sites. - The risk of lymph node involvement by metastasis varies depending on the site of origin,
size of primary tumor, histologic grade of the primary tumor, perineural invasion,
perivascular invasion, and extracapsular spread. - The most important factor in prognosis of Squamous cell carcinoma involving the oral cavity
is the status of cervical lymph nodes. - Lymph node metastasis reduces the survival rate of patients with squamous cell
carcinoma by half. - Therefore, Neck dissections are performed in the hope of controlling metastatic cancer
within cervical lymph nodes from primary cancers in the head and neck region.
Management of Oral Cancer
Neck Dissection - Indications
- 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
Surgical Management of Oral Cancer
Why is Neck Dissection so critical?
* A single ipsilateral metastatic lymph node reduces survival by –%.
* A single contralateral metastatic lymph node reduces survival by –%.
* Extra-nodal spread reduces survival a further –%.
50
50
50
Neck Dissection - Classification
The RND is classified according to the Academy’s Committee for Head and Neck
Surgery & Oncology into four major types:
(3)
- Radical Neck Dissection (RND)
- Modified Radical Neck Dissection (MRND)
- Selective Neck Dissection (SND)
Neck Dissection
(3)
- Radical Neck Dissection
- Modified (functional) Neck Dissection
- Selective (functional) Neck Dissection
- Modified (functional) Neck Dissection
(4)
- Preservation of at least one of the following:
- Cranial Nerve XI (Spinal Accessory Nerve)
- SCM (Sternocleido Mastoid Muscle)
- IJV (Internal Jugular Vein)
- Selective (functional) Neck Dissection
(2)
- Not all lymph node regions dissected for e.g
- Supraomohyoid neck dissection
Management of Oral Cancer
Adjuvant Therapy
- Additional cancer treatment like Chemotherapy and Radiation treatment after surgery
in order to lower the risk of recurrence is called as adjuvant therapy
Reconstruction of Oral Cavity Defects following Surgical
Resection of Oral Cancer - Rationale
* To Restore the:
- Form of the Maxilla and mandible
– Maintain correct anatomical relation to the jaws
– Important for dental rehabilitation (endosseous implant placement) - Function
- Mastication
- Speech
- Aesthetics
Reconstruction of Oral Cavity Defects following Surgical Resection of Oral
Cancer
(4)
- Soft Tissue Reconstruction
- Hard Tissue Reconstruction
- Soft and Hard Tissue Reconstruction
- Functional Reconstruction including Dental Implant Treatment
Soft Tissue Reconstruction
(6)
- Primary closure
- STSG(Split Thickness Skin Graft)/ dermal graft
- Local flaps – Mucosal or skin
- Regional flaps
- Myocutaneous flaps
- Free flaps with microvascular anastomosis
Hard Tissue Reconstruction
(5)
- No reconstruction
- Irradiated bone
- Pedicled vascularized flap
- Free flap - vascularized bone with microvascular anastomosis
- Osteointegrated titanium implants (Functional Reconstruction)
Microvascular Flaps Used for Reconstruction of Defects of the Oral Cavity
((4)
- Radial Forearm Flap
- Ileum
- Scapula
- Fibula
Oral Cancer - Post-treatment follow-up intervals
* Every – for the first year
* Every – for the second year
* Every – for the third year
* Every – thereafter for life
6-8 weeks
2-3 months
3-4 months
6-12 months
