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Oral medicine > key points OSCC > Flashcards

key points OSCC Flashcards

1
Q

benign nomenclature

A

-oma

except epithelial neoplasms classified on their microscopic or macroscopic pattern

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2
Q

malignant nomenclature

A
  • carcinoma for epithelial origin

- sarcoma for CT

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3
Q

most common types of oral cancer

A

SCC
NHL
mucoepidermoid carcinoma

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4
Q

which area has highest prevalence?

A

southern asia

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5
Q

high risk sites

A

tonsils (HPV)
tongue (smoking)
base of tongue
FOM

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6
Q

what does OSCC arise from?

A

oral keratinocytes

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7
Q

high risk sites for OSCC

A

tongue
FOM
gingiva

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8
Q

high risk sites for OSCC if betel quid chewing

A

buccal mucosa and gingiva

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9
Q

characteristics of benign tumours

A 
expansive growth
rare and typical mitoses
no metastasis
local consequences variable - compressions
no recurrences
general consequences none except secretory tumours/particular sites
freq stabilisation
typical structure
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10
Q

characteristics of malignant tumours

A 
infiltrating growth
atypical structure
numerous and atypical mitoses
metastasis
severe local consequences - infiltration, destruction, necrosis
constant and severe general consequences
always fatal
common recurrences
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11
Q

clinical appearance

A

OPMDs
ulceration
- solitary lesion not healing/responding to conservative
management
- irregular and indurated margins usually
speckled
- ill-defined mixed white red lesions with granular aspects
exophytic growth
- irregular outgrowth with a smooth or verrucopapillary
surface above normal mucosa
- verrucopapillary surface - verrucous carcinoma

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12
Q

subtypes of OSCC

A 
verrucous carcinoma
basal SCC
papillary SCC
spindle cell SCC
adenosquamous carcinoma
lymphoepithelial carcinoma
acantholytic SCC
carcinoma cuniculatum
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13
Q

which subtypes have exophytic verruco-papillary component?

A

verrucous carcinoma
carcinoma cuniculatum
papillary SCC

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14
Q

late clinical features

A

pain - mostly if ulcerated
trismus (buccal mucosa and infratemporal fossa)
FOM - restriction of tongue mobility, progressive difficulty in mastication and speech, drooling of saliva
gingiva - excessive mobility of involved teeth
tongue base - fullness in throat sensation, dysphagia, lump in neck sensation, voice changes, ear pain

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15
Q

diagnostic pathway

A

history and exam
histopathology and clinical adjuncts
radiologic imaging

= then grading and staging

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16
Q

predictors of prognosis

A

grading and staging

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17
Q

grading

A

cytologic differentiation of cells
how bad do the cells look?
how much do they look like healthy cells under microscope?

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18
Q

staging

A

where has the cancer spread?

size of primary lesion, LNs, metastases

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19
Q

morphologic features for grading

A

degree of keratinisation (ideally high)
nuclear polymorphism (ideally little)
number of mitoses (ideally low) - excluded from Bryne system
pattern of invasion (ideally pushing, well-delineated, infiltrating borders)
host response (ideally marked - lymphoplasmacytic infiltrate)

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20
Q

Grade X

A

differentiation can’t be assessed

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21
Q

Grade 1

A

well-differentiated

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22
Q

Grade 2

A

moderately differentiated

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23
Q

Grade 3

A

poorly differentiated

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24
Q

Grade 4

A

undifferentiated/anaplastic

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25
Q

how does the grade affect prognosis?

A

lower grade = better prognosis

predicts how quickly the cancer will spread

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26
Q

staging (TNM)

A

Tumour T0-4
Node N0-3
Metastasis M0-1

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27
Q

8th edition cancer staging

A

Tumour thickness TT
DOI
ENE

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28
Q

TT

A

perpendicular from mucosal surface of tumour to deepest point of tissue invasion

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29
Q

DOI

A

level of basement membrane adjacent to normal mucosa to deepest point of tumour invasion
>10mm sig increased risk of recurrence and nodal metastasis
elective neck dissection should be consideration for tumours <5mm deep

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30
Q

ENE

A

extension of metastatic cells through the nodal capsule into the perinodal tissue

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31
Q

what is CT used for?

A

detecting primary tumour and local bone infiltration

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32
Q

MDCT

A

precisely determine tumour boundaries

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33
Q

CECT

A

accurately determine LN metastases

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34
Q

what can’t CT do?

A

differentiate between recurrences, surgical scars and adverse reactions after radio

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35
Q

imaging without ionising radiation

A

MRI

US

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36
Q

MRI

A

good for STs, bone marrow, vessels and nerves

can detect local LN and distant metastases

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37
Q

US

A

evaluate superficial lesions, LNs and to guide FNAB
with colour doppler can use US to determine type of blood vascularity in a lesion, often increasing the specificity of diagnosis

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38
Q

PET-CT

A

can use to look for primary tumour site when metastases are found earlier (CUP)
may detect malignancy in structures which appear normal/difficult to assess on CT/MRI e.g. small vol LN metastases
routinely used to detect recurrence and distant metastasis of known primary tumours, as well as 2nd primary tumours
recommended in advanced cancer stages and the whole body imaging improves analysis of TMN

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39
Q

cTMN

A

estimate of cancer based on results of physical exams, imaging, endoscopy, biopsy, done before tx starts

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40
Q

pTNM

A

relies on results of exams and tests before surgery, as well as what is learned about cancer during surgery
gives more precise info, can be used to help determine what other txs might be needed, as well as to help predict tx response and outcomes (prognosis)

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41
Q

first stage before imaging

A

establish primary site and any neck metastases clinically and have histological diagnosis

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42
Q

role of radiology

A

accurately stage full extent and distant spread with TNM

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43
Q

T groupings

A 
TX
Tis
T1
T2
T3
T4a
T4b
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44
Q

N groupings

A 
NX
N0
N1
N2a
N2b
N2c
N3a
N3b
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45
Q

what are involved LNs initially?

A

soft, mobile, non-tender

46
Q

advanced stage LNs

A

enlarged
firm/hard texture
usually non-tender fixation of nodes to adjacent tissue due to invasion of cells through the capsule

47
Q

M groupings

A

cM0
cM1
pM1 - microscopically confirmed

48
Q

what increases the chance of bilateral cervical nodal spread?

A

the closer to the midline the primary tumour is

49
Q

prognostic overall staging groups

A 
0
1
2
3
4a
4b
4c
50
Q

oropharynx includes:

A 
inferior (anterior) surface of SP and uvula
base of tongue
anterior and posterior tonsillar pillars
pharyngeal tonsils
lat and posterior pharyngeal walls
51
Q

overall tx modalities

A

surgery
chemo
radio
multimodal approach

52
Q

OSCC stage 1 and 2 tx

A

surgery or RT

53
Q

OSCC stage 3 and 4 tx

A

concomitant radio/chemo with surgery best outcome

54
Q

what are definitive RT, concurrent CRT and sequential therapy typically reserved for?

A

medically inoperable pts
unresectable disease
resectable disease where surgical resection cannot be accomplished with acceptable long-term fct consequences

55
Q

contraindications to open resection

A

T4b - invasion of masticator space, pterygoid plates, skull base or carotid encasement
pt perception of QOL

56
Q

goal of surgery

A

completely resect primary tumour and any neck deposit to prevent recurrence and high survival rate
attempt to ensure negative resection margins - increased risk of tx failure in pts with positive surgical margins
- specimen examined and margins checked

57
Q

surgical techniques

A

open resection
TORS
TLM

58
Q

minimally invasive surgery: TORS and TLM

A

may provide improved fct outcomes with min surgical morbidity and enhance the pathologic staging
surgeon distant from pt controlling robotic unit

59
Q

indications for minimally invasive surgery

A

T1-2 tumours of oropharynx but only if surgeon has good oral access

60
Q

contraindications for minimally invasive surgery

A

retrognathia
class 2 occlusion
limited cervical extension
SP tumour: higher rate of rhinolalia, velopharyngeal insufficiency and nasopharyngeal reflux

61
Q

pros of minimally invasive surgery

A 
no external incision
reduced immediate post-op toxicity
shorter post-op hospitalisation time
faster fct recovery
enhanced visualisation: 3D and magnification of field
elimination of physiologic tremors
movements can be scaled
fatigue reduction
62
Q

cons of minimally invasive surgery

A

absence of tactile sensation: unable to feel resistance or how tight a knot is
equipment size and weight
cost - installation and annual maintenance

63
Q

surgery - neck dissection types

A

comprehensive
selective
superselective
elective

64
Q

neck dissection - comprehensive

A

all LN levels of the neck are removed +/- 3 non-lymphatic structures (SCM, IJV, CN11)

65
Q

neck dissection - selective

A

not all neck LN levels are dissected

e.g. OSCC at least level 1-3, oropharynx SCC at least level 2-4

66
Q

neck dissection - superselective

A

dissection of only one or two contiguous LN levels to further reduce the morbidity of neck dissection

67
Q

neck dissection - elective

A

dissection of the appropriate nodal level, based on the risk of occult microscopic metastases
for OSCC SLNB or DOI currently best predictors
DOI ≥ 4mm accurate cut off value for preforming an elective neck dissection in early stage OSCC

68
Q

SLNB

A

identifying and harvesting the initial node to which the primary tumour drains

69
Q

indications for a SLNB

A

assess pts with biopsy-proven OSCC staged as early tumours with clinically (palpation) and radiologically (US, CT, MRI) N0 neck
assess bilateral N0 necks in primary tumours close to or crossing the midline

70
Q

accuracy of SLNB

A

high

using immunohistochemistry can increase SLNB diagnostic accuracy

71
Q

how does RT work?

A

uses high energy ionising radiation to disrupt the integrity of malignant cells through focal DNA damage, while doing as little harm as possible to normal cells

72
Q

uses of RT

A

exclusive tx of primary cancer
adjuvant therapy after surgery
adjuvant therapy before surgery
palliative

73
Q

uses of RT - exclusive tx of primary cancer

A

early stage or unresectable/advanced stage in combination with chemo

74
Q

uses of RT - adjuvant therapy after surgery

A

+/- chemo to control positive neck nodes and/or kill remaining cancer cells in positive margins

75
Q

uses of RT - adjuvant therapy before surgery

A

+/- chemo to shrink tumour

76
Q

uses of RT - palliative

A

control symptoms of advanced OSCC e.g. pain, bleeding, dysphagia, and problems caused by bone metastases, and to give pt a better QOL

77
Q

types of RT

A

EBRT

brachytherapy

78
Q

EBRT

A

machine used to aim high energy rays/beams from outside the body into the tumour
- focus on exact location to spare normal tissues as much as possible

79
Q

EBRT usual radiation schedule

A

tx usually 5 days a week for 6-7wks

80
Q

other EBRT schedules

A

hyperfractionation
accelerated fractionation
may reduce risk of cancer coming back in or near place it started (local recurrence) but tend to have more severe SEs

81
Q

hyperfractionation

A

total radiation dose in a larger number of doses e.g. 2 smaller doses per day

82
Q

accelerated fractionation

A

≥ 2 doses each day so tx completed faster e.g. 3 wks instead

83
Q

simulation technique

A

determine areas that will be radiated through a stimulator, scan to identify target vols
mark with tattoos

84
Q

types of EBRT

A 
intensity-modulated (IMRT) - most common
3D conformal (3D-CRT)
image guided (IGRT)
volumetric modulated arc therapy (VMAT/Rapid Arc)
intensity modulated proton therapy (IMPT)
stereotactic radiosurgery (SRS)
stereotactic body (SBRT)
intraoperative (IORT)
85
Q

IMRT

A

a high precision RT that uses computer-controlled linear accelerators to deliver precise radiation doses to a malignant tumour or specific areas within a tumour
- dose to target usually proportional to estimated tumour burden

+ allows higher radiation doses to be focused on tumour
+ spare OAR

86
Q

internal radiation therapy (brachytherapy)

A

hollow catheters placed into/around tumour during surgery
left in place for several days while pt stays in hospital
radioactive material put into tubes for short time each day
small radioactive pellets (rice) put right into tumour
give off low levels of radioactivity for several weeks and over time lose strength
pellets just left in place and rarely cause problems

87
Q

short term RT SEs

A 
visible during/immediately after RT and may last for 2-3wks after tx
oral mucositis
dental pain
taste loss
trismus (due to pain)
odynophagia
dysphagia
candidiasis
radiation dermatitis (RD)
ORN
88
Q

long term RT SEs

A

visible several weeks after RT and may last long time/permanently after tx
salivary gland hypofct
trismus - muscle fibrosis
extensive dentition breakdown due to radiation caries
ORN can develop months/years after completion of RT

89
Q

ORN

A

irradiated bone becomes devitalised and exposed through the overlying skin or mucosa without healing for 3m, without recurrence of tumour

90
Q

why is the mandible more affected by ORN?

A

only supplied by inferior alveolar artery, whereas maxilla supplied by anterior, middle and posterior superior alveolar arteries

91
Q

ORN classification

A

no universally used staging classification

- Marx, Epstein et al

92
Q

what % of ORN cases develop within 3yrs after RT?

A

70-94%

93
Q

risk factors for ORN

A

hyperfractionated irradiation regimen - high total dose
literature suggests chemo coupled with radio increases incidence
pre- irradiation and post-irradiation dental extractions
poor OH and PDD
tobacco and alcohol use

94
Q

ORN conservative tx

A 
improve OH
ABs
minimal surgical debridement
hyperbaric O2 therapy
medical management: pentoifylline, tocopherol
95
Q

chemo

A

a drug tx to kill fast growing cancer cells that multiply much more quickly than host cells in body

96
Q

indications for chemo

A

can be used as primary/sole tx for cancer
adjuvant therapy after surgery (+/- RT to kill any residual cancer cells)
adjuvant therapy before surgery (+/- radio to shrink size of tumour)
palliative therapy (to relieve S+S of advanced OSCC and give pt a better QOL)

97
Q

types of chemo

A

adjuvant
induction
concomitant

98
Q

adjuvant chemo

A

given after surgery for reducing the incidence of distant metastatic recurrence

99
Q

induction chemo

A

given before definitive tx (radio/surgery) in order to potentially reduce the risk of distant metastasis and the size of the primary tumour to improve locoregional control

100
Q

concomitant chemo

A

given with surgery/radio to achieve radiosensitisation

101
Q

CRT

A

chemo is given as a radiation sensitiser with the goal of reducing radiation resistance

102
Q

chemo oral side effects

A 
mucositis
infection
oral lichenoid reactions
hyperpigmentations
hyposalivation
altered taste
bleeding
MRONJ
SJS/TEN
103
Q

RFs for cancer

A

predisposing factors
genetic susceptibility
OPMDs
oral microbiome

104
Q

predisposing factors - synergistic effect

A

social - alcohol and tobacco
diet - low fruit and veg intake
physical agents - UV light, radiation
chemicals (env and occupational exposures) - arsenic, benzene, asbestos

105
Q

one way alcohol causes cancer

A

ethanol broken down into acetaldehyde then acetate
if too much alcohol drunk - body can’t process it fast enough so get build up of acetaldehyde - toxic and causes DNA damage

106
Q

diet and oral cancer

A

fruit and veg reduce risk
fish and omega 3 fatty acids may reduce risk
high consumption of processed meat increases risk
no significant association between total/red/white meat and risk
dietary supplements don’t have same effect on risk reduction

107
Q

oral hygiene and oral cancer

A

risk factor
may also be a prognostic factor
increases carcinogenity of other known carcinogens e.g. tobacco and alcohol

108
Q

oral microbiome and oral cancer

A

candida associated with increased risk

HPV

109
Q

oral HPV manifestations

A

verruca - verruca vulgaris or common wart
condyloma - condyloma acuminatum
papilloma
NOT OPMDs

110
Q

why can’t early diagnosis of HPV-related OSCC be accurately established?

A

because the clinical lesions of early HPV-related OSCC are unknown

111
Q

infection with high risk HPV

A

16 or 18
typically lasts 12-18m and is cleared eventually by the immune system
if host immune system fails to clear and it persists for long time - get overexpression of main viral oncoproteins E6 and E7, inhibition of TSPs, p53, pRb
dysplasia

112
Q

epigenetic events

A

DNA methylation
histone modifications
miRNAs

Oral medicine (14 decks)

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