Oral Cancer Flashcards
What are some potentially malignant conditions?
Lichen planus (erosive)
Oral sub mucous fibrosis
Iron deficiency
Tertiary syphilis
What are potentially malignant lesions?
Leukoplakia
Erythroplakia
What is leukoplakia?
A white patch which cannot be rubbed off with no identifiable cause
What is the term given to a white patch which can be rubbed off?
Pseudomembranous candidiasis
What is most common for malignant change- erythroplakia or leukoplakia?
Erythroplakia
50% are already a carcinoma
What are common causes of white patches in the mouth (differential diagnosis)?
Traumatic lesion (frictional keratosis, chemical burn, cheek/ tongue biting)
Infection (chronic/ acute hyperplastic candidosis)
Lichen planus (or lichenoid reaction)
Smokers keratosis
Squamous cell carcinoma
Leukoplakia (unknown cause)
what is sublingual keratosis and its malignancy potential?
Refers to a white patch on floor of mouth or ventral surface of tongue
Usually bilateral
Site is high risk of malignancy
What is smokers keratosis?
A white patch of no known cause found in the mouth of a smoker
Flat, homogenous white patch on non-keratinised mucosa
What is frictional keratosis?
White patch along occlusal line/ lateral tongue due to trauma - from sharp teeth/ restorations/ tongue or cheek biting.
These lesions are gradual and often have a shredded surface.
Resolve on removing the cause.
What is chronic hyperplastic candidosis?
Candidato leukoplakia
Commonly on bucal mucosa and dorsal of tongue
May be associated with red areas
Biopsy and resolution following anti viral treatment
What are the common features of lichen planus?
Usually bilateral white patches
Common on bucal mucosa
Skin involvement
Desquamative gingivitis
What is the clinical appearance of an aspirin burn?
Application of aspirin directly to mucosa in bucal sulcus which affects both sides of the the site where the tablet was placed.
Why are biopsy’s performed
White lesions require biopsy (except typical keratotic leukoplakia and typical LP).
- To exclude/ confirm SCC
- If not malignant, to determine whether dysplasia is present
- To identify chronic candida infection if present
- To help identify specific conditions and causes of lesion
What is the ideal biopsy sample?
For a white patch:
10mm long and 4-5mm wide width sufficient depth to support the epithelial sample.
Should extend to muscle and contain mostly the lesion but with part of the margin and normal surrounding mucosa
What is dysplasia?
Disordered maturation in tissue (histopathological finding, not clinical diagnosis)
What is the grade of dysplasia based on?
Cellular atypia and epithelial architectural organisation
What are signs of high risk of malignancy (from histological sample)
Dysplasia
Atrophy
Candida
What are the histological features of dysplasia?
Failure to form organised epithelial layer
Disordered maturation and differentiation of single cells
Abnormalities of cell nuclei
Abnormal growth regulation
What are the grades of dysplasia?
Hyperplasia
Mild
Moderate
Severe
Carcinoma in situ
What are the high risk sites for malignant transformation?
Floor of mouth and ventral tongue
What is field cancerisation
There is a high cancer risk in a 5cm radius of the original primary
(Therefore, most of the mouth and pharynx)
- risk of development of abnormal area of epithelium in area close to area of transformation
what are the hallmarks of cancer? (6)
- Evading apoptosis
- Self sufficiency in growth signals
- Insensitivity to anti growth signals
- Tissue invasion and metastasis
- Limitless replicative potential
- Sustained angiogenesis
What is angiogenesis?
Formation of new blood vessels
How is cancer staged?
T - tumour size
N - lymph node involvement
M - distance metastasis
What are risk factors for oral cancer?
Smoking
Alcohol
Socioeconomic status
FH
Poor OH
Sexual activity
What should be included when describing a red/ white patch (lesion)?
Size
Site
Shape
Colour
Surface
What it feels like (firm/ attached etc)
If it can be rubbed off
What are the main features of a malignant lesion?
Red/ speckled areas
Non-healing ulceration
Rolled everted ulcer margin
Induration of surrounding tissue
Bleeding from surface
Fixation of tissues
Destruction of adjacent bone
Enlarged lymph nodes
What is the grading of oral cancer? And what does this tell us?
Grading predicts how quickly the cancer will spread and is based on the degree of differentiation under the microscope
◦ GX- grade cannot be evaluated
◦ G1- the cells look more like normal tissues and are well differentiated (low grade)
◦ G2- the cells are only moderately differentiated
◦ G3 and G4- the cells do not resemble normal tissue and are poorly differentiated
What are the margins for biopsy of OPMD? And how does this differ to biopsy margins for SCC?
1mm (very narrow) for OPMD
Thicker and deeper for SCC eg 1cm
What is the aim of treatment of OPMDs?
To eliminate infection and inflammation
What is the best way to test malignancy risk of OPMD?
H&E staining to assess degree of dysplasia
What is the oral cancer urgent referral pathway?
3 weeks
What is the malignant transformation rate of erythroplakia?
40-50% (3x higher than leukoplakia)
What are some acute oral side effects of radiation therapy to head and neck?
Mucositis
Taste loss/ alteration
Candidosis
Trismus
Radiation dermatitis
Dysphagia
What are the long term side effects of radiation to head and neck?
Long term - loss of salivary gland function, trismus due to muscle fibrosis, radiation caries and ORN
What is Mucositis?
A severely debilitating condition characterized by erythema, edema, and ulcerations of the oral mucosa
Extremely painful and self limiting
What is the management for Mucositis?
Local analgesics - benzydamine mouthwash/ spray, lidocaine gel.
Ice cooling
Hydration
Saliva replacements
What is the prevention for Mucositis?
Good OH
Alcohol free mouthwash
Hydration
Avoid oral irritants (alcohol, tobacco, spicy foods)
Leave out dentures
When does Mucositis usually begin?
1-2 weeks after treatment starts
When does Mucositis usually resolve
Around 6 weeks after treatment has finished
How is caries prevented in patients with oral Mucositis who struggle to brush?
Tooth mouse
Fluoride gel in mouth guard
Why does the oral cavity suffer so many side effects from radiation/ chemotherapy?
Chemo/ RT targets cells with high turnover (oral cavity)
Why does RT cause xerostomia?
Damage to the salivary glands results in dysfunction through cell death and fibrosis
What are the local measures for management of xerostomia?
Advice - frequent sips tap water, ice, sugar free gum
Glandosane spray (for edentulous as acidic)
Salivez spray
BioXtra gel
What is ORN?
Osteoradionecrosis of the jaw
An area of exposed bone of at least 3 months duration in an irradiated site and not due to tumour recurrence
What is a complication of ORN?
Pathological fracture
In what cases should patients who have undergone radiation therapy be referred for extractions?
Refer to OMFS department if tooth to be extracted is in a field of >50 gray.
Otherwise, a traumatic technique and primary closure of socket
When would a non healing extraction socket be os ORN suspicion?
8 weeks non healing post XLA
What does ‘dentally fit’ mean?
No possible source of dental infection.
When should teeth be extracted in terms of starting cancer treatment?
10 days
What antifungals can be prescribed for candida infections?
Chlorohexidine mouthwash
Miconazole (topical)
Fluconazole (systemic) - be careful with interaction
Nystatin
What virus can be reactivated during cancer treatment?
Herpes simplex virus
Causes painful ulceration with sudden onset
What is radiation induced caries?
Indirect effect of non surgical cancer treatment
Reduced salivary flow and altered saliva function in combination with high protein and calorie diet = caries
Often circumferential around teeth- cervical margins and incisal edges.
How is ORN prevented?
Remove teeth of doubtful prognosis in radiation field.
Extractions completed 10 days prior to treatment starting.
Encourage healing by primary closure/ sutures
What technique can reduce ORN risk when extractions need to be carried out?
Extractions in combination with hyperbaric oxygen therapy - increased oxygen supply to damaged tissue to stimulate healing.
What puts patients at increased risk of ORN?
Radiation dose >60 grays
Dose fraction was large with high number of fractions
Local trauma
Immunodeficiency
Malnutrition
Why is the mandible more at risk of ORN?
Less vascular than maxilla
