Oral Cancer Symposium

Question 1

Patient presents with IO sign and you have suspicion of oral cancer. What investigation would you undertake ?

Answer 1

OPT - to assess bone involvement.
Clinical imaging.
Biopsy.

Question 2

Patient presents with persistent neck lump and you have suspicion of oropharyngeal cancer. What investigation would you undertake ?

Answer 2

Ultrasound with guided biopsy.

Question 3

Name some common features of oral cancer seen on OPT.

Answer 3

Moth eaten bone.
Pathological fractures.
Non-healing sockets.
Floating teeth.
Widening of PDL space in otherwise sound dentition.
Unusual periodontal bone loss or RR in otherwise sound dentition.
Loss of bony outlines for anatomical features.
Thinning of corticoendosteal margin.
Spiculated periosteal reaction.

Question 4

Patient presents with moth eaten bone on OPT. What can you include in your differential diagnosis ?

Answer 4

ORN or oral cancer.

Question 5

Spiculated periosteal reaction is characteristic of what type of oral cancer ?

Answer 5

Osteosarcoma.

Question 6

What are the characteristic signs of cancer with lymph node involvement on ultrasound ?

Answer 6

Rounded, enlarged lymph nodes.
Conglomerate nodes.
Necrosis of nodes.
Increased vascularity.
Loss of hilum.
Internal calcification - very concerning.
Extracapsular spread - loss of outline and starts outlining other structures.

Question 7

Internal calcification is characteristic of what types of cancers ?

Answer 7

Metastatic SCC or metastatic papillary carcinoma.

Question 8

What types of imaging can be used for staging of oral cancer ?

Answer 8

Large field of view for distant metastasis - i.e. CT or MRI.

Question 9

What are the benefits of CT scans ?

Answer 9

Quick, good for soft tissue and bone visualisation.

Question 10

What are the drawbacks of CT scans ?

Answer 10

Iodinated contrast required to enhance tumour.
Ionising radiation - large dose.

Question 11

What are the benefits of MRI scanning ?

Answer 11

No ionising radiation, good for soft tissues and bone marrow.

Question 12

What are the drawbacks of MRI scanning ?

Answer 12

Take longer to take and interpret, cannot show hard tissues as clearly.

Question 13

Describe when you can use PET/CT scanning.

Answer 13

Used when you cannot visualise primary tumour but patient presenting with clinical signs.

Question 14

Describe how PET/CT scanning works.

Answer 14

Looks for metabolically active tissues using radioisotope 18-FDG contrast. Image is superimposed over CT to show anatomical detail and hotspots of cell growth and metabolism.

Question 15

What is the problem with PET/CT scanning ?

Answer 15

Can give false positives - active muscles or infection.
Cannot differentiate between varying activity.

Question 16

Where are the most common sites for distant metastasis following head and neck cancer ?

Answer 16

Brain, chest, abdomen and pelvis.
All require imaging following diagnosis of primary tumour.

Question 17

How quickly should a patient be seen by MaxFax or ENT following suspicion of cancer referral ?

Answer 17

2 weeks.

Question 18

How quickly should a MDT meeting, patient be diagnosed and decision of treatment be made ?

Answer 18

28 days.

Question 19

How quickly should a patient start definitive treatment for oral cancer since initial GDP referral ?

Answer 19

62 days.

Question 20

How quickly does oral mucositis commonly occur after starting chemotherapy ?

Answer 20

1-2 weeks.

Question 21

How long can oral mucositis persist after completing treatment ?

Answer 21

> 6 weeks.

Question 22

What are the effects of oral mucositis ?

Answer 22

Extreme pain intra-orally.
Difficulty maintaining food and fluid uptake.
Requirement for opioid medication.

Question 23

What treatments can be used to ease symptoms of oral mucositis ?

Answer 23

Caphosol - neutral supersaturated calcium phosphate mouthwash.
Gelclair.
Muguard - mucoadhesive oral rinse.
Soluble aspirin.
Difflam spray (0.15%).
Aloe vera.
Low level laser therapy in radiotherapy without chemotherapy - only offered to children in Glasgow.

Question 24

What advice should you give a patient using Difflam spray to treat oral mucositis ?

Answer 24

15ml mouthwash 4-8x daily before radiotherapy and continue for 2-3 weeks - prophylactic treatment.