SCC Flashcards
Differential diagnosis of ulcerative lesion (chronic >3months)
Recurrent long standing traumatic ulcer (causative factor)
Erosive lichen planus (may have white striations)
Mucous membrane pemphigoid (assoc with ocular or genital lesions)
SCC (ulcerated and indurated with rolled margins)
Behcets syndrome (triad of oral, ocular, genital)
Give conditions/lesions with malignant potential and the risk of scc
Lesion:
Erythroplakia 25%
Leukoplakia 1% - ^^ up to 16% with dysplasia
Proliferative verrucous leukoplakia - 75%
Chronic hyperplastic candidiasis
Conditions: Lichen planus - esp erosive type (1-3%) Oral submucous fibrosis - 10% Syphillitic glossitis Sideropenic dysphagia (They have potential to turn malignancy due to the atrophy within the mucous membrane)
What is proliferative verrucous leukoplakia
Veruciform white lesion that has mutifocal papillary like growth.
Which has 75% risk of transforming into verrucous carcinoma or SCC
Histopath of leukoplakia
- Parakeratosis
- Loss of rete ridges
- Epithelial dysplasia with cellular pleormorphism
- Hyperchromatism
- Increase mitotic figures
- Increase nuclear cell ratio
- anisocytosis
- koilocytosis - Loss of basal cell polarity
- Intact basement membrane
what is aim of tx for leukoplakia
To prevent malignant transformation
To resolve the lesion
Tx modalities for dysplasia (leukoplakia/erythroplakia)
Carbon dioxide laser ablation
Surgical excision
Chemoprevention:
Beta carotene
Retinoids
Adv of co2 laser
Minimal damage to adjacent tissues
Minimal scarring
Minimal wound contraction
Clinical features of SCC include
Symptoms Painless ulcer with swelling Lump in the neck Throat swelling, or discomfort with sensation of a foreign body Dysphagia Dysphoria Otalgia Weight loss
Signs Indurated ulcer Exophytic mass Red lesions Cervical lymphadenopathy (reactive or metastatic) mets nodes: - hard, nontender, fixed, nonmobile CN involvement CN V - paraesthesia CN IX - soft palate paresis/paralysis CN XII - deviation of tongue to affected side with wasting and fasciculations
Must include NASOENDOSCOPY in all oropharyngeal tumors
Whats the role of OPG in OSCC
- To assess bony involvement - signs of bony destruction/ decalcification as a result of direct pressure or invasion - scc invasion will show loss of cortical outlines and irregular areas of radiolucency
- Dental assessment prior to definitive treatment of surgery or RT to ensure appropriate dental treatment can be undertaken including exos
- Planning of bony resection or access osteotomies
- Post op for assuring adequate reduction and fixation of access mandibulotomies or where reconstruction done - to confirm bony continuity, plates position and condyle in glenoid fossa
Role of CXR in OSCC
- Preanaesthetic evaluation prior to surgery esp in increased age and smokers
- Pretreatment baseline
- Screening for lung ca or lung lesions (frequently requires chest ct)
Role of CT primary tumor and neck in OSCC
- To see size and extension of lesion
- To see potential involvement of surrounding structures
- To detect positive nodal mets
- increase in size (>1cm)
- central necrosis
- rim contrast enhancement
- exttacapsular extension
- onliteration of surrounding fat planes - For clinical tnm staging to decide on definite treatment plan
- To allow for planning of surgical resection
- To allow surgical guide in reconstruction
- To assess for vessel patency in recons
Signs if nodal involvement in OSCC
Clinically - enlarged palpable nodes - nontender - hard - fixed to underlying structure CT scan with contrast - enlarged nodes >1cm - central necrosis with contrast enhancement at the rim - extracapsular extension - obliteration of fat planes
Role of MRI in SCC investigation
With contrast (gadolinum)
- Indicated in soft tissue oropharyngeal tumor (tongue, soft palate, tonsil, posterior pharyngeal wall)
- Indicated in salivary gland ca
- to see size and depth of tumor
- to detect vascular or perineural involvement
- detect nodal mets (similar accuracy with ct)
- for clinical tnm staging
- to allow planning of resection
- to assess vessel patency for reconstruction
Role of USS in neck mass
Y
Can you decide on a definite therapy upon diagnosis of FNAC/FNAB
Fine needle biopsy or cytology POSITIVE
- > excisional biopsy of the lesion thru a “denfensive neck incision”
- > if ca + then proceed to END, SND, RND
What is the role of SNB in OSCC?
M
How is SNB done in H&N SCC
L
Whats the role of FDG-PET/CT in oral scc
Indicated in high risk patients and advanced dz
- Detect synchronous primaries
- Detect distant mets in advanced dz
- Upstaging of dz - to ensure adequate tx to improve overall survival
- Detect recurrence if suspected but cannot be detected by other methods
Increase metabolic activity of ca cells will increase FDG uptake - detection of ca
- not permissable to do after biopsy or surgical tx as it will cause false positive due to increase inflammatory response post op
How does HPV positive SCC has better prognostic value compared to negative HPV
those with HPV-positive tumors typically exhibit a better response to chemotherapy and/or radiation therapy, with an approximately 60% reduction in risk of death and 30% greater 5-year absolute survival rate.
Improved survival may reflect the unique biology of HPV- positive carcinomas as well as the low rate of comorbidity among the relatively young age group typically affected.
Possible biologic reasons for favorable prognosis include an intact p53-mediated apoptotic response to radiation and a lack of field cancerization (see next section).
How is oral cancer tx based on TNM staging
Y
What are adverse features in cancer?
- Extranodular extension pN+ with ENE (+)
- Positive margin
- T3 and T4 tumors
- N2 or N3
- Nodal mets at level IV or V
- Perineural invasion
- Vascular embolism
What are indications of elective neck dissection?
- In cases without neck mets, certain cancer staging still requires the neck to be selectively dissected - to prevent further neck mets.
- has said to improve survival rates (%)
- elective neck dissection in oral scc includes level 1,2,3.
Indicated in cases where occult mets are at higher risk
- T2 or T3 with N0
- Location of tumor at tongue and FOM
- DOI > 3mm in tongue or FOM at any T size
- Poorly differentiated tumor (G3)
When and what is SND?
Selectively dissecting neck according to most likelihood lymphatic drainage.
Oral ca - level 1,2,3
Oropharyngeal - level 2,3,4
Done on cN0 but has risk of occult mets
- T2 or higher
- location tongue, FOM, RMT
- DOI > 3mm in tongue at any size
- DOI > 5mm anywhere else
What is RND and MRND and when is it indicated
Removal of ALL neck nodes from level I-V together with IJV, SCM, SAN
MRND removes nodes at level I-V but preserving the IJV, SAN, SCM
Indicated when cN+
Adjuvant therapy. When is it indicated?
adjuvant therapy involves RT +/- CT when adverse features are present
- ENE (+)
- Margin (+)
- T3, T4
- N2, N3
- Nodal disease at level 4,5
- Perineural invasion
- Vascular embolism
What is RT?
J
What is Cancer therapy?
Prescription of chemotherapeutic drugs such as
platinum based,
5-FU,
Methotrexate,
Taxane,
Monoclonal antibodies
To induce cell death including cancer cells
3 types Neoadjuvant - before surg/rt Concurrent - during rt Adjuvant - after surgery or rt Chemo alone.
Possible complications for RADICAL RESECTION?
H
Possible complications for NECK DISSECTION?
H
Possible complications fir RADIOTHERAPY?
Acute effects RT
- mucositis
- skin erythema/ulceration
- loss of taste
- infection
- bleeding
- lymphoedema
Late
- fistula
- impaired healing
- orn
- xerostomia
- radiation caries
- radiation induced tumors (sarcoma)
- neuropathies
- fibrosis
Postop management of cancer patients include?
H
Postchemo or postradio, patients will be neutropenic/leukocytosis. How do you manage?
They are prone to infection
May present with febrile neutropenia
Mx:
prevent infection
Antibiotic prophylaxis
Neupogen (G-CSF: Filgrastim) - effective for 5 days.
