10. Oral cavity cancer presentation Part 2.pptx

Oral cavity cancer presentation Part 2

1. CARCINOMA ORAL CAVITY PART II PRESENTER- Dr. ABHISHEK MEWARA MODERATOR- Dr. UPEN K. MATHUR DATE- 30.5.2024 1

2. TOPICS COVERED IN PART I INTRODUCTION INCIDENCE, EPIDEMIOLOGY, ETIOLOGY ANATOMY MOLECULAR BIOLOGY NATURAL HISTORY- THE PREMALIGNANT LESIONS PATTERN OF SPREAD PATHOLOGICAL CLASSIFICATION STAGING 2

3. OVERVIEW OF PART II CLINICAL PRESENTATION DIAGNOSTIC EVALUATION MANAGEMENT- GENERAL OVERVIEW SURGERY RADIATION THERAPY CHEMOTHERAPY FOLLOW UP SUBSITE-SPECIFIC TREATMENT- REVIEW SUMMARY 3

4. 1. CLINICAL PRESENTATION 4

5. CA TONGUE- small ulcers ,which gradually invade the musculature of the tongue. Advanced lesions can be ulcerative or exophytic. Disease MC along the lateral borders of the tongue. FLOOR OF THE MOUTH- often infiltrative and may invade bone, the muscles of the floor of the mouth, and the tongue. The frenulum is a frequent site of involvement. ALVEOLAR RIDGE- pain while chewing, loose teeth, or ill-fitting dentures. Often arise in edentulous areas or along the free margin of the mandibular alveolus. Anesthesia of the lower lip and teeth may indicate involvement of the mandibular canal and inferior alveolar nerve. 5

6. RETROMOLAR TRIGONE- usually an exophytic growth and limited involvement of underlying bone. Often induce trismus early. BUCCAL MUCOSA- rarely symptomatic early in its course. Lesions may be papillary or erosive. Often manifest as leukoplakia. HARD PALATE- often painless, and the sole presenting symptom may be an irregularity in the mucosa or ill-fitting dentures. Other presenting symptoms include nonhealing ulcers, intermittent bleeding, and pain. 6

7. 7 CA TONGUE CA MANDIBULAR ALVEOLUS CA MANDIBULAR ALVEOLUS, GBS

8. 8 T3 LESION RMT, TONSILLAR PILLAR, BOT

9. 2. DIAGNOSTIC EVALUATION 9

10. History, GPE. Detailed visual and digital examinations. Biopsy. CT scan- Face and Neck, X-Ray- Chest, MRI- whenever required, and important for accurate staging of the tumor and treatment planning. 10

11. HISTORY AND GPE- Tobacco and alcohol abuse; dysphagia; odynophagia; pain; trismus; difficulties with speech; hoarseness; loose teeth; ill-fitting dentures; hypoesthesia of the face, lips, or mandible; weight loss; malnutrition. Otalgia- ninth or tenth cranial nerve. Facial numbness- fifth cranial nerve. Hypoesthesia of mandibular region usually results from perineural invasion, often from penetration of the mandible and spread along the inferior alveolar nerve. Trismus indicate extension into the pterygoid musculature, signifying locally advanced disease. Any comorbid illnesses is considered in designing the overall treatment strategy, e.g. T2DM, HTN, etc. 11

12. LOCAL EXAMINATION- Full inspection of the oral cavity. Assess bony involvement, tongue fixation, depth of involvement. Deviation or fixation of the tongue- suggests involvement of extrinsic muscles of the tongue. Bimanual palpation can help assess the depth of tumor invasion into musculature of the tongue and floor of the mouth. Thorough palpation of the neck is important to assess regional nodal disease status. 12

13. IMAGING- Chest x-ray- to exclude lung metastases or a second primary cancer. CT- used to determine the extent of soft tissue and bony involvement, any occult disease in the neck. CT also determines the extent of invasion into the deep musculature of the tongue and adjacent structures. MRI may be used in case of contrast allergy or a lesion that is not well visualized on CT. MRI provides excellent definition of tumor involving the tongue and is a good modality for evaluating the possibility of perineural spread. 13

14. PET and PET/CT- for staging disease in the neck, evaluation of perineural spread, skull base involvement, identification of distant metastases, detection of recurrence. It is more sensitive and specific in evaluating lymphatic metastases compared to CT and MRI. Clinical application of PET/CT is limited by the fact that there is suboptimal detection of small metastases. 14

15. 3. MANAGEMENT 15

16. GENERAL OVERVIEW- Surgical resection (MC), radiation, chemotherapy, or combined modalities. The choice of treatment modality, either singly or in combination, depends on the stage, size of the tumor and patient factors such as general condition, toxicity, performance status, comorbid disease, and convenience. The overall health and functional status of the patient are important determinants in choosing between surgical and nonsurgical approaches. 16

17. SURGERY- Treatment of choice for early stage disease. If not surgery, then radiation is considered for patients with early-stage disease who are either not surgical candidates or refuse surgical management. For patients with advanced lesions of the oral cavity, combined modality approach is used. In patients with high risk pathologic features, the addition of concurrent chemotherapy during the postoperative radiation treatment course may further augment tumor control rates. High-risk features commonly include ENE, positive resection margins, perineural involvement, multiple cervical nodes involvement, etc. 17

18. The primary objectives of surgery includes complete resection of primary tumor with negative margins, staging and treatment of the regional lymphatics. Margin status is one of the most important variables associated with survival. Done with either transoral approach or with a lip-split incision. The selection of type and extent of neck dissection is dependent on whether the patient is clinically node negative or not, which in turn is based on physical examination and imaging. Iatrogenic cranial nerve injuries and vascular insult are significant complications of neck dissection. 18

19. Conventional morbid operations have been replaced by more selective approaches to involve only the nodal basins with expected metastasis, with preservation of uninvolved non-lymphatic structures including IJV, SCN, SAN, etc. Radical and modified neck dissections are reserved for patients with advanced nodal disease (N3), disease extending into level V or invading critical structures in the neck. Another option for managing the clinically node-negative neck is SLNB, a less invasive approach, which accurately identify occult metastasis in early-stage oral cancer. It is based on the principle that cancer spreads first to a primary lymph node known as the “sentinel node” that can be readily identified and meticulously evaluated for microscopic disease. 19

20. Patients with oral cancers requiring mandibulectomy need mandibular reconstruction with bone grafting. The major cosmetic goal of mandibular reconstruction is to providing facial height and projection, to prevent the “Andy Gump” deformity. Major objectives of buccal reconstruction include resurfacing the cheek with prevention of cicatricial scaring and trismus. 20

21. RADIOTHERAPY- For early-stage disease- a combined approach including both EBRT and interstitial brachytherapy is used. Common S/E are xerostomia, mucositis, dermatitis of exposed skin, dental and gum injury and occasional osteoradionecrosis. For advanced lesions of the oral cavity (T3 and T4)- adjuvant or neoadjuvant radiation therapy is used. Postoperative radiation treatment carries the advantage of no delay in the implementation of surgical resection and complete pathologic staging of the tumor, and is hence preferred. 21

22. Traditionally, indications for postoperative radiation therapy include multiple cervical metastases, positive or close margins, extracapsular extension, perineural invasion, advanced T stage, and mandibular bone involvement. Adjuvant radiation is done as soon as surgical wounds are well healed, optimally 4 to 6 weeks after completion of surgery. Chemoradiotherapy is done in patients with ENE and/ or microscopically involved surgical margins. 22

23. CONVENTIONAL 2-D RADIOTHERAPY- Position- patient supine, with neck slightly extended. Fields used- 2 types- 2 lateral parallel opposed fields- 2 fields. 2 lateral + 1 anterior field for lower neck- 3 fields. Upper border- zygomatic arch (vary according to location of tumor). Inferior border- just above clavicle for 2 fields and approximately at the thyroid notch for 3 fields. Posterior border- at the line starting from tip of mastoid process/ line passing midline through vertebral body. Anterior border- 1-2 cm beyond the diseased part. Lower neck field- Upper border approximately at thyroid notch, and lower border 1-2 cm below clavicle. 23

24. For radical/ definitive treatment- 70 Gy at 2 Gy /#, total 35 fractions. For adjuvant treatment- total 54- 60 Gy at 2 Gy /#, total 30-33 fractions. For positive microscopic margins- 60 Gy at 2 Gy /#, total 30 fractions. If there is gross residual disease, either further surgical resection or focal boosting up to 70 Gy at 2 Gy /#, total 35 fractions. 24

25. GRADING OF MUCOSITIS- Grade 1 (Mild)- Irritation with slight pain, not requiring intervention. Grade 2 (Moderate)- Patchy, with serous discharge, require mild analgesia. Grade 3 (Severe)- Fibrinous mucositis, requiring narcotics. Grade 4 (Life threatening)- Ulceration, hemorrhage, necrosis. 25 GRADING OF DERMATITIS- Grade 1- Faint or dull erythema, dry desquamation. Grade 2- Tender bright erythema, moist desquamation on skin folds. Grade 3- Tender bright erythema, moist desquamation on areas other than skin folds. Grade 4- Ulceration, hemorrhage, necrosis.

26. XEROSTOMIA GRADING- Mild- mildly thick, dry, copious saliva, no significant dietary alteration. Moderate- significant/ complete dryness of secretions, difficulty in swallowing solid food, semi-solid food indicated. Severe- complete necrosis of salivary glands, inability to take any oral feeds, I/V feed or NG tube feed indicated. 26 DYSPHAGIA GRADING- Mild- no significant dietary alteration, can take solid feed. Moderate- significant dietary alteration, requiring semi solid feed. Severe- complete dysphagia, requiring I/V or parenteral feed.

27. 27 IMRT-

28. Simulation- in the supine position with the neck extended. A thermoplastic mask is used to immobilize patients during simulation and treatment. Shoulder immobilization is also done. A bite block should be used to depress the tongue away from the hard palate, some institutions use a cork and tongue blade or a custom intraoral stent, at our institute we use 20 ml syringe. CT simulation should be performed using a slice thickness of ≤5 mm. 28

29. 29 TONGUE BITE BLOCK

30. 30

31. BRACHYTHERAPY- U sed to boost the primary site before or following EBRT. When used as a sole treatment, doses of 65 to 75 Gy are commonly prescribed over 6 to 7 days. C an be accomplished either with rigid cesium needles or with iridium 192 sources. Surface mold radiation can also be considered for small tumors <1 cm depth or superficial lesions. 31

32. INTRA ORAL CONE- It is another delivery tool to enable boosting of radiation dose while avoiding direct dose to the mandible. This technique is generally best suited for anterior oral cavity lesions. Should take place prior to EBRT so that the lesion can be adequately visualized. A major advantage is that it is highly focal to the tumor bed and noninvasive. 32

33. CHEMOTHERAPY- Used in high-risk disease. High risk disease is defined as any of the following: two or more involved lymph nodes, ENE, and microscopically involved resection margins. For unresectable oral cavity squamous cell carcinoma, neoadjuvant chemotherapy is used as a means of downstaging disease in order to enable surgical resection. 33

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35. 4. FOLLOW UP 35

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37. 5. SUBSITE-SPECIFIC TREATMENT- REVIEW 37

38. LIP- Surgical excision alone or f/b RT. When primary RT is used to treat lip cancer, the target volume should include the primary tumor plus a 1.5 to 2 cm margin. The recommended dose is 50 Gy in 4.5 to 5 weeks for smaller lesions and 60 Gy in 5 to 6 weeks for larger lesions. TONGUE- Primary surgery. Postoperative RT is recommended for patients with large primary tumors (T3, T4), close or positive surgical margins, perineural spread, multiple positive nodes, or ENE. Postoperative chemoradiation considered for patients with adverse risk factors and are able to tolerate combined modality treatment. Primary RT- for those who refuse or are unable to tolerate surgery. 38

39. FLOOR OF MOUTH- Surgery preferred. Advanced stage is usually managed by a combination of surgery and RT or chemoradiation. Advanced lesions and high-risk disease should receive RT to bilateral necks. Small (T1 and T2) lesions may be treated with a combination of EBRT and boost with interstitial implant or intraoral cone. Lesions that are infiltrating mandible and advanced lesions following surgical resection should receive postoperative RT. 39

40. HARD PALATE AND UPPER ALVEOLAR RIDGE- Surgery is mainstay. Postoperative RT when there are adverse features. RETRO MOLAR TRIGONE- Usually advanced at presentation because only a thin layer of soft tissue overlies the bone in this region and invasion of the underlying bone may occur early. Surgery with adjuvant or neoadjuvant RT. BUCCAL MUCOSA- Most often, verrucous carcinoma occurs in the buccal mucosa, has a more favorable prognosis, as it is considered a low-grade malignancy. Surgical resection is the preferred treatment. Transoral resection is preferred and is most convenient for small lesions. Larger tumors may require surgery combined with RT or chemoradiotherapy. 40

41. 6. SUMMARY 41

42. 42 CA LIP

43. 43

44. 44 CA TONGUE, FLOOR OF MOUTH, BUCCAL MUCOSA, HARD PALATE, ALVEOLAR RIDGE, AND RETROMOLAR TRIGONE

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46. BOUNDARIES OF CERVICAL LYMPH NODES LEVEL IA- anteriorly mandibular symphysis, posteriorly body of the hyoid, and cranially geniohyoid muscle. LEVEL IB- mandible laterally, digastric muscle medially, mandibular symphysis anteriorly, and the submandibular gland posteriorly. LEVEL II- base of the skull to the carotid bifurcation (surgical landmark) or the caudal body of the hyoid bone (clinical landmark). LEVEL III- carotid bifurcation superiorly, omohyoid muscle inferiorly, sternohyoid medially, posterior aspect of the SCM posteriorly. 46

47. LEVEL IV- located around the inferior third of the internal jugular vein, bounded by the omohyoid muscle superiorly, the clavicle inferiorly, and the posterior aspect of the sternocleidomastoid posteriorly. LEVEL V- base of the skull superiorly, clavicle inferiorly, posterior aspect of the SCM anteriorly. THE RETROPHARYNGEAL NODES- skull base cranially to hyoid bone caudally, anteriorly boundary of the retropharyngeal space is the pharyngeal constrictor muscles and the posterior boundary is the prevertebral fascia. 47

48. REFERENCES- PEREZ G.K. RATH DEVITTA NCCN V.4- 2024 GOOGLE SEARCH ENGINE 48

49. THANK YOU, AND HAVE A NICE DAY! 49