Ca. Tongue.pptx

Lecture notes for medical students

1. Tips on using my ppt. You can freely download, edit, modify and put your name etc. Don’t be concerned about number of slides. Half the slides are blanks except for the title. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. At the end rerun the show – show blank> ask questions > show next slide. This will be an ACTIVE LEARNING SESSION x three revisions. Good for self study also. See notes for bibliography.

2. Learning Objectives

3. Learning Objectives Introduction & History Relevant Anatomy, Physiology Aetiology Pathophysiology Pathology Classification Clinical Features Investigations Management Prevention Guidelines Take home messages

4. Introduction & History.

5. Introduction & History. Seen typically on the lateral border of the tongue as a red lesion ( erythroplakia ), white lesion ( leukoplakia ), or a mix of the two ( erythroleukoplakia ) with an ulcer.

6. Aetiology

7. Aetiology Idiopathic Congenital/ Genetic Nutritional Deficiency/excess Traumatic Infections /Infestation Autoimmune Neoplastic (Benign/Malignant) Degenerative / lifestyle Iatrogenic Psychosomatic Poisoning/ Toxins/ Drug induced

8. Aetiology Idiopathic Congenital/Genetic Traumatic Infections /Infestation Autoimmune Neoplastic ( Benign /Malignant) Degenerative Iatrogenic

9. Aetiology Multifactorial and strongly related to lifestyle, mostly habits and diet (particularly tobacco alone or in combination with betel, and alcohol use. Immune defects or immunosuppression , defects of carcinogen metabolism, or defects in DNA-repair enzymes underlie some cases of SCC.

10. Aetiology Tobacco and alcohol use Betel-quid chewing and oral snuff diet low in fresh vegetables and fruits  human papillomaviruses (HPVs ) Cigarette smoking:  Oral health Mouthwash use: The effect of the alcohol in mouthwash appears to be similar to that of alcohol used for drinking ,

11. Aetiology oral submucous fibrosis oral lichen planus lupus erythematosus dyskeratosis congenita Fanconi anemia ).

12. Pathophysiology

13. Pathophysiology The genetic aberrations involving chromosomes 9, 3, 17, 13, and 11. Inactivated TSGs ( Tumor Supressor Genes) especially  P16,  and  TP53 in western countries Overexpressed oncogenes, especially  PRAD1 and Harvey ras (H- ras ). In Indians. Defective Carcinogen-metabolizing enzymes

14. Pathophysiology Defective Carcinogen-metabolizing enzymes – alcohol dehydrogenase type 3 genotypes Cytochrome P450 GSTM1 has a decreased capacity to detoxify tobacco carcinogens. N -acetyl transferase NAT1*10 genotypes. Defective DNA repair genes has also been found to underlie some OSCCs. An immune deficiency state may predispose one to a higher risk of developing OSCC, especially lip cancer.

15. Pathology

16. Pathology SCC is the most common type of malignancy leiomyosarcomas and rhabdomyosarcomas are also encountered (rarely ) The development of cervical metastases is related to the depth of invasion, perineural spread, advanced T stage, and tumor differentiation .

17. Pathology Metastases from the anterior of the tongue most frequently spread to the submental and submandibular regions. Tumors located more posteriorly often metastasize to levels II and III

18. Pathology nests and islands of squamous cells invading the underlying connective tissue . aberrant keratinization, forming whorls of keratin within Poorly differentiated OSCC consists of sheets of cells showing extreme pleomorphism , giant nuclei, and multiple and bizarre mitoses difficult to distinguish from other malignancies, particularly poorly differentiated lymphoma or melanoma . immunocytochemical markers such as keratins, common leukocyte antigen, and melanoma-specific antibodies

19. Clinical Features

20. Clinical Features Demography Symptoms Signs Prognosis Complications

21. Demography

22. Demography The oral cavity is one of the 10 most frequent sites of cancer internationally. OSCC is particularly common in the developing world, mostly in older males. In parts of India, oral cancer can represent more than 50% of all cancers. The prevalence of lip cancer appears to be decreasing, but the prevalence of intraoral cancer appears to be rising in many countries, especially in younger people and women.

23. Demography Race -higher (by approximately 50%) in blacks compared with whites. More in males but equalising.   occurs in middle-aged and older persons. However, in recent years, an increase in younger patients

24. 7Warning Signs of Cancer .

25. 7Warning Signs of Cancer Change in bowel or bladder habits. A sore that does not heal. Unusual bleeding or discharge. Thickening or  lump  in the breast or elsewhere. Indigestion or difficulty in swallowing. Obvious change in a wart or mole. Nagging cough or hoarseness. .

26. History Some OSCCs arise in apparently normal mucosa, but many are preceded by premalignant disorders- Erythroplakia (red patch) 90% Leukoplakia (white patch) –rare chance. Erythroleukoplakia (red and white patch) Verrucous leukoplakia . Speckeled leukoplakia .

27. Symptoms

28. Symptoms A red lesion ( erythroplakia ) A granular ulcer with fissuring or raised exophytic margins A white or mixed white and red lesion An indurated lump/ulcer ( ie , a firm infiltration beneath the mucosa) A nonhealing extraction socket A lesion fixed to deeper tissues or to overlying skin or mucosa Cervical lymph node enlargement,

29. Symptoms Early carcinomas may not be painful later, they may cause pain and difficulty with speech and swallowing.

30. Signs

31. Signs The most common sites tongue, mainly the lateral and ventrolateral aspects, Ulcers, red or white areas, lumps, or fissures. Red oral lesions usually are more dangerous than white oral lesions. Erythroplakia is a red and often velvety lesion, which, unlike leukoplakias , may not form a plaque but is level with or depressed below the surrounding mucosa

32. Signs Lesions always must be palpated after inspection to detect induration and fixation to deeper tissues. Some OSCC can also appear as a white patch. Late OSCC may manifest as an exophytic lesion or an area of ulceration with induration A typical malignant ulcer is hard with heaped-up and often everted or rolled edges and a granular floor,

33. Signs RULE Any single lesion that persists more than 3 weeks, especially if red, ulcerated, or a lump, especially with induration (ie, the RULE mnemonic) should be regarded with suspicion and a histopathological diagnosis established.

34. Signs

35. Signs Second primary tumors are additional primary carcinomas (synchronous tumors ) present in as many as 10-15% . From 30-80% of patients with oral cancer have metastases in the cervical lymph nodes at presentation. Later, dissemination to the lungs, liver, or bones may occur.

36. Prognosis

37. Prognosis Depends on stage. 5-year survival rate for oral and pharyngeal cancers is approximately 66%. HPV-positive tumors tend to respond better to chemotherapy and/or radiation therapy compared with those with HPV-negative tumors

38. Prognosis When OSCC is fatal, it almost always is either because of failure to control the primary tumor or because of nodal metastases. Death resulting from distant metastasis is unusual .

39. Investigations

40. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histology Germ line Testing and Molecular Analysis Diagnostic Laparotomy.

41. Investigations Laboratory Studies Routine Special Imaging Studies Tissue diagnosis Cytology FNAC Histology

42. Diagnostic Studies Imaging Studies

43. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan

44. Diagnostic Studies Imaging Studies X-Ray USG CT Angiography MRI Endoscopy Nuclear scan PET CT Scan.

45. Diagnostic Studies Imaging Studies Photography for monitoring the clinical state and site of premalignant lesions. Chest radiography and endoscopy synchronous second primary tumors Jaw radiography (often rotating pantomography ) may show invasion USG Abd . CT Chest PET scan

46. Diagnostic Studies Tissue Diagnosis Cytology Histopathology

47. Diagnostic Studies Cytology Brush Cytology Imprint Cytology FNAC of Lymph nodes Ultrasound-guided fine-needle aspiration cytology.

48. Diagnostic Studies Histopathology Punch biopsy Avoid excisional biopsy Always take a biopsy specimen of the red lesions if both red and white lesions are present  Guided biopsy by vital staining - Staining with toluidine blue followed by a rinse with 1% acetic acid and then saline Various light sources are becoming available to help delineate areas for biopsy

49. Differential Diagnosis

50. Differential Diagnosis Actinic Keratosis Erythroplasia Lichen Planus Lichenoid lesions Mucosal Candidiasis Traumatic lesion

51. TNM Classification .

52. TNM Classification Primary tumor T0 - No primary tumor Tis - Carcinoma in situ T1 - Tumor 2 cm or smaller T2 - Tumor 4 cm or smaller T3 - Tumor larger than 4 cm T4 - Tumor larger than 4 cm and deep invasion to muscle, bone, or deep structures .

53. TNM Classification Lymphatic node involvement N0 - No nodes N1 - Single homolateral node smaller than 3 cm N2 - Nodes(s) homolateral smaller than 6 cm N3 - Nodes(s) larger than 6 cm and/or bilateral

54. TNM Classification M0 - No metastasis M1 - Metastasis noted

55. TNM Classification Stage I - T1, N0, M0. Stage II -T2, N0, M0. Stage III : T3, N0, M0 T1, T2, T3, N1, M0 Stage IV : T4, N0, M0 Any T, N2 or N3, M0 Any T, any N, any M

56. Management

57. Management Surgery Radiotherapy Chemotherapy Targeted therapy

58. Management Oral squamous cell carcinoma (OSCC) currently is treated largely by surgery and/or irradiation. Photodynamic therapy and chemotherapy have occasional applications T here is an increased use of chemotherapy including targeted therapy

59. Operative Therapy

60. Operative Therapy The goal of surgery for oral squamous cell carcinoma (OSCC) is to remove the primary tumor together with a margin of clinically normal tissue. Small tumors can be widely excised followed by prrimary or delayed closure.. Excision of larger tumors requires partial glossectomy or hemiglossectomy .

61. Operative Therapy If at least one node has clinical signs of invasion, a reasonable presumption is that others may be involved and must be removed by traditional radical neck dissection. Reconstruction.

62. Operative Therapy Advantages- Surgery provides complete tumor and lymph node excision . A full histologic examination can be performed for staging purposes and to help predict prognosis and the need for adjuvant radiotherapy . Surgery also provides another option of treatment for radiotherapy-resistant tumors.

63. Operative Therapy Disadvantages- P erioperative mortality and morbidity. aesthetic and functional defects.

64. Operative Therapy Indications for postoperative radiation therapy include evidence of perineural or angiolymphatic spread and/or positive nodal disease.

65. Radiotherapy

66. Radiotherapy Advantages of radiotherapy Normal anatomy and function are maintained G eneral anesthesia  is not needed . Disadvantages adverse effects are common C ure is uncommon, especially for large tumors S ubsequent surgery is more difficult and hazardous and survival is reduced further.

67. Radiotherapy:Adverse effects Short term complication- Oral mucositis invariable Longer-term complications dry mouth ( xerostomia ) loss of taste osteoradionecrosis (ORN) .of mandible.

68. Radiotherapy External beam radiation ( teletherapy ), which is commonly accompanied by adverse effects , Interstitial therapy

69. Interstitial therapy

70. Interstitial therapy Brachytherapy- intrralesional Plesiotherapy – Surface therapy causes fewer complications but is suitable only for tumors that are smaller than 2 cm and located in selected sites.

71. Targeted therapy

72. Targeted therapy Cetuximab and panitumumab . Cetuximab   Erlotinib and gefitinib Lapatinib

73. cancer-prevention tips.

74. cancer-prevention tips. Don't use tobacco Avoid Alcohol Eat a healthy diet. ... Maintain a healthy weight and be physically active. ... Protect  yourself from the sun. ... Get vaccinated. ... Avoid  risky behaviors . ... Get regular medical care. .

75. Prevention

76. Prevention Screening Risk reduction

77. Prevention Diet richer in vegetables and fruits Avoid Tobacco Avoid Betel nut, Paan , Gutkha Avoid alcohol consumption. Self examination. Good oral hygiene.

78. Early Detection

79. Early Detection Dental practitioners and dental care professionals should remain vigilant for signs of potentially malignant disorders and oral cancer while performing routine oral examinations.   The mnemonic RULE Red Ulcerated Lump Extending for 3 or more weeks. Biopsy

80. Early Detection

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