24. neoplasms of the oral cavity

Neoplasms of the oral cavity

Dr. Krishna Koirala

19/12/2016; 2:15 PM

Subsites of the oral cavity • Lips• Buccal mucosa• Retromolar trigone • Gingiva• Hard palate • Anterior two-thirds

of

the tongue• Floor of mouth

Benign neoplasms• Fibroma • Papilloma• Peripheral giant cell granuloma• Pyogenic granuloma

• Lipoma• Hemangioma• Lymphangioma

Malignant neoplasms• Squamous cell carcinoma (90%)• Verrucous carcinoma• Minor salivary gland tumors (5%)• Melanoma• Lymphoma• Sarcoma

2-5%

Risk factors

• Tobacco : Smoking , Chewing tobacco (>90% )

• Alcohol• Diet and nutrition : – Deficiencies of vit A, C, E, Iron, selenium,

folate

• Viruses: HPV, EBV,HSV (role unclear )• Oral hygiene : Poor oral hygiene, ill

fitting dentures• Premalignant conditions : Leukoplakia,

erythroplakia• Others : sepsis, spices, sharp tooth

Clinical presentation• A red lesion ,white or mixed white and red

lesion• An ulcer with fissuring or raised exophytic

margins• An indurated lump (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

(infection, reactive hyperplasia 20 to tumor , or metastatic disease)

Screening of oral cancer• The VELscope device– The VELscope Hand piece emits a safe

blue light into the oral cavity, which excites the tissue from the surface of the epithelium to the basement membrane and into the stroma causing it to fluoresce

– The clinician is then able to immediately view the different fluorescence responses to help differentiate between normal and abnormal tissue

• Healthy tissue appears as a bright apple-green glow • Suspicious regions are identified by a loss of fluorescence, which thus appear dark

OraScan, OraScreen , ‘OraTest’ • Tolonium chloride or toluidine blue (TB) is an

acidophilic metachromatic dye of the thiazine group that preferentially stains nucleic acids and abnormal tissues

• The increased nuclear density and the loss of intracellular adherence in dysplastic and malignant tissues allows TB dye to penetrate through the epithelium and be retained in these tissues, thereby staining these areas of abnormality as blue

Chemiluminescent illumination positivity

Toluidine blue positivity

Investigations• Incisional biopsy– Essential to confirm the diagnosis– Biopsy must be performed on any oral

mucosal lesion suggestive of cancer, including any ulcer that does not heal within 2-3 weeks

– In vivo staining with toluidine blue followed by a rinse with 1% acetic acid and then saline may stain the areas most appropriate for the biopsy if widespread lesions are present

Imaging studies• B wave USG : Helpful in assessing the depth

of invasion in oral tongue • MRI : Imaging mode of choice for soft tissue

lesions of oral cavity • CT scan : Bone invasion• Orthopantomogram (OPG) : To assess the

state of dentition and potential gross mandibular invasion

• Technetium Bone scan : mandibular invasion

CT scan of mandible

UICC/AJCC Staging system for oral cancer

• Primary Tumor (T) – TX : Primary tumor cannot be assessed – T0 : No evidence of primary tumor – Tis : Carcinoma in situ – T1: Tumor 2 cm or less in greatest dimension – T2 : Tumor >2 cm but < 4 cm in greatest dimension – T3 : Tumor more than 4 cm in greatest dimension– T4 : Tumor invades adjacent structures (eg,

through cortical bone, into deep muscles of tongue, maxillary sinus, skin)

• Regional Lymph Nodes (N)

–NX : Regional lymph nodes cannot be

assessed

–N0 : No regional lymph node

metastasis

–N1 : Metastasis in a single

ipsilateral lymph node , 3 cm

or less in greatest dimension

• N2:

– N2a : Metastasis in single ipsilateral lymph

node more than 3 cm but not more than 6 cm

in greatest dimension

– N2b : Metastasis in multiple ipsilateral

lymph nodes, none more than 6 cm in

greatest dimension

– N2c : Metastasis in bilateral or

contralateral lymph nodes, none more than 6

cm in greatest dimension• N3 : Metastasis in a lymph node more than 6

cm in greatest dimension

• Distant Metastasis (M) –MX : Presence of distant metastasis

cannot be assessed –M0 : No distant metastasis –M1 : Presence of distant metastasis

Staging of oral cancerStage I T1, N0, M0

Stage II T2, N0, M0

Stage III T3, N0, M0T1, T2, T3, N1, M0

Stage IV T4, N0, M0

Any T, N2 or N3, M0

Any T, any N, any M

Management of cancer of oral tongue according to tumor

thicknessTumor Thickness

Recommended management

< 3 mm Partial glossectomy alone

4-9 mm Partial glossectomy +/- Elective ipsilateral level I - IV , selective neck dissection

> 10 mm Partial glossectomy, neck dissection and post operative Radiotherapy tom primary site and neck

• Management of Stage I – II oral tongue carcinoma – Transoral resection and primary closure • Wide local resection with at least 1.5 cm margin• Partial glossectomy• Hemiglossectomy

– Brachytherapy– Curative radiotherapy• 66 -74 Gy (2.0 Gy/fraction; Sunday-Thursday in 7wk)

• May be used with adequate results

Wide local excision of tongue carcinoma

• Management of Stage III - IV oral tongue cancer– Partial to subtotal glossectomy

– Ipsilateral selective level I- IV resection for N 0 Neck

– Modified radical neck dissection type III for N positive neck

– Commando operation (composite resection) : Combined mandibulectomy and neck dissection ( removal of the primary tumor along with a segment of the mandible, and ipsilateral neck dissection all as one continuous block for FOM tumors involving the mandible)

– Postoperative radiotherapy of oral cavity and neck (66 -74 Gy (2.0 Gy/fraction; Sunday-Thursday in 7wk)

Classification of Tongue Defects

• Oral Hemiglossectomy : Hemiresection of the oral tongue with resection of less than half of the base of tongue

• Hemiglossectomy : Hemiresection of the whole tongue

• Subtotal or total oral glossectomy – Subtotal or total resection of the oral tongue

with resection of less than half of the base of the tongue

• Subtotal glossectomy : Subtotal resection of the whole tongue

• Total glossectomy– Total resection of the whole tongue

Classification of Tongue Defects

Reconstruction techniques in oral cancers

• Aim– Mucosal resurfacing and replacement of tongue

volume• Techniques– Pectoralis major myocutaneous flaps ( Poor tongue

mobility, bulk )– Local muscle flaps e.g. masseter and cutaneous flaps– Free radial forearm fasciocutaneous flap– Anterolateral thigh flap ( greater soft tissue volume

to improve swallowing function)

Reconstruction by using PMMC flap

Free radial forearm flap for tongue reconstruction

Reconstruction of oncological oro -mandibular defects with double skin paddled - free fibula flap

Chemoradiation in oral cavity cancers

• Radiotherapy

– Larger lesions where excision would

compromise speech and swallowing

ability

• Combined modality therapy of surgery,

radiation therapy and chemotherapy

– Patients with local or regionally

advanced disease

• Concomitant chemotherapy (with 5 - Fluorouracil and cisplatin) and radiation therapy – Most effective sequencing of treatment – Drugs with single agent activity in this setting

include methotrexate, 5FU, cisplatin, paclitaxel, docetaxel

– Combinations of carboplatin and 5FU, and cisplatin and paclitaxel are also used

• Palliative intent – Patients with recurrent and/or metastatic disease

• Rehabilitation