Higher State Educational Establishment of Ukraine ... · membrane of an oral cavity, tongue. 2.4. To classify malignant new growths of lips, a mucous membrane of an oral cavity, tongue

Ministry of Public Health of Ukraine

Higher State Educational Establishment of Ukraine

“Ukrainian Medical Stomatological Academy”

“APPROVED”

at the meeting of the Department

of surgical stomatology

and maxillofacial surgery with plastic and

reconstructive surgery of the head and neck

Minutes No.1

Head of the Department

D.Med.Sci., Prof. __________D.S. Avetikov

METHODICAL GUIDANCE

for students’ self-directed work when preparing for

and during the practical session

Academic subject Surgical stomatology

Module No. 3

Content module No. 3

Topic of practical session Cancer of lip and organs of oral cavity (tongue,

cheeks, floor of oral cavity, soft and hard palate:

treatment, complications and prophylaxes.

Year of study IV

Faculty Foreign Students Training (Stomatology)

Poltava

1. Relevance of the topic.

In recent years continuous growth of frequency of incidence on a cancer of a

mucous membrane of an oral cavity and tongue is observed. Therefore future doctor

should be informed with the reasons of emergence of a cancer; necessary

understanding of carcinogenesis without what it is not possible to prove theoretically

application both preventive measures, and treatment methods. Efficiency of

treatment of malignant tumors completely depends on diagnostics condition,

mastering by principles and practical skills from prevention, early diagnostics,

knowledge of indications and contra-indications to modern methods of treatment of

oncological diseases and the organization of oncological service is necessary for the

timely direction of patients with tumors to specialists oncologists.

2. Specific aims:

2.1. To analyse incidence of malignant new growths of a lip, language, a mucous

membrane of an oral cavity.

2.2. To explain pathogenesis of emergence of malignant new growths of lips, a

mucous membrane of an oral cavity, tongue.

2.3. To offer methods of diagnostics of malignant new growths of lips, a mucous

membrane of an oral cavity, tongue.

2.4. To classify malignant new growths of lips, a mucous membrane of an oral

cavity, tongue.

2.5. To treat pathological anatomy of malignant new growths of a lip, tongue, a

mucous membrane of an oral cavity.

2.6. To draw schemes, graphs of malignant new growths of a lip, tongue, a mucous


2.7. To analyse conclusions of diagnostic methods of malignant new growths of a

lip, tongue, a mucous membrane of an oral cavity, to establish the diagnosis.

2.8. To combine the plan of treatment of malignant new growths of a lip, tongue, a

mucous membrane of an oral cavity depending on a stage of a disease and clinical

group.

3. Basic knowledge and skills necessary to study the topic (interdisciplinary

integration).

The preceding subjects The obtained skills

1. Human anatomy.

1.

Description of an anatomic structure and features of blood

supply, innervation, lymphatic system of head and neck.

2. Histology.

Knowledge of a histological structure of tissues of lips,

tongue, mucous membrane of an oral cavity.

3. Pathological anatomy.

Knowledge of pathological changes in a histological

structure of fabrics of lips, tongue, mucous membrane of an

oral cavity at malignant new growths.

4. Internal diseases.

Description of patient's records, comparison of clinical

inspections.

5. General surgery.

The schematic image of operations at malignant new

growths of lips, a mucous membrane of an oral cavity,

tongue.

6. Propaedeutics of surgical

stomatology.

Possession of a fence of a material for cytological research.

4. The tasks for students’ self-directed work during preparation for the class.

4.1. The list of basic terms, parameters and characteristics which students

should master while preparing for the class: Term Definition

1. A cancer on a place. It is cancer in situ.

2. Total biopsy. Biopsy in toto.

3. Disease continuation. Prolongatio morbid.

4. Metastasis. The secondary pathological center which results from

transfer in an organism of a different pathological

material.

5. Carcinogenesis. Mechanism of development of a cancer.

4.2. Theoretical questions for the class:

1. What principles of treatment of malignant new growths of lips, tongue, mucous


2. What is the combined treatment?

3. What is the complex treatment?

4. What is the palliative treatment?

5. How medical examination of patients with malignant new growths of lips, tongue,

mucous membrane of an oral cavity is carried out?

4.3. Practical tasks to be completed during the class:

1. To investigate the patient with a malignant new growth of lips, a mucous

membrane of an oral cavity or tongue.

2. To fill medical documentation on the patient with a malignant new growth of lips,

a mucous membrane of an oral cavity or tongue.

3. To combine the plan of investigation of the patient with a malignant new growth

of lips, a mucous membrane of an oral cavity or tongue.

4. To take a material for cytological research of a tumor.

5. To carry out a fence to a material for cytological research of lymph nodes.

6. To carry out a fence to a material for histological research (to execute a biopsy).

7. To put and prove the clinical diagnosis.

8. To combine and prove the treatment plan.

9. To appoint to the patient dispensary supervision.

The content of the topic.

Treatment options of cancer of oral cavity by stage

Stage I Lip and Oral Cavity Cancer

Treatment of stage I lip and oral cavity cancer depends on where cancer is

found in the lip and oral cavity.

Lip

If cancer is in the lip, treatment may include the following:

Surgery (wide local excision).

Internal radiation therapy with or without external radiation therapy.

Front of the tongue

If cancer is in the front of the tongue, treatment may include the following:


Internal radiation therapy with or without external radiation therapy.

Radiation therapy to lymph nodes in the neck.

Buccal mucosa

If cancer is in the buccal mucosa (the lining of the inside of the cheeks),

treatment may include the following:

Surgery (wide local excision) for tumors smaller than 1 centimeter, with

or without internal and/or external radiation therapy.

Surgery (wide local excision with skin graft) or radiation therapy for

larger tumors.

Floor of the mouth

If cancer is in the floor (bottom) of the mouth, treatment may include the

following:

Surgery (wide local excision) for tumors smaller than ½ centimeter.

Surgery (wide local excision) or radiation therapy for larger tumors.

Lower gingival

If cancer is in the lower gingiva (gums), treatment may include the following:

Surgery (wide local excision, which may include removing part of the

jawbone, and skin graft).

Radiation therapy with or without surgery.

Retromolar trigone

If cancer is in the retromolar trigone (the small area behind the wisdom teeth),



jawbone)


Upper gingiva or hard palate

If cancer is in the upper gingiva (gums) or the hard palate (the roof of the

mouth), treatment is usually surgery (wide local excision) with or without radiation

therapy.

Stage II Lip and Oral Cavity Cancer

Treatment of stage II lip and oral cavity cancer depends on where cancer is


Lip



External radiation therapy and/or internal radiation therapy.

Front of the tongue


Radiation therapy and/or surgery (wide local excision).

Internal radiation therapy with surgery (neck dissection).

Buccal mucosa



Radiation therapy for tumors that are 3 centimeters or smaller.

Surgery (wide local excision) and/or radiation therapy for larger

tumors.

Floor of the mouth


following:

Surgery (wide local excision)

Radiation therapy

Surgery (wide local excision) followed by external radiation therapy,

with or without internal radiation therapy, for large tumors

Lower gingival



jawbone, and a skin graft).

Radiation therapy alone or after surgery.

Retromolar trigone



Surgery (wide local excision, which includes removing part of the

jawbone).



If cancer is in the upper gingiva (gums) or the hard palate (the roof of the

mouth), treatment may include the following:

Surgery (wide local excision) with or without radiation therapy.

Radiation therapy alone.

Stage III Lip and Oral Cavity Cancer

Treatment of stage III lip and oral cavity cancer depends on where cancer is


Lip


Surgery and external radiation therapy with or without internal radiation

therapy.

A clinical trial of chemotherapy before or after surgery.

A clinical trial of chemotherapy and radiation therapy.

A clinical trial of hyperfractionated radiation therapy.

Front of the tongue


External radiation therapy with or without internal radiation therapy.

Surgery (wide local excision) followed by radiation therapy.



Buccal mucosa




Radiation therapy




Floor of the mouth


following:


jawbone, with or without neck dissection).

External radiation therapy with or without internal radiation therapy.




Lower gingival



Radiation may be given before or after surgery.



Retromolar trigone



Surgery to remove the tumor, lymph nodes, and part of the jawbone,

with or without radiation therapy.




Upper gingival

If cancer is in the upper gingiva (gums), treatment may include the following:

Radiation therapy

Surgery (wide local excision) and radiation therapy.



Hard palate

If cancer is in the hard palate (the roof of the mouth), treatment may include

the following:

Radiation therapy




Lymph nodes

For cancer that may have spread to lymph nodes, treatment may include the

following:

Radiation therapy and/or surgery (neck dissection).



Stage IV Lip and Oral Cavity Cancer

Treatment of stage IV lip and oral cavity cancer depends on where cancer is


Lip


Surgery and external radiation therapy with or without internal radiation

therapy.




Front of the tongue


Surgery to remove the tongue and sometimes the larynx (voice box)

with or without radiation therapy.

Radiation therapy as palliative therapy to relieve symptoms and

improve quality of life.




Buccal mucosa



Surgery (wide local excision) and/or radiation therapy.





following:

Surgery before or after radiation therapy.




Lower gingival


Surgery and/or radiation therapy.




Retromolar trigone



Surgery to remove the tumor, lymph nodes, and part of the jawbone,

followed by radiation therapy.





If cancer is in the upper gingiva (gums) or hard palate (the roof of the mouth),


Surgery with radiation therapy.




Lymph nodes

For cancer that may have spread to lymph nodes, treatment may include the

following:

Radiation therapy and/or surgery (neck dissection).




Treatment Options for Recurrent Lip and Oral Cavity Cancer

Treatment of recurrent lip and oral cavity cancer may include the following:

Surgery, if radiation therapy was used before.

Surgery and/or radiation therapy, if surgery was used before.

A clinical trial of chemotherapy with or without radiation therapy.

A clinical trial of hyperthermia therapy.

Tongue Cancer

The main reason for treating small sqamous cancer of the oral tongue with

surgery is that it is at least as curative as radiation, possibly better, it is over with

quickly, oftentimes done as an out patient procedure instead of 5 - 6 weeks of daily

therapy, it may be significantly less expensive, and finally, and most importantly, it

means that if a patient were to later present with a 2nd or 3rd Squamous Cell Cancer

of the mouth/throat/or voice box area, you would still have radiation therapy as a

treatment option, perhaps then being able to avoid a significant and disfiguring

operation. There is a limit as to how much radiation normal tissue can take before it

dies.

Some cases of Oral Tongue Cancer can be treated with just removal of the

primary tumor in the tongue. But as the size of the primary tumor increases the

statistical possibility of some cancer cells spreading through lymphatic vessels to the

lymph nodes of the neck increases. The site and pattern of the involved lymph nodes

is pretty much constant – that is to say we know where in the neck to look for

enlarged lymph nodes that might contain metastatic cancer cells from the oral tongue

cancer. Exceptions to these rules are sometimes seen, but they are uncommon. When

the presence of enlarged lymph nodes in the neck is detected or when the index of

suspicion is high that there may be cancer cells present in lymph nodes, then an

operation called a neck dissection is performed to remove these "secondary" deposits

of cancer. Remember, the oral tongue cancer is the "primary" tumor from where the

spreading cells originate.

There are many forms of neck dissections from radical to conservative and I

can not really go into the differences and unique characteristics of each one. Suffice

to say that this is an area of medical judgement and decision making that relies

heavily on the experience of the surgeon. While many physicians may have had

some exposure to neck dissections at some point in their career, there are very few

Head and Neck Surgeons, usually found in large medical centers, who can truly say

that their career has been dedicated to this type of disease and they have done

hundreds or perhaps thousands of these procedures. At The Head and Neck Surgery

Clinic of Houston, we will have been doing Head and Neck cancer surgery and neck

dissections for half a century come 1999.

Finally, there may sometimes be the need to perform plastic surgery and/or

reconstruction following removal of the tumor, and radiation treatments may have

to be given after the surgery to try to minimize the possibility of recurrence of the

disease and ultimate treatment failure. Yes, sometimes in spite of every effort, every

bit of hard work, in spite of supportive care and even our prayers, some patients will

be lost to this disease. It is a sad thing to have to watch and be a part of, but it is one

of life's unpleasant realities. For now, we will have to content ourselves with the

knowledge that most of our tongue cancer patients survive quite nicely and hope that

new research and new discoveries in the future will allow us to help our patients

even more.

Palate Cancer

Treatments

Radiation therapy is the primary treatment for moderate or advanced cancers

of the soft palate. Laser microsurgery is used for small and medium-sized tumors.

Radiation may be combined with chemotherapy or surgery when needed.

Surgery is the preferred treatment for cancer of the hard palate.

6. Materials for self-check:

A. Tasks for self-check (tables, schemes, drawings, graphs):

Lymphatic apparatus of neck

Anatomic scheme of classification of stages of lip’s cancer

Anatomic scheme of classification of stages of tongue’s cancer

B. Situational tasks for self-check:

1. What histologic forms of a cancer of a lip meet more often?

(Answer: planocellular).

2. What stages of a cancer of tongue consider started?

(Answer: III and IV stage).

3. Specify an optimum method of a cancer therapy of the T1N0M0.

(Answer: focus X-ray).

C. Materials for test control. Test tasks with the single correct answer (α = 2):

1. Cancer cases of a mucous membrane of an oral cavity:

A. Decreases.

B. Stable.

C. Raises.

(Right answer: С).

2. The most frequent morphological form of malignant tumors of a mucous

membrane of an oral cavity is:

A. Planocellular cancer.

B. Sarcoma.

C. Mucoepidermoid tumor.

D. Cylindroma.

E. Not differentiated cancer.

(Right answer: А).

3. The most frequent localization of a cancer of a mucous membrane of an oral cavity

is:

A. Tongue.

B. Mouth floor.

C. Mucous cheeks.

D. Mucous soft palate.

E. Mucous alveolar shoot of a jaw.

(Right answer: В).

D. Training problems of the 3rd level (atypical tasks):

1. At the patient, in 55 years, in the center of a lower lip the ulcer of 2 cm in diameter,

with platen-like edges is observed, the infiltration of tissues which surround an ulcer

is observed. Make the previous diagnosis? In what lymph nodes possible

metastasizes? Define a method of treatment of the patient.

(Answer: cancer of a lower lip possible metastasizes in submaxillary lymph

nodes. Treatment is combined).

2. The patient, 60 years, addressed with complaints to pain during swallowing that

arose about 3 weeks ago and gradually amplifies. During the review on a lateral

surface of tongue at the left the found ulcer with transition to a mucous membrane

of a mouth floor, to 2 cm in diameter, painful at a palpation, with a bleeding bottom,

is observed restriction mobile tongue. Surrounding tissues are infiltrating. Make the

previous diagnosis and specify, what methods of research need to be carried out for

diagnosis specification.

(Answer: cancer of a lateral surface of tongue at the left. It is necessary to

carry out a biopsy (a histological method) and cytological research of ulcer).

3. The dentist of policlinic found in sick defeat of a lower lip, suspicious on a cancer.

To what clinical group the patient belongs? What further tactics of the dentist?

(Answer: clinical group 1. It is necessary to conduct a biopsy or cytological

research, to send the patient to an oncological clinic).

References:

Basic:

1. Peterson’s Principle of oral and maxillofacial surgery. 3rd Edition / M. Miloro,

G.E. Ghali, P.E. Larsen, P.D. Waite. – Hamilton London, BC Decker Inc, 2012. –

1664 p.

2. Oral and maxillofacial surgery : textbook / Ed. by prof. V. Malanchuk / part one.

– Vinnytsia : Nova Knyha Publishers, 2011. – 424 p.

3. Oral and Maxillofacial Surgery / J. Pedlar, J. Frame. – Edinburg, London, New

York, Philadelphia, Sydney, Toronto: Churchill Livingstone, 2003. – 325 p.

4. Principle of oral and maxillofacial surgery / Ed. by U.J. Moore. – Blackwell

Science, 2001. – 276 p.

5. Skikevich M.G. Benign tumors and tumor-like formations of maxilla-facial

region / M.G. Skikevich, V.N. Gavrilyev. – Poltava : ASMI, 2008. – 132 p.

6. Textbook of general and oral surgery / D. Wray, D. Stenhouse, D. Lee, A. Clark.

– Edinburg, London, New York, Philadelphia, St Louis, Toronto, Churchill

Livingstone, 2003. – 322 p.

Additional:

1. Mitchell D. An Introduction to Oral and Maxillofacial Surgery / D. Mitchell. –

Oxford University Press, Jan, 2006. – 356 p.

2. Coulthard P. Master dentistry / P. Coulthard, K. Horner PH. Sloan, E. Theaker. –

Edinburg, London, New York, Philadelphia, St Louis, Toronto, Churchill

Livingstone, 2003. – 267 p.

3. Tkachenko P.I. Propaedeutics of surgical stomatology and inflammatory diseases

of maxillofacial region / P.I. Tkachenko, A.I. Pan’kevich, K.Yu. Rezvina. – Poltava

: ASMI, 2011. – 283 p.

4. Web sources:

[http://www.sciencedirect.com/science/article/pii/0030422080900754], 2016

[http://www.sciencedirect.com/science/article/pii/S0140673605666585], 2015

http://www.sciencedirect.com/science/article/pii/0030422080900754

http://www.sciencedirect.com/science/article/pii/S0140673605666585

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Higher State Educational Establishment of Ukraine ... · membrane of an oral cavity, tongue. 2.4. To classify malignant new growths of lips, a mucous membrane of an oral cavity, tongue