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Oral cancer
- 1. (Oral!Cancer!1)! !ORAL!CANCER:!A!Silent!Killer! Dr. Adel I. Abdelhady !Assistant!Professor!Oral!!Surgery! College!of!Den5stry,!Dammam!University! !
- 2. Introduc7on! • Cancer!of!the!oral!cavity!in!Saudi!Arabia!is!not!an!uncommon! disease!! • It!account!for!more!than!25%!of!all!malignancies,!in!the! Southern!region,!it!might!reach!up!to!35%!! • In!males,!it!is!third!in!frequency!following!lung!and!prostate! cancer! • In!females,!it!is!second!following!breast!cancer!!
- 3. Introduc7on! • The!spectrum!of!malignant!tumours!to!affect!the! oral!cavity!vary!widely!and!includes:! – Surface(epithelium( • Squamous!cell!carcinoma!over!90%! – Glandular(epithelium( • Adenocarcinomas!in!females! • Mucoepidermoid!carcinomas!in!males! – Mesenchymal(5ssues( • Lymphomas,!Sarcomas!are!very!rare!
- 4. Introduc7on! Surface(Epithelium • 1K!Squamous!cell!Carcinoma! • Undifferen5ated!carcinoma! • Differen5ated!carcinoma! • Adenoid!squamous! carcinoma! • Verrucous!carcinoma! • 2K!Basal!cell!carcinoma! • 3K!Malignant!Melanoma !! !!
- 6. Introduc7on! • Acquired)capability)of)cancer)cell:) – Limitless!replica7ve!poten7al! – Evading!apoptosis! – SelfJsufficiency!in!growth!signal! – Insensi7ve!to!an7growth!signals! – Sustained!angiogenesis! – Tissue!invasion!and!metastasis!
- 8. Squamous!Cell!Carcinomas!! • More!than!90%!of!cancers!of!the!oral!cavity!and! oropharynx!are!squamous!cell!carcinomas!! • Squamous!cells!are!flat,!scaleJlike!cells!that!normally! form!the!lining!of!the!oral!cavity!and!oropharynx.!! • Invasive!squamous!cell!carcinoma!means!that!the! cancer!cells!have!spread!beyond!this!layer!into! deeper!layers!of!the!oral!cavity!or!oropharynx.!!
- 9. E7ology!&!Risk!Factors! ! Tobacco:!About!90%!of!people!with!oral! cavity!and!oropharyngeal!cancer!use!tobacco!! ! Alcohol:!Drinking!alcohol!strongly!increases!a! smoker's!risk!of!developing!oral!cavity!and! oropharyngeal!cancer.!! ! Ultraviolet!light:!More!than!30%!of!pa7ents! with!cancers!of!the!lip!have!outdoor! occupa7ons!associated!with!prolonged! exposure!to!sunlight.!! ! Irrita5on:!LongJterm!irrita7on!to!the!lining!of! the!mouth!caused!by!poorly!fi[ng!dentures!!
- 11. E7ology!&!Risk!Factors! – Chemicals:! • Asbestos,!NickelKChromate,!in!nasal!and!paranasal!sinuses! tumours! • Wood!dust!in!Adenocarcinoma!of!the!nose! – Dietary!factors:! • Vitamin!A!deficiency! • Vitamin!B!deficiency,!PateresonKKelly!syndrome! – Radia7on!exposure! – Viruses:!! • • • • Human!Papilloma!Virus!HPV! EpsteinKBarr!Virus!EBV! Human!Immunodeficiency!!Virus!HIV! Hepa55s!virus!
- 12. • The!overall!survival!rate!for!oral!cancer!in!the!general! ! popula7on!is!52%,!a!survival!rate!worse!than! prostate,!uterine,!breast,!bladder,!cervical!and!colon! cancers! • A!5Jyear!survival!rate!for!African!American!men!with! oral!cancer!is!approximately!34%.!With!early! detec7on!and!treatment,!the!5Jyear!survival!rate!can! increase!up!to!85%.! • Even!though!Oral!cancer!is!typically!a!disease!of!older! people!(60J70),!usually!because!of!their!longer! exposure!to!the!risk!factors,!it!does!occur!in!younger! individuals.!
- 14. Tobacco!&!Alcohol! ! Tobacco when kept in ! Scien7sts!are!not!sure! mouth leaches out whether!alcohol!directly! carcinogens, which damages!DNA,!but!they! act on oral mucosa have!shown!that! causing neoplastic alcohol!increases! changes. penetra7on!of!many! ! Habit of smoking is DNAJdamaging! also equally dangerous. chemicals!into!cells!! !
- 16. Epidemiology! • Incidence:! • Global!incidence!of!cancer!is!10!million,!with!6!million! deaths!(Sikora,!1999).!! • Each!year,!oral!cancer!kills!more!people!in!the!US!than! does!cervical!cancer,!malignant!melanoma,!or!Hodgkin's! disease.! • Oral!cancer!more!common!than!cervical!cancer!(Ries!et! al.,!1998).!! • Worldwide,!oral!cancer!is!the!sixth!most!common!cancer,! represen7ng!about!5.5!%!of!all!malignancies!and! approximately!2%!of!all!cancer!deaths.! • However,!the!worldwide!incidence!of!oral!cancer!varies! (India!and!Brazil!=!40%).!!!
- 17. Oral!Cavity!Cancer:! Approximately!50%!of!pa7ents!diagnosed!with!oral!cancer!will! ul7mately!die!of!their!disease! ! Annual!incidence!31,000!Americans;!350,000!worldJwide! ! Sixth!most!common!cancer!worldJwide! ! One!pa7ent!dies!from!oral!cancer!every!hour!in!the!U.S.! ! High!mortalityJ!50%!live!less!than!5!years!following!diagnosis! ! Disease!of!middleJage!and!elderly!males!95%!over!40;!66%! males! ! Known!risk!factors:!alcohol!and!tobacco;!viruses!(HPV?)! ! Incidence!relates!to!socioJeconomical!factors! ! 90+%!squamous!cell!carcinomas! ! Frequent!lymph!node!metastasis! ! Mul7ple!primaries!
- 20. Precancerous)lesions)! ! • 1.Oral leucoplakia • It is characterized by white patch on the buccal mucosa or any place in the mouth and is adjacent to the place where the tobacco quid is kept. The less likely place is floor of the mouth and tongue although 93% of leucoplakia at this sites turn malignant!
- 23. 3.Oral sub mucous fibrosis! • This condition is characterized by limited opening of mouth and burning sensation on eating of spicy food. This is a progressive lesion in which the opening of the mouth becomes progressively limited, and later on even normal eating becomes difficult.
- 24. Carcinogenesis! • The!mucosa!is!thought!to!be! primed!to!develop!malignant! tumours!by!exposure!to!repeated! carcinogenic!insults!which!cause! mucosal!altera7ons.! • !These!altera7ons!may!include:! • Chromosome!altera7ons,!! • Gene!muta7ons,!! • Other!molecular!abnormali7es! • Field!canceriza7on!
- 26. Field change & arising of a further tumour
- 29. Metasta7c!Carcinoma!In!Jaws! • 1.! ! Metastasis! in! jaws! or! (rarely)! oral! so_! 5ssues,! especially!from!cancer!of:! • • • • • • Breast!! Lung!! Prostate! Thyroid! Kidney! Stomach!!
- 32. Theories!Of!Invasion! Three! theories! about! invasion! exist! (Pauli,! B.! U.! and! !! Knudson,!W.,!1988): (1)!The!Mechanical!Theory:!! ! whereby! the! tumour! mass! is! rapidly! increasing! by! permanent! cycling! and! prolifera7on,! so! that! the! surrounding! 7ssues! are! at! first! compressed! by! the! growing! mechanical! pressure,! and! later,! the! normal! cells! separate! to! give! way! to! the! invading! front! of! tumour!cells.!
- 34. Theories!of!invasion! (3)!The!migratory!theory:! ! ! It!originates!from!the!idea!that!tumour!cells!become! mobile! and! migrate! into! the! surrounding! normal! 7ssue.! ! ! Malignant! cells! may! detach! from! the! main! tumor!mass,!enter!the!surrounding!7ssues,!penetrate! basement! membranes,! and! enter! thinJwalled! lympha7cs,! capillaries,! or! venules.! Malignant! cells! within!these!vessels!are!known!as!"tumor!emboli."! • As!Pauli!and!Knudson!have!carefully!discussed,!these! mechanisms!are!interdependent!and!must!act!in!coJ ordina7on!to!enable!tumour!cells!to!spread!from!the! primary!tumour!to!distant!sites.!!
- 36. Featured)Which)Demand)Careful) ConsideraCon)From)Examiner)Are)) 1JChronic!ulcer!or!fissures!with!no!apparent!cause,!or! ones!which!do!not!respond!to!simple!treatment! ! 2JSwelling!with!no!apparent!cause,!but!no!marked! edema!or!redness! ! 3JRapid!and!unexpected!loosening!of!a!group!of! teeth,!irregular!bone!destruc7on!seen! radiographically! ! 4JSigns!of!infiltra7on,!such!as!tethering!of!an!organ! or!lump!or!limita7on!of!normal!movement!of!the!part! !
- 38. ! 9JAn!abscess!with!no!apparent!cause!which! !! ! may!be!a!necro7c!neoplasm! ! 10JAnaemia!with!no!obvious!cause! ! 11JSwea7ng,!malaise,!and!toxicity!not!due!to! an!obvious!infec7on!! ! 12Jdifficulty!chewing!or!swallowing,!ear!pain,! difficulty!moving!the!jaw!or!tongue,! hoarseness,!numbness!of!the!tongue!or!other! areas!of!the!mouth,!or!swelling!of!the!jaw!that! causes!dentures!to!fit!poorly.!!!
- 41. Signs!and!Symptoms! • It!can!go!unno7ced,!it!can!be!painless! • It!may!appear!as!a!white!or!red!patch!of!7ssue!in!the! mouth,!or!a!small!indurated!ulcer! • May!be!or!not!accompanied!with!relevant! lymphadenopathy! • It!is!important!to!have!a!biopsy!for!any!sore!or! discolored!area!in!the!pa7ent’s!mouth,!which!does! not!heal!within!14!days!!
- 45. What!You!Can!Do?! • EXAMINE!your!pa7ents!at!each!visit! • TAKE!A!HISTORY!of!their!alcohol!and! tobacco!use!! • INFORM!your!pa7ents!of!the!associa7on!between! tobacco!use,!alcohol!use,!and!oral!cancer!! • FOLLOWKUP!to!make!sure!a!defini7ve!diagnosis!is! obtained! • Have!a!biopsy!from!any!non!responding!lesions!
- 47. Instruc7ons!to!the!Pa7ent! • You!should!always!contact! your!doctor!or!den7st! immediately!if!you!no7ce!the! following!symptoms!in! yourself!or!a!loved!one:! • A!sore!or!lesion!in!the!mouth! that!does!not!heal!within!two! weeks.!! • A!lump!or!thickening!in!the! cheek.!! • A!white!or!red!patch!on!the! gums,!tongue,!tonsil,!or! lining!of!the!mouth.!! • A!sore!throat!or!a!feeling! that!something!is!caught! in!the!throat.!! • Difficulty!chewing!or! swallowing!dysphagia!or! painful!of!swallowing! • Difficulty!moving!the!jaw! or!tongue.!!! • Numbness!of!the!tongue! or!other!area!of!the! mouth.!! • Swelling!of!the!jaw!that! causes!dentures!to!fit! poorly!or!become! uncomfortable.!!
- 48. Management!of!oral!cancer! • The!management!of!oral!cancer!has!undergone! radical!change!in!the!last!10!years!and!con7nues!to! evolve!rapidly.! • Discoveries!in!molecular!biology,!diagnos7c! techniques,!surgery,!radia7on!therapy!and!medical! oncology!have!altered!many!tradi7onal!concepts! • Of!all!the!procedures!available!to!control!oral!cancer,! none!has!affected!survival!as!much!as!has!early! detec7on.!.!
- 49. Examina7on!and!diagnos7c!methods! • Health!history! • History!of!the!lesion! • Clinical!examina7on! • Radiographic!examina7on:!Head!and!Neck!CT,!MRI!for! the!primary!lesion!and!lymph!nodes!by!FNA!and!PER.! • Laboratory!inves7ga7on:! • Blood,!enzymes,!electrolytes,!biopsies!
- 53. • ! Diagnosis! Ini7ally!oral!cancer!may! ! • Diagnosis!is!established!by! be!asymptoma7c!but!a! check!up!of!a!small! ulcera7ve!lesion!from!a! professional!is! recommended.! • !But!pa7ents!normally! presents!when!pain!and! discomfort!is! predominant!and!then! the!prognosis!becomes! poor.! ! many!ways!like!applying!dyes! like!toluidine!blue!which!may! give!false!posi7ve!results!in! inflammatory!lesion!but!never! false!nega7ve,!using!X!rays!and! scans!to!see!the!extension!of! the!lesion!and!the!bony! involvement!and!the!most! confirmatory!test!is!biopsy!of! the!lesion!and!its!histoJ pathological!examina7on!
- 55. !
- 59. Surgical!anatomy! • The(Lip:( – Covered!with!nonKkera5nized! stra5fied!squamous!epithelium! which!is!transparent,!appear!red,!and! contain!no!hair,!sebaceous!gland!or! pigments! – On!the!vermilion!border!it!closely! cover!the!orbicularis!oris!muscle!but! on!the!lingual!side!mucous!gland!is! present!within!the!muscle!and! mucosa! – The!epithelium!is!2!mm!away!from! the!muscle,!ulcera5ve!lesions!will!be! fixed!early!in!the!disease!!!
- 60. Surgical!anatomy!The(Lip( – Lympha7c!drainage:! • Mucosal!and!cutaneous!systems.! • Lower!lip:! – One!medial!trunk!which!drain!the!inner!third!of!the!lip!into! the!submental!group! – Two!lateral!trunk!which!drain!the!outer!twoJthird!into!the! submandibular!lymph!nodes! – Anastomosis!account!for!bilateral!metastases! • Upper!lip:! – Drain!into!the!periauricular,!paro7d,!submandibular!and! submental!lymph!nodes!
- 61. Surgical!anatomy!The(Lip( • Age!and!sex:! – The!sixth!decade!and!Male!:!female! ra5o!is!80:1! • 93%!affect!the!lower!lip!with! squamous!cell!carcinoma,! exophy7c!type!! • 5%!in!the!upper!lip!and!commonly! basal!cell!carcinoma,!commoner! in!females! – Solar!exposure,!more!radia5on!on! the!lower!lip! – Commoner!in!fair!complexion! – Smoker!mainly!pipe! – In!the!upper!lip,!SCC!metastasizes! earlier!than!lower!lip!!
- 64. Surgical!anatomy!! • The!buccal!mucosa:! – Covered!with!nonJkera7nizing! stra7fied!squamous! epithelium!with!mul7ple! minor!salivary!glands! – It!is!7ght!over!the!buccinator! muscle!and!fixed!to!the!upper! and!lower!sulci! – Lympha7c!drainage:! • The!submandibular!lymph! nodes!to!the!lower!deep! cervical!chain!
- 66. Tongue! • With!the!pa7ent's!tongue!at!rest,! and!mouth!par7ally!open,!inspect! the!dorsum!of!the!tongue!for!any! swelling,!ulcera7on,!coa7ng!or! varia7on!in!size,!colour,!or! texture.!! • Also!note!any!change!in!the! paeern!of!the!papillae!covering! the!surface!of!the!tongue!and! examine!the!7p!of!the!tongue.! ! !The!pa7ent!should!then!protrude! the!tongue,!and!the!examiner! should!note!any!abnormality!of! mobility!or!posi7oning.!
- 68. Surgical!anatomy! • The(tongue:( – Specialized!kera7nized!epithelium! with!collec7on!of!minor!salivary! gland!and!muscle!fibres! – The!interlacing!muscle!fibres!form! an!easy!pathway!for!cancer! spread!and!the!constant! movement!of!the!tongue! disseminates!the!disease!widely! • Excision!should!be!wide!with!2!cm! safe!margin!
- 69. Ventral surface of the tongue and floor of the mouth • Then!examine!the!ventral! surface.!Palpate!the!tongue! to!detect!growths.! • With!the!tongue!s7ll! elevated,!inspect!the!floor!of! the!mouth!for!changes!in! color,!texture,!swellings,!or! other!surface!abnormali7es.!
- 70. Surgical!anatomy!The(tongue( • A!disease!of!the!middle!age!and! elderly!with!equal!sex!incidence! • 85%!occurs!in!the!lateral!border!of! the!anterior!2/3,!!while!7p,! dorsum!and!ventral!surface!are! rarely!involved! • The!lesion!may!be!infiltra7ve! (small!on!the!outside!but! palpa7on!shows!deep!invasion)!or! exophy7c!and!usually!of!the!wellJ differen7ated!type!
- 75. SCC of the body of the mandible Intra-oral photograph * CT Scan (Bony invasion)
- 76. Factors!describes!the!degree!of! malignancy! • The!degree!of!histological!differen7a7on!of! Malignant!neoplasm!are!histologically! classified!as:! • 1JWell!differen7ated! • 2J!Moderately!differen7ated! • 3J!Poorly!differen7ated!
- 77. Most!common!routes!of!! spread!of!oral!carcinoma! • 1JLocal!spread!is!achieved!by!direct!invasion! and!infiltra7on!of!adjacent!stractures.! • 2JPerineural!invasion!! • 3JRegional!spread!to!the!neck!lymph!nodes! occurs!via!lympha7c!route! • 4JSpread!to!distal!organs!follows!the! hematogenous!route!
- 78. Test!for!metasta7c!workJup!of!oral! cancer! • 1J!Blood!and!biochemical!profile! • 2JChest!xJray,!liver!ultrasound(abdominoJ pelvic!sonar),!bone!scan! • 3J!CT!and!MRI! • 4J!PanJendoscopy!
- 82. Assessment! • Whether!to!treat!or! not!depend!on:! – the!age! – the!health!status!of! the!pa5ent!! – advance!stage! – local!disease!!
- 83. Assessment! • Full!assessment!will!lead!to! one!of!the!following! conclusions:! – Pa5ent!is!poten5ally! curable! – Primary!tumour!is!curable! but!pa5ent!develop! another!illness! – Pa5ent!is!incurable!and! should!not!be!treated!
- 84. Assessment! • The!pa7ent!general!condi7on:! – Assessed!with!full!inves7ga7on!and!classified!for! performance!status! 1. Grade)0 !Fully!ac7ve!without!restric7on! 2. Grade)1 !Ambulatory!but!restricted!in!!!! physically!strenuous!ac7vity! 3. Grade)2 !Ambulatory!but!unable!to!carry!out! any!work!ac7vity! 4. Grade)3 !Confined!to!bed!but!capable!of! limited!self!care! 5. Grade)4 !Confined!to!bed!and!unable!to!carry! out!any!self!care! ! ! ! ! ! !Karnofsky(Status(
- 85. Assessment! • Examina5on:! – Think!in!term!of!T!Staging,!delineate!its!border!by! inspec7on!and!palpa7on! – Record!and!draw!the!lesion!from!different!angles! using!normal!anatomical!landmarks! – The!status!of!teeth!should!be!assessed!as! causa7ve!and!if!radiotherapy!is!to!considered!!
- 86. Assessment! • Staging!of!cancer:! – Subdividing!the!malignant!lesion!into! groups!with!similar!behavior! • Act!as!a!guide!to!appropriate!treatment!! • Act!as!a!guide!to!prognosis! • Permits!more!reliable!comparison!of!results! – Primary(site:( » Histological!type,!size!and!extend!of!the!primary! – Node(metastasis( – Haematogenous((metastasis(
- 87. Staging)TNM) • Primary(Tumour:( – Indicated!by!the!leeer!T!and!the!suffix!1,2,!3! or!4!represent!more!advancing!disease! • T1(–!tumour!2!cm!or!less! • T2!–!tumour!more!than!2!but!less!than!4!cm! • T3(–!tumour!more!than!4!cm! • T4!–!Tumour!more!than!4!cm!with!deep!invasion!of! underlying!7ssues! – T0!–!No!evidence!of!primary!tumour! – Tis!–!Carcinoma!in!Situ! – TX!–!Extend!of!primary!tumour!cannot!be!assessed!
- 88. Staging! • Lymph!node:! – Is!used!to!describe!progressive!lymph!node! involvement! – NxJ!Regional!lymph!node!cannot!be!assessed! – N0J!No!Regional!lymph!node!metastasis!! • N1!–!Metastasis!in!a!single!ipsilateral!nodes!!!>3!cm!!! • N2!–!Single!ipsilateral!nodes!!<!!3!cm!but!!>6!cm,!or! mul7ple!clinically!posi7ve!ipsilateral!less!than!6!cm! – N2a!–!Single!<!!3!cm!but!!>6!cm! – N2b!–!Mul7ple!none!!<!6!cm! – N2CJ!metastasis!in!a!bilateral!or!!contralateral!!LN! • N3(–!Clinically!posi7ve!ipsilateral!more!than!6!cm,! Bilateral!or!contralateral! – N3a!–!ipsilateral!more!than!6!cm! – N3b!–!Bilateral,!each!side!staged!separately! – N3c!–!Contralateral!only!
- 89. Staging! • Distant!metastasis:! – M0!–!No!metastases!present! – M1!–!Metastases!clinically!demonstrable! • MX!–!Metastases!cannot!be!assessed!
- 90. Staging! • TNM!Staging:! – Stage!I:!T1,!N0,!M0! – Stage!II:!T2,!N0,!M0! – Stage!III:!T3,!N0,!M0! !! !!!!!T1,!2!or!3,!N1,!M0! – Stage!IV:!T4,!N0!or!1,!M0! !! !!!!!T1!–!4,!N2!or!3,!M0! !! !!!!!T1!–!4,!N1!–!3,!M1!!! !! ! ! ! ! !AJCC(1983(
- 91. Staging! Stage!I!! • compromise!nega7ve!nodes!and!operable!primary! Stage!II!! • operable!primary!with!operable!nodes! Stage!III! • inoperable!due!advanced!primary!or!advanced!nodal! involvement! Stage!IV!! • Distant!metastases!preclude!any!surgical!interven7on!!
- 93. (Oral!Cancer!2)! !ORAL!CANCER:!A!Silent!Killer! Dr. Adel I. Abdelhady !Assistant!Professor!Oral!!Surgery! College!of!Den5stry,!Dammam!University! !
- 94. ! BIOPSY!
- 96. BIOPSY!
- 110. Method!! • Give!LA!which!should!not!be!closer!than!2cm! from!the!site.! • Stabilize!the!lesion!via!the!suture.! • Incise!mucosa!around!the!base!of!the!lesion!in! an!ellip7cal!shape.! • Place!specimen!immediately!in!a!fixa7ve.! • Close!the!wound!using!suture.!
- 113. Method! • Administer!LA.! • Iden7fy!the!apparent!junc7on!between!normal! 7ssue!&!the!lesion!select!the!specimen!across!region.! • Stabilize!the!specimen!with!a!suture.! • Dissect!the!specimen!from!the!edge!of!the!lesion!&! include!a!margin!of!apparently!normal!7ssue.! • The!specimen!should!include!representa7ve!area!of! the!lesion.! • Place!the!specimen!immediately!in!a!prescribed! specimen!boele!containing!10%!formalin.! • Close!surgical!site!by!sutures.!
- 120. MISJDiagnosis! • 1JInadequate!oral!examina7on! • 2JInnocuons!appearance!of!mucosa! • 3JLow!index!of!suspicion( • 4JLack!of!experience)
- 121. Treatment!plan!is!based!on:! ! Staging!of!disease!using!TNM!classifica7on! ! T = Tumour size ! N = Nodal status ! M = Metastases ! !!!!!!!!!!Eg.!T3N2M0!laryngeal!carcinoma!!
- 122. Introduc7on! • Prognos5c(Indicators:! – Sex:!Poor!prognosis!in!females! – General!condi5on!&!health!status!of!pa5ent! – T!stage! – Number!of!histologically!posi5ve!nodes!! – Surgical!margin!status! – Type!of!therapy!and!blood!transfusion!!
- 125. Dental!Management! Will!involve!:! ! General!Den7st! ! Hygienist! Dental!Assistant! Recep7on!Staff!
- 127. Dental!Consulta7on!! • Diagnoses! – Dental! • Caries! • Periodontal!disease! • Other!Pathology! – Medical! • coJmorbidi7es!
- 140. SCC!in!FOM!
- 141. Metasta7c!carcinoma!in!jaws! • Metastasis! in! jaws! or! (rarely)! oral! so! 7ssues,!especially!from!cancer!of:! • Breast!! • Lung!! • Prostate! • Thyroid! • Kidney! • Stomach!!
- 142. Referrals!for!biopsy! • Health!of!pa7ent!! • surgical!difficulty! • Poten7al!for!malignancy!
- 146. Nutri7onal!Implica7ons!of!Cancer! Therapy! • Chemotherapy! ! !—Taste!abnormali7es,!diarrhea,!cons7pa7on! • Radia7on!therapy! ! !—Fa7gue,!loss!of!appe7te,!skin!changes! • Surgery! !—Fa7gue,!pain,!loss!of!appe7te! • Immunotherapy! ! !—Flulike!symptoms,!decreased!food!intake!
- 148. Factors!affec7ng!the!decision! • Aggressiveness!of!lesion! • Anatomic!loca7on!of!lesion! • Dura7on!of!lesion! • Reconstruc7ve!efforts! • Reconstruc7on!of!jaws!aer!removal!of!oral! tumours! • Histopathologic!diagnosis! • Presence!and!degree!of!metastasis! • RadioJsensi7vity!and!chemoJsensi7vity! • Age!and!condi7on!of!the!pa7ent! • Experience!of!the!clinicians! • Wishes!of!the!pa7ent.!
- 150. 2. Advanced!stages!(III!and!IV)!treated!with!a! combina7on!of!surgery!and!radia7on! therapy,!although!this!increases!the! complica7ons!and!morbidity.! 3. Chemotherapy!is!added!in!order!to:! • decrease!the!possibility!of!metastasis,!! • sensi7ze!the!malignant!cells!! • !radia7on,!or!for!those!pa7ents!who!have!confirmed! distant!metastasis!of!the!disease.!
- 152. Mul7ple!carcinomas!
- 155. Alveolar!SSC!
- 156. Alveolar!SSC!1!
- 159. Melanoma!
- 160. Radiotherapy! • Tumour!cells!are!more!suscep7ble!to!ionizing!radia7on!! • Radia7on!can!be!delivered!by:! ! Implanta7on!of!the!radioac7ve!material!into!the!tumour! ! Use!of!external!xJray!generators! • Radia7on!therapy!can!be!delivered!by!two!mechanisms:! ! Frac7ona7on! ! Mul7ple!ports! • Using!directed!radia7on!and!intensity!modulated!radia7on!therapy!(IMRT)! (focused!to!the!target)!and!accelerated!and!HyperJfrac7ona7on!regimens! (higher/more!frequent!doses!are!used)! • Preven7on!of!xerostomia!by!shielding!the!paro7d!gland!and!using!directed! radiotherapy!and!using!pilocarpine!during!and!aer!radia7on.!
- 161. RADIOTHERAPY!
- 163. • The!use!of!ionising!radia7on!to!cure!disease!or! make!the!symptoms!of!a!disease!less!severe! i.e.!palliate.! • Radiotherapy!is!used!mainly!to!damage!or! destroy!prolifera7ng!cells.! • The!faster!the!cellular!turnover,!the!more! suscep7ble!the!7ssue!to!the!damaging!effects! of!radia7on.!!
- 165. • Direct!effects:! !!!!!!!!these!result!from!damage,!mainly!to!DNA,! by!the!high!energy!of!radia7on.!This!can!cause! changes!in!DNA!structure!resul7ng!in!point! muta7on!or!chromosomal!breaks.! !!!!J!The!effects!may!be! 1. Arrest!the!mito7c!division! 2. Cells!death!by!apoptosis!
- 168. • Results!in!epithelial!thinning,!erosion!and! ulcera7on.!! • Affects!nonJkera7nized!mucosa!first.! • Usually!presents!within!1J2!weeks!and! increases!in!severity!to!a!maximum!at!4!weeks.!
- 172. • Pa7ent!undergoing!radiotherapy!may!have! altera7on!in!the!normal!flora.! • Bacterial,!viral!and!fungal!infec7ons!can!occur! in!the!presence!of!mucosi7s.! • The!most!common!infec7on!is!Candida.!
- 175. • Most!severe!if!bilateral!salivary!glands!are! exposed!to!radia7on! • Results!in!acinar!cell!atrophy!and!necrosis,! changes!in!the!vascular!CT!and!altered! neurological!func7oning.! • Serous!acini!affected!first!then!mucinous.! • Predisposing!factor!infec7on,!candida,!and! caries.!
- 177. • Typically!affects!the!gingival!1/3!and!incisal!/! cusp!7ps!of!teeth.! • Not!limited!to!teeth!within!radia7on!field.! • Related!to!xerostomia!leading!to!loss!of! remineralisa7on!poten7al,!loss!of!buffering! capacity,!increased!acidity!and!a!change!in! bacterial!flora.!
- 178. • preJradia7on!OHI,!diet!counseling!and! treatment!of!any!ac7ve!caries.! • regular!follow!up!during!Treatment.! • Treat!xerostomia.! • Use!fluoride!mouthwashes!or!gels.!
- 180. • Radia7on!effects!on!bone:! !!!!!!!Hypovascularity,!Hypocellularity!and!Hypoxia!leading! to!poor!ability!to!repair!and!remodel!! • Sign!and!symptom:!! !!!!!!discomfort,!tenderness,!bad!taste,!paraesthesia!and! anaesthes.! • Risk!factors!for!development!of!ORN!are:! !!!!!!!Dose,!frac7on,!volume!of!bone!exposed,!presence!of! teeth!in!high!dose!radia7on!field,!immunodeficiency,! smoking!and!alcohol.!
- 181. Non!healing!wound! Hypovascular,!hypoxia,!hypocellular!!! ! ! irradia7on! 3H’s! Tissue!breakdown!
- 183. • PreJirradia7on!management.! • During!irradia7on!management.! • PostJirradia7on!management.!
- 186. • Management!of!oral!complica7ons.! • Keep!op7mal!oral!hygiene.! • Topical!fluorid!applica7on!by!mean!of!custom! carrier.! • Regular!follow!up.!
- 190. ! • Radiotherapy!can!affect!all!oral!and!perioral! 7ssues.! • Preven7on!management!of!disease!prior!to! radia7on!treatment!can!significantly!reduce! the!incidence!and!severity!of!poten7al! complica7ons.!! • •Symptoma7c!relief!and!rapid!management! of!oral!complica7ons!is!an!important!role!of! the!den7st,!as!part!of!the!mul7disciplinary! team.!
- 192. Chemotherapy! • Used!only!in!cases!IV!with!poor!prognosis! • Currently!used!agents!include:! • • • • ! cispla7n,!! carbopla7n,!! 5Jfluorouracil! taxanes!(paclitaxel!and!docetaxel),!! !The!last!to!agents!are!also!used!as!radia7on!!!!! !sensi7zers.!! • Recent!interest!has!been!shown!in!intraJarterial! delivery!of!chemotherapy,!which!increases!the!drug! dose!to!the!tumor!and!decreases!systemic!toxicity.! • Combina7on!therapy!(radioJchemoJtherapy)! increases!the!survival.!
- 195. Treatment!delay!
- 196. Morbidity!of!cancer!therapy! • Surgery:! • • • • Quality!of!life! Func7on! Esthe7c! Cost!of!rehabilita7on! • Radiotherapy:! • • • • • • Xerostomia! Mucosi7s! Taste!sensa7on!! Osteoradionecrosis! Rampant!caries! PreJmalignancy!! • Chemotherapy:! • Blood!cell!disorders! • Alopecia!! • mucosi7s!
- 197. Osteoradionecrosis!
- 198. Radia7on!Mucosi7s!!
- 199. Cancer!pa7ent!and!Quality!of!life!! • Every!Oral!cancer!pa7ent!has!to!be!seen!by! specialist!of!the!following:! • Speech!therapy! • Diet! • Psychic!condi7on! • Esthe7c! • Physical!therapy!!