oral cancer TNM staging neck dissection radiotherapy chemotherapy palliative surgery

1. ORAL CANCER
Dr. Haydar Munir Salih Alnamer
BDS, PhD (BOARD CERTIFIED)

2. ORAL CANCER
Oral cancer accounts for less than 3% of all cancers. It is the
eleventh most common cancer worldwide. Squamous cell
carcinoma (SCC) is the predominant form of oral cancer and
accounts for greater than 90% of malignant pathology.
More than 92% of oral and pharyngeal cancers occur in individuals
older than 40 years, with the average age being 63
The fundamental regulatory mechanism in carcinogenesis is
thought to be the cellular balance between oncogenes and tumor
suppressor genes. The proto-oncogenes stimulate cell growth and
proliferation and are under negative control of the tumor
suppressor genes, which prevent overgrowth.

3. ETIOLOGY
1. Tobacco smoking
2. Betel quid
3. Alcohol
4. Chronic irritation
5. Phenolic agents
6. Radiation
7. Iron deficiency
8. vitamin A deficiency
9. Syphilis (tertiary stage)
10. Candidal infection
11. Oncogenic viruses
12. Immunosuppression
13. Oncogenes and Tumor suppressor genes:

4. SITE DISTRIBUTION
Tongue - 35% (31% lateral border, 2% tip and 2% dorsum).
Floor of mouth - 30% (25% anterior and 5% posterior).
Lower alveolus - 15%.
Buccal mucosa- 10%
Upper alveolus -5%.
Hard palate -3%.
Retromolar trigon -2%.

5. Exophytic or mass forming
lesion which typically has a
surface that is irregular,
fungating, papillary, or
verruciform, and its color
vary from normal to red to
white, depending on the
amount of keratin and
vascularity. The surface is
often ulcerated, and the
tumor is indurated on
palpation.
CLINICAL PRESENTATION
Dr. Haydar Munir Salih

6. CLINICAL PRESENTATION
Endophytic growth pattern
which has a depressed,
irregularly shaped,
ulcerated, central area with
a surrounding rolled border
of normal, red or white
mucosa. The rolled border
results from invasion of the
tumor downward and
laterally under adjacent
epithelium with induration
of the underlying tissues.

7. CLINICAL PRESENTATION
Leukoplakic, Erythroplakic or
combined Erythroleukoplakic
lesions (speckled leukoplakia)
which has a high incidence of
malignant transformation. A
thorough examination of the
upper aerodigestive tract
mucosa should be performed
in every case since synchronous
multiple primary cancers occur
in approximately in 4% of
patients with oral cancers

8. SYMPTOMS
Lesions in the floor of mouth or
tongue may be painful, infiltrative
lesions of the floor of mouth also
may extend to invade bone
anteriorly muscles of the floor of
mouth deeply, or tongue
posteriorly. Patients may complain
of difficulty in swallowing or
speaking, which becomes even
more pronounced when the tumor
spreads to the floor of the mouth Squamous cell carcinoma of
Floor of the mouth

9. SYMPTOMS
Squamous call carcinoma
Of the buccal mucosa & retromolar region
Early spread to the alveolus and
periosteum of the mandible is common;
clinical fixation of the tumor to the
mandible indicates periosteal
involvement, and direct bone invasion
may be present in a high number of
cases. Patients may report pain while
chewing, intermittent bleeding, loose
teeth or ill-fitting dentures in gingival or
alveolar ridge lesions.

10. CLINICAL STAGING
The TNM system stages cancer purely on the anatomic
extent of disease and does not account for the many
biologic, molecular, or host characteristics that are known to
influence prognosis.
TNM system
T= Tumor size.
N=Nodal status in the cervical region.
M=Metastatic disease beyond the cervical lymph nodes.

11. DEFINITION OF PRIMARY TUMOR (T)

12. DEFINITION OF REGIONAL LYMPH NODE (N)

14. DEFINITION OF DISTANT METASTASIS (M)

15. GRADING

16. HISTOPATHOLOGIC GRADING
Histopathologic grading of SCC is based upon the
degree of differentiation and resemblance to normal
squamous epithelium and the amount of keratin
production. It consists of 3 grades:
Grade 1 (well differentiated)
Grade 2 (moderately differentiated)
Grade 3 (poorly differentiated)

17. RADIOGRAPHIC ASSESSMENT
Computed Tomography The
most common imaging
modality used. The main
advantages are: excellent
bone detail, adequate soft
tissue enhancement, and
relatively low cost and
availability. While the main
disadvantages include;
ionizing Radiation, artifacts
created by metallic dental
restorations

18. RADIOGRAPHIC ASSESSMENT
Magnetic Resonance Imaging
Advantages are superior soft tissue
details and lack of ionizing radiation.
MRI is superior to CT when there is
suspicion of perineural invasion, skull
base invasion or intracranial
involvement. The main disadvantages
are; more sensitive to motion artifacts,
expensive, difficult for patients who
suffer from claustrophobia, and it is
contraindicated in case of presence of
ferromagnetic implants

19. RADIOGRAPHIC ASSESSMENT
Ultrasound Advantages:
quick, inexpensive, non-
invasive, lymph nodes can
be sampled under
ultrasound guidance. The
main disadvantages include;
limited utility in the oral
cavity, bone does not
transmit sound, it is highly
technique sensitive, and
operator dependent with
steep learning curve

20. RADIOGRAPHIC ASSESSMENT
 Positron Emission Tomography (PET)
Functional imaging with 18F-
fluorodeoxyglucose PET has been shown
to be an effective tool in the diagnosis of
head and neck cancer. PET has shown
promise in the evaluation of metastatic
disease, tumor recurrence, and treatment
response after chemotherapy or radiation
therapy. The integration of PET and CT
technology is more accurate than either
modality alone in the depiction of head
and neck malignancies.

21. TREATMENT
1. Cure of the cancer.
2. Preservation or restoration of speech, mastication,
swallowing, and external appearance.
3. Minimization of the sequelae of treatment such as dental
decay, osteonecrosis of the mandible, and trismus.
4. Awareness of the risk of subsequent primary tumors and
their management.
The main modalities of treatment are surgery, radiotherapy
and chemotherapy

22. TREATMENT
surgery is the preferred treatment for Tl and T2 tumors of the
oral cavity.
The excision of the lesions should include at least 1 cm of
adjacent normal tissues as safe margin. Superficial lesions of the
floor of mouth, buccal mucosa and soft palate can be excised
through per-oral approach, also Tl and most T2 lesions of the
anterior two thirds of the tongue (oral tongue) where the
mobility of the tongue is not restricted, and the tumor does not
extend to involve the adjacent floor of the mouth or cross the
midline are amenable for partial glossectomy through per-oral
approach.

23. TREATMENT
In advanced stage (T3 and T4) oral cancer combining surgery
with adjuvant postoperative radiotherapy offers improved
locoregional control but does not improve survival
The most important high-risk features for combining surgery
and radiotherapy are:
1. Positive margins.
2. Extranodal spread.
3. Multiple positive nodes.
4. Perineural or vascular invasion.
5. Metastasis to lymph node levels IV and V.

24. ACCESS TO THE ORAL CAVITY: PERORAL OR TRANSORAL
APPROACH
Squamous cell carcinoma
of the floor of the mouth
Mucosal incision

25. ACCESS TO THE ORAL CAVITY: PERORAL OR TRANSORAL
APPROACH
Dissection of Wharton's duct Reconstruction the defect
With skin graft

26. ACCESS TO THE ORAL CAVITY: PERORAL OR TRANSORAL
APPROACH
The appearance of skin graft 8 weeks later
It is just look like leukoplakia !
Immediate post operative dressing with
Idoform gaze

27. ACCESS TO THE ORAL CAVITY: MANDIBULOTOMY
Incision for mandibulotomy Exposure the site of mandibulotomy

28. ACCESS TO THE ORAL CAVITY: MANDIBULOTOMY
Panoramic radiograph show
the site of mandibulotomy
The mandible divided in 2 segments and
Retract laterally

29. ACCESS TO THE ORAL CAVITY: MANDIBULOTOMY
Incision made in floor of mouth Closure with plates

30. ACCESS TO THE ORAL CAVITY: MANDIBULOTOMY
Postoperative panoramic radiograph show the plates
Across mandibulotomy site

31. ACCESS TO THE ORAL CAVITY: MANDIBULOTOMY
3 months after the surgery

32. ACCESS TO THE ORAL CAVITY: VISOR FLAP

33. MAXILLARY RESECTION PROCEDURES : PARTIAL
MAXILLECTOMY
Partial Maxillectomy in malignant tumors of the floor of the maxillary sinus
with spread toward the oral cavity or in the early malignant tumors of the
maxilla, the procedure is done through the mouth and it requires removal of
the lower half of the maxilla

34. MAXILLARY RESECTION PROCEDURES : PARTIAL
MAXILLECTOMY

35. MAXILLARY RESECTION PROCEDURES : SUBTOTAL
MAXILLECTOMY
Subtotal Maxillectomy for larger tumors of the maxilla with
Weber- Fergusson approach

36. MAXILLARY RESECTION PROCEDURES : SUBTOTAL
MAXILLECTOMY
The defect 3 months later Obturator prosthesis

37. MANAGEMENT OF THE NECK
The status of the cervical lymph nodes is the most
important prognostic factor in SCC of the head and neck.
The overall survival rate decreases by approximately 50% in
patients with metastases to the cervical lymph nodes.
Approximately 40% of patients will initially be found to have
evidence of regional nodal metastasis
Therefore, management of the cervical lymph nodes is an
important component of the overall treatment of patients
with head and neck cancer.

38. MANAGEMENT OF THE NECK
Anatomy and biology of lymphatic metastasis Cervical lymph
nodes are categorized into five nodal levels, and additionally
levels VI and VII encompassing central compartment and
superior mediastinal nodes.
Levels I, II, and V are further subdivided into sublevels A and
B. For primary tumors in the oral cavity, the regional lymph
nodes at highest risk for early dissemination by metastatic
cancer are limited to levels I, II, and III

39. MANAGEMENT OF THE NECK

41. CLINICAL EVALUATION AND DIAGNOSTIC IMAGING
characteristic changes
apparent on CT and MRI
suggestive of metastatic SCC
including:
1. Enhancement.
2. Poorly circumscribed
margins.
3. Central necrosis.
4. Nodal size in excess of 1 cm
in diameter.

42. CLASSIFICATION OF NECK DISSECTION
1. Radical Neck Dissection (RND) involves the en bloc removal of all
ipsilateral lymph nodes from levels I through V, along with the ipsilateral
spinal accessory nerve (SAN), internal jugular vein (IJV), and
sternocleidomastoid muscle (SCM).
2. Modified Radical Neck Dissection (MRND) When one or more non-
lymphatic structures are preserved during the dissection, structures can
be preserved if they are not involved with tumor by skeletonizing them
during the dissection. MRND can be sub classified as follows:
1. Type I MRND preserves the SAN
2. Type II MRND preserves the SAN and IJV
3. Type III MRND preserves the SAN, IJV, and SCM. This modification is also
termed functional neck dissection.

43. CLASSIFICATION OF NECK DISSECTION
3. Selective Neck Dissection (SND) when one or more lymph node
groups are preserved during cervical lymphadenectomy that are
routinely removed with RND. The lymph node groups that are
removed are dependent on the predictable patterns of metastases
from the primary site. The levels of lymph nodes removed are
identified (e.g., SND levels I to III).
4. Extended Neck Dissection when one or more lymph node groups
or non-lymphatic structures, or both, that are not usually involved in
RND are removed. Examples of lymph node groups include the
parapharyngeal, paratracheal, and superior mediastinal nodes.
Examples of non-lymphatic structures include the carotid artery,
hypoglossal nerve, and paraspinal muscles.

44. NECK DISSECTION: TYPES OF INCISION

45. NECK DISSECTION
Incision line
Dissection through platysma
And identified facial vein

46. NECK DISSECTION
Mobilize the soft tissue along
The lower border of mandible
Exposure the lateral border of
Mylohyoid muscle

47. NECK DISSECTION
The fascia along the anterior border of
sternocleidomastoid muscle retracted
Carotid sheath expose

48. NECK DISSECTION
Dissection along the internal jugular vein
Surgical field after remove of lymph nodes

49. NECK DISSECTION
The drain secured in place Postoperative appearance

50. PROPHYLACTIC OR PREFERABLY "ELECTIVE" NECK
DISSECTION
Studies have demonstrated that occult metastasis occurs in
approximately 20-45% of patients who were clinically staged
as NO. One option is performing elective neck dissection
(END) in patients with no clinical evidence of nodal metastases.
However, this may lead to 55-80% of patients undergoing
unnecessary neck dissections, along with the associated
morbidity, particularly postoperative shoulder dysfunction.
Various techniques have been used to detect cervical occult
metastasis of the clinically negative neck like ultrasound, CT,
MRI scans, PET, PET/CT and sentinel lymph node biopsy.

51. SENTINEL LYMPH NODE BIOPSY
A handheld gamma probe.
A preoperative technetium 99m–labeled sulfur
colloid scan showing a sentinel node in the left
lower neck.

52. PROGNOSTIC VARIABLES OF NODAL METASTASIS
Primary site.
Perineural invasion.
Lymphovascular invasion.
Histopathologic grading.
T stage

53. RADIATION VERSUS SURGERY IN TREATMENT OF ORAL SCC
Surgery allows histopathologic analysis of the nodes, thus
leading to more accurate staging of the cancer and
determination of potential further treatment requirements.
The choice of treatment of the primary tumor.
If radiation therapy is used as the initial primary treatment
modality for early SCC of the oral cavity, this will exhaust its
use in the event of future recurrence.

54. RADIATION VERSUS SURGERY IN TREATMENT OF ORAL SCC
Surgical salvage for recurrent cancer in an irradiated field
can be very challenging.
Radiation therapy also has potentially significant morbidity
associated with the treatment, including osteoradionecrosis,
mucositis, xerostomia, dysphagia, subcutaneous fibrosis,
and poor wound healing This can lead to a more
prolonged and difficult recovery than occurs with END

55. POSTOPERATIVE FOLLOW UP
Postoperative visit Examination schedule
0-3 months Biweekly examination
3-12 months Monthly examination
1-2 years Examination every 2 months
2-4 years Examination every 4 months
4-5 years Examination every 6 months

56. RADIOTHERAPY
Radiotherapy can be used as a definitive
treatment or combined with other modalities,
surgery or chemotherapy. It is best at eradicating
small volumes of disease but it is more likely to
fail if there is a large bulky tumor

57. PREOPERATIVE RADIOTHERAPY
Preoperative radiotherapy is infrequently used and should
not be considered to be a standard of care. It can be
considered in some situations such as:
Fixed, inoperable neck nodes.
In situations where the initiation of postoperative
radiotherapy is likely to be delayed by more than 6-8 weeks
due to the need for extensive surgical reconstruction.
In patients who have undergone an open, incisional biopsy
of a positive neck node.

58. POSTOPERATIVE RADIOTHERAPY
It should start no later than 6 weeks after surgery.
Absolute indications for postoperative irradiation are; involved
(positive) margins at the primary tumor resection site and
extracapsular spread of involved lymph nodes.
Near absolute indications include close (less than 5 mm)
margins, two or more involved cervical lymph nodes and
invasion of the soft tissues of the neck.
The relative indications include; the presence of lymphovascular
space invasion and perineural invasion.

59. TECHNIQUES OF RADIOTHERAPY
Brachytherapy (internal radiotherapy)
Brachytherapy describes the situation in which radioactive
sources are brought close to the tumor mass (or even
implanted within it) to deliver a highly localized radiation
dose, it uses radioactive isotopes e.g., Radium, Iridium or
Radon

60. BRACHYTHERAPY

61. TECHNIQUES OF RADIOTHERAPY
Conventional (external beam or teletherapy) radiotherapy
In which abeam of radiation is directed toward the tumor
bearing part of the patient who is a distance away. It uses
photons (like X-rays or Gamma rays) or particles like protons.

62. CONVENTIONAL (EXTERNAL BEAM OR TELETHERAPY)
RADIOTHERAPY

63. TECHNIQUES OF RADIOTHERAPY
Intensity modulated radiotherapy (IMRT)
This is an advanced approach to three-dimensional
conformal radiotherapy. It optimizes the delivery of
irradiation to irregularly shaped volumes and has the ability
to treat concave volumes. IMRT uses sophisticated computer
software and hardware to vary the shape and intensity of
radiation delivered to different parts of the treatment volume

64. TECHNIQUES OF RADIOTHERAPY

65. FRACTIONATION OF RADIOTHERAPY
Since the maximum radiation in a single dose is limited by
the normal tissue tolerance, the total dose is divided into a
number of small doses (fractions):
Conventional 65 Gy (Gray) is given in protracted treatment
course of 2 Gyx 30 fractions for 42 days (conventional).
Hyperfractionation: when the number of fractions is
increased beyond the conventional levels, so the ratio of
dose/fraction is reduced. The treatment should be given 2-
3 times/day with 6 hours interval

66. FRACTIONATION OF RADIOTHERAPY
Acceleration: is reduction in overall treatment time.
Continuous hyperfractionated accelerated radiation therapy
(CHART): 12 days, 3 fractions/ day, 7 days/week. This is
given to prevent repopulation of malignant cells.
Split courses: designed to reduce the severity of mucosa!
reaction, so the radiotherapy course is divided into 2 halves
separated by 2 weeks, but this may lead to repopulation of
tumor cells so it is condemned

68. CHEMOTHERAPY
In SCC of the head and neck chemotherapy is used in
combination with radiotherapy and/or surgery in radical
treatment or alone in palliative treatment. Failure of cancer
treatment is due to inherent or acquired resistance of malignant
cells.
The main benefit is improved local control. Adjuvant
chemotherapy is not a routine management in head and neck
SCC
Chemotherapy is also considered in patients with significant
symptoms due to advanced or recurrent tumors only to
improve symptoms with short lived benefit.

69. SCHEDULING OF CHEMOTHERAPY
Before radiotherapy (Neoadjuvant or Induction).
During radiotherapy (Synchronous or Concomitant).
After radiotherapy (Adjuvant or Subsequent).
Chemotherapy can be given as a single agent with
reported response rate of 40% or in combination with
response rate of 75%.

70. CONCOMITANT CHEMORADIATION
Use of concomitant chemoradiotherapy is based on a belief
that chemotherapy synergistically acts with radiotherapy by:
Inhibiting repair of DNA damage caused by radiotherapy,
arresting cells in radiosensitive phases and possibly
preventing regrowth between radiotherapy treatments.
In addition it is thought that chemotherapy may treat
radio-resistant tumor lineages such as hypoxic cells.

71. PALLIATIVE TREATMENT AND TERMINAL CARE

72. PALLIATIVE TREATMENT AND TERMINAL CARE
Treatment is usually radical in intent; also, any salvage
treatment is aimed to cure the patient. The treatment may
progress to palliative and finally to terminal care which is a
right to every patient and duty of every health professional.
The aim of terminal care is to:
1. Make the patient free of pain.
2. Mobile.
3. Sufficiently alert.