Oral cancer management Flashcards
Diagnosis of SCC - radiology (2)
For the ‘typical’ oral cavity SCC, Radiology is not needed for diagnosis as the clinical appearance provides the most insight
-painless ventral tongue ulcer with raised, rolled edges that is indurated (hard to palpation).
Diagnosis of lump in neck or salivary glands - radiology (3)
Not all of these patients will have cancer, and imaging to separate out the benign from the malignant is readily available in all Hospitals. This is usually done with ultrasound as neck lumps are often superficial, and when combined with image-guided biopsy can produce a histological diagnosis in 1 visit.
What is the purpose of staging? (3)
to accurately define the extent of the primary cancer, including the structures that it invades into as well as those structures that might be included in the resection if surgery is performed. As well as documenting the primary tumour, spread to regional lymph nodes is also evaluated, as is distant spread outside normal anatomical bounds. The almost universal standard for cancer staging is the TNM manual
Why stage cancers? (3)
Staging cancers is an important process that helps to select the most appropriate treatment options, e.g. whether a curative or palliative route is planned and also whether surgery or chemoradiotherapy or combined treatment is thought to be best.
Staging also helps to predict prognosis as larger cancers with extensive lymph node spread have a poorer prognosis than smaller cancers without lymphadenopathy.
In cases of advanced disease, staging may spare the patient debilitating surgery that will not have any significant effect on survival.
The TNM classification: T-stage (4)
T0: no evidence of 1° tumour
T1: ≤2cm, depth of invasion (DOI) < 5mm
T2: ≤ 2cm, DOI >5mm but ≤ 10mm OR 2cm and ≤ 4cm, DOI ≤10mm
T3: > 4cm, DOI > 10mm
T4: invades deep structures e.g. bone, masticatory muscles
The TNM classification: N-stage (5)
N0: no lymph node metastases
N1: single ipsilateral node < 3cm, ENE -ve
N2a: single ipsilateral node > 3cm but < 6cm, ENE –ve
N2b: multiple ipsilateral nodes < 6cm, ENE -ve
N2c: contralateral/bilateral node(s) < 6cm, ENE -ve
N3a: any node > 6cm, ENE -ve
N3b: any node that is ENE +ve
The TNM classification: M-stage (2)
M0: no distant metastases M1: distant metastases present e.g. lung
Extra-nodal extension (ENE) (2)
Spread of carcinoma though the fibrous capsule of a lymph node into the surrounding soft tissues is termed extra-nodal extension (aka extra-capsular spread). This can be detected clinically (fixation/tethering, skin invasion, cranial nerve defects) with radiological confirmation or pathologically. ENE is a new addition to the 8th Edition of the TNM manual, but has been known for some time to confer a poor-prognosis in oral cancer.
Survival rates for mouth cancers (1)
Survival rates for mouth cancers have risen slightly over the last 20 years. Of all the people diagnosed with cancer of the mouth and oropharynx, 55% live for at least 5 years.
5-year survival for
- lip
- tongue
- oral cavity (3)
Lip: 90% survival at 5 years
Tongue: 50% survival at 5 years
Oral cavity: 47% survival at 5 years
MRI vs CT (2)
Soft tissue resolution a lot better with MRI scans - always investigation of choice
Prognosis significantly affected by.. (3)
Prognosis is significantly affected by lymph node spread - survival falls by half when comparing N0 patients to N1 patients, and again falls by half for spread to the contralateral neck (N2c). In the UK, many oral cancers still present as stage IV disease.
Staging of a pt with oral cancer and metastases (2) and tx (1)
M1 - Stage IVc
Tx will be palliative rather than curative
Distant mestastases usually occur in chest, either as spread to mediastinal LN or as lung metastases
-therefore all pts usually have some form of chest imaging in their diagnostic work up
Surveillance (4)
Continued for usually 5 years
Both surgery and radiotherapy alter the appearance of the oral cavity and neck as well as it’s texture, due to scarring, which makes the detection of cancer recurrence difficult if you rely solely on the clinical examination .
Imaging helps to identify recurrent tumour, though distinguishing the effects of treatment from cancer recurrence can be very difficult. Imaging is usually with MRI and repeated imaging using the same modality can be used to monitor suspicious sites and make serial measurements.When both the clinical examination and MRI are uncertain, positron emission tomography (PET) can be used to measure glucose metabolism – cancer cells are more metabolically-active than normal cells, which can be useful to identify a site for biopsy.
Role of the pathologist prior to treatment (1)
establish/confirm the
diagnosis; report on prognostic features
Role of the pathologist during treatment (1)
provision of frozen section
diagnosis to determine completeness of excision
Role of the pathologist after treatment (1)
determine completeness of
excision, report on factors important in prognosis & planning of further treatment.
Incisional biopsy - what are we looking at (3)
• Depth of invasion: superficial or into underlying structures? • Pattern of invasion: are the tumour islands cohesive or non- cohesive? • Degree of differentiation: well, moderately or poorly differentiated
Frozen section reporting (2)
- Determine whether the surgeon has completely excised the tumour
- If not, surgeon may remove more tissue
Why is frozen section reporting controversial? (3)
Prolongs operation
Expensive and time consuming
May not increase pt survival/ prognosis
After treatment report on (2)
Extent of spread
• primary tumour
• any tumour present in lymphatics, blood vessels &
nerves
• tumour to lymph nodes in the neck
• from nodes into the tissues of the neck (ECS)
Completeness of excision- soft tissue & bone
What are we looking at histology of tumours (3)
Surface diameter Depth of invasion Pattern of invasion: cohesive or noncohesive Distance of tumour from mucosal and deep excision margins: • >5mm = clear; • < 5mm = close; • <1/at margin- involved
Final report - primary tumour (6)
• Diameter of tumour • Depth & pattern of invasion • Clearance from deep and mucosal excision margins • Invasion into bone • Clearance of bone margins • Lymphatic, vascular or peri-neural invasion
Neck dissection - final report (4)
• Number of nodes at each level • Number containing metastasis at each level • Number showing metastatic spread at each level • pTNM
MTD meeting (3)
- Multidisciplinary Team Meeting
- Pathologist reports on completeness of excision & other factors important in prognosis
- Liaises with surgeons, oncologists, radiologists, speech therapists, dieticians and others about appropriate treatment.
