Diagnosis and Surgical Management of Oral Cancer

Question 1

Oral cancers are part of a group of cancers commonly referred to as head and neck cancers,
and they comprise about –% of that category.

Answer 1

85

Question 2

Oral cancer can develop in

Answer 2

any part of the oral cavity or the oropharynx

Question 3

Origin of Malignancies in the Oral Cavity
(4)

Answer 3

• Epithelium:
• Connective Tissue:
• Salivary Gland:
• Metastatic disease:

Question 4

• Epithelium:

Answer 4

“90% of oral cancer cases is Squamous cell carcinoma” and they arise in
epithelial surface layer of oral mucosa.

Question 5

• Connective Tissue:

Answer 5

Sarcomas account for 2% of oral cancer cases. For e.g. Osteosarcoma,
Chondrosarcoma, Ewings sarcoma, Kaposi’s sarcoma, Lymphoma etc.,

Question 6

• Salivary Gland:

Answer 6

Accounts for 4 to 8% of oral cancer cases. For e.g. Mucoepidermoid carcinoma,
Adenoid cystic carcinoma, Adenocarcinoma, Acinic cell carcinoma etc.,

Question 7

• Metastatic disease:

Answer 7

Accounts for less than 1%, of oral cancer cases. Most originate from common
primary sites including lung, kidney, skin (melanoma), prostate in men and breast in women. Metastatic to
Mandible and occasionally soft tissues i.e to gingiva or tongue.

Question 8

“—” is the most common oral malignancy that accounts for –%
of all Oral cancers).

Answer 8

Squamous cell carcinomas
90

Question 9

• Lip - –%
• Tongue - –%
• Floor of the Mouth - –%
• Palate/tonsil - –%
• Gingiva - –%
• Other - –%

Answer 9

38
22
17
11
6
6

Question 10

The Importance of Oral Cancer Screening

Answer 10

• Early diagnosis, prompt referral and appropriate treatment is critical for favourable
  long term prognosis and survival of patients with oral cancer

Question 11

he Spread of Oral Squamous Cell Carcinoma
Local Invasion

Answer 11

Squamous cell carcinoma of the oral cavity first grows locally by progressive infiltration,
invasion and destruction of the surrounding tissue leaving them poorly demarcated

Question 12

Squamous cell carcinoma of the oral cavity first grows locally by progressive infiltration,
invasion and destruction of the surrounding tissue leaving them poorly demarcated.
* Important to local extension is the …
* Muscle is easily invaded while periosteum offers a …

Answer 12

anatomic location of the tumor and the adjacent tissues next to
the tumor.
good barrier to invasion.

Question 13

The Spread of Oral Squamous Cell Carcinoma
Regional Spread through Lymphatic Spread
As the tumor progresses,

Answer 13

the oral cancer spreads to the regional lymph nodes of the neck through the
lymphatic channel.

This is the most important and most frequent pathway for the spread of oral squamous cell
carcinoma.

Question 14

The Spread of Oral Squamous Cell Carcinoma
Regional Spread through Lymphatic Spread

Answer 14

• The cancer invades the local lymphatic supply and travels to the regional lymph node(s)
  draining the site.
• Usually oral squamous cell carcinoma spreads to the ipsilateral cervical lymph nodes i.e lymph
  nodes on the same side of the neck as the cancer.
• The lymph node containing the tumor cells is typically firm to stony hard (Indurated), non-
  tender and enlarged.
• Lymph nodes are freely movable at first but as the tumor breaks through the capsule, the node
  becomes fixed.
• Lymphadenopathy does not indicate metastasis for certain as it can result from inflammation
  associated with the presence of tumor also.

Question 15

The Spread of Oral Squamous Cell Carcinoma
Distant Metastasis Through Hematogenous Spread
* In the later stages of the disease process, the tumor …

Answer 15

spreads into the vascular channel
(hematogenous metastasis) and may seed other parenchymal sites if tumor invasion is not
controlled at the lymphatic level.

Question 16

• The usual sites of secondary spread (distant metastases) include the (5)

Answer 16

lungs, liver, bone, brain, and
adjacent skin, as well as other sites, depending on the tumor histology

Question 17

Oral Cancer – Diagnosis and Workup
(6)

Answer 17

• Health History
• Detailed Patient History
• Head and Neck examination
• Imaging Studies - Radiographs, CT Scan/MRI exam, Bone Scan, PET Scan
• Biopsy
• Staging and Grading of Oral cancer

Question 18

Health History

Answer 18

• It is important to evaluate the medical status of the patient in detail before
  finalizing a surgical treatment plan.

Question 19

Detailed Patient History - Signs and Symptoms
(9)

Answer 19

• Painless lump or ulcer (in the early stages)
• Posteriorly no symptom until it reach a size of 2-3 cm swelling then manifests as dysphagia
• Ear pain
• Difficulty in moving the jaw or tongue
• Hoarseness
• Paraesthesia (Tongue, lip etc.,)
• Swelling
• Non healing ulcer
• Absence of symptoms until the tumor metastasize to regional lymph nodes (hard lump on the
  neck)

Question 20

Indirect Laryngoscopy

Answer 20

• As patients diagnosed with oral cancer are also at increased risk for other head and
  neck cancers, it is important to examine other areas of the throat for any additional
  tumor process,

Question 21

Oncologic Lymph Node Levels Of The Neck
Level I -
Level II -
Level III -
Level IV -
Level V -

Answer 21

Submental/submandibular nodes
Upper jugular nodes
Middle jugular nodes
Lower jugular nodes
Posterior triangle nodes

Question 22

The Lymphatic Spread of Tumor is Orderly and Logical
* Lymphatic spread usually occurs first in the
* The most commonly involved node in case of oral and pharyngeal cancer is the

Answer 22

uppermost, then middle and finally the
lower cervical lymph nodes.

subdigastric (juglo-digastric) lymph nodes.

Question 23

Examination of the Lymph nodes of the Neck
(5)

Answer 23

*Location
*Size(< measured in cm >)
*Tenderness
*Consistency(soft, firm or Hard)
*Mobility(mobile or fixed)

Question 24

Palpation of the Lymph Nodes of the Neck
* Finding a palpable lymph node is helpful in the management of the

Answer 24

cancer
patient but it is not diagnostic of metastatic tumor.

Question 25

Occult Metastasis of Primary Tumor to Neck Lymph Nodes * It is important to be aware of the phenomena of “Occult Metastasis “ of the primary oral cancer into the Lymph nodes of the neck. * In this case

Answer 25

you will not be able to detect any lymph node enlargement by routine clinical and radiographic examination. However, there is microscopic metastasis of the oral squamous cell carcinoma from the oral cavity into the neck.

Question 26

Occult Metastasis of Primary Tumor to Neck Lymph Nodes * In patients with Oral Squamous cell carcinoma, the phenomena of occult metastasis occurs at rate of - --% of the floor of mouth lesions - --% of the tongue lesions - --% of the gingival lesions - --% of the tongue lesions - --% of the lesions of the hard palate - --% of the lesions of the buccal mucosa

Answer 26

20-35 38-52 17 38-52 22 16

Question 27

Therefore, in order to minimize the risk of tumor recurrence, the surgeons perform a

Answer 27

prophylactic neck dissection to remove some of the most commonly associated lymph nodes in the neck along with surgical resection of the primary tumor.

Question 28

Likely sites of involved cervical lymph nodes from the spread of primary head/neck SCC Primary Site (2)

Answer 28

– Lower lip – Floor of the Mouth – Posterior mouth – Oropharynx

Question 29

Site of Metastasis (4)

Answer 29

– Submental nodes – Submental nodes – Superior jugular/digastric – Jugulo-digastric chain or retropharyngeal nodes

Question 30

Radiographic Examination - Panorex Useful in cases of

Answer 30

bony involvement or to rule out any bony involvement - Panoramic views shows lytic lesions

Question 31

C.T.Scan with I.V contrast (Level: From base of skull to clavicles) C.T Scans help with

Answer 31

precise delineation of the tumor extent and thus provides valuable information about the size, shape and position of any tumors.

Question 32

CT Scans with contrast also help reveals

Answer 32

enlarged lymph nodes suggestive of metastatic adenopathy (seen on C.T.Scan as enhancement of the nodal capsule).

Question 33

C.T Scans also helps us evaluate adjacent

Answer 33

bony structures and erosions involving the paranasal sinuses, base of skull and the cervical spine

Question 34

Magnetic Resonance Imaging (MRI) * MRI is less commonly used as it is less precise than CT scan in identifying tumor necrosis and extracapsular spread, but MRI is better in assessing

Answer 34

enlarged lymph nodes that do not necessarily represent metastasis. * However, MRI gives a better resolution for soft tissue tumors.

Question 35

Limitations of C.T.Scan and MRI

Answer 35

* Both C.T.Scan and MRI cannot detect lymph nodes smaller than 1 cm. which, on occasion, independently of the size, are involved in metastasis (Occult Metastasis)

Question 36

Management of Oral Cancer Additional Investigations (4)

Answer 36

* Bone scan * PET (Positron Emission Tomography) Scan * Chest X-ray; if abnormal, then CT Scan of Chest must be examined * Liver Function test

Question 37

Bone Scan * In a patient with squamous cell carcinoma of the oral cavity, it is important to determine the extent of

Answer 37

bone involvement of the tumor process. Bone scans are highly sensitive in detecting earlier changes in the bone.

Question 38

* Bone invasion is considered positive when bone scans reveal an asymmetrical or increased activity in the area of jaw bone which corresponded to the

Answer 38

clinical site of the primary tumor. Thus, they help clinicians with preoperative evaluation of any evident tumor infiltration of bone.

Question 39

* Although the Bone scans lack anatomical definition, they are useful in planning treatment for a patient with

Answer 39

oral cancer planning treatment for a patient with oral cancer.

Question 40

PET (Positron Emission Tomography) Scan * PET provides information about the * Positron emission tomography (PET) has been used to assist in the diagnosis of * A minimal amount of tumor tissue must be present for the finding to be positive. Thus, precision of PET is limited to about -- mm.

Answer 40

metabolic activity of the tissues. lymph node metastasis or spread of tumor to other parts of the body. 5

Question 41

Purpose and Principles of TNM Staging System of Malignant Tumors * Once all clinical and imaging information is collected, the tumor can be accurately staged based on

Answer 41

AJCC (American Joint Committee on Cancer) -TNM classification.

Question 42

The --- is the most widely used cancer staging system in the world

Answer 42

TNM system

Question 43

The TNM staging is very useful in facilitating discussion about the

Answer 43

type of malignant tumor that the patient has between clinicians.

Question 44

Purpose and Principles of TNM Staging System Staging looks at the size and depth of the cancer (tumor) and whether it has spread anywhere else in the body.

Answer 44

As the primary tumor (T) increases in size over time, local invasion occurs followed by Spread to the regional lymph nodes (N) draining the area of the tumor followed by Spread to other parts of the body i.e Distant Metastasis (M) T - the size and depth of the primary tumor N - whether the cancer has spread to the lymph nodes M - whether the cancer has spread to another part of the body i.e distant metastases

Question 45

The TNM system is an expression of the anatomic extent of disease and is based on the assessment of three components:

Answer 45

T The extent of the primary tumor. N The absence or presence including extent of regional lymph node metastasis. M The absence or presence of distant metastasis

Question 46

The use of numerical subsets of the TNM components indicates the

Answer 46

progressive extent of the malignant disease i.e to determine how early or advanced the cancer is..... - T0, T1, T2, T3, T4, - N0, N1, N2, N3, - M0, M1.

Question 47

Primary Tumor Indicated by the letter “--” and the suffix --- represent more advancing disease

Answer 47

T 1,2, 3 or 4

Question 48

TX

Answer 48

Primary tumor cannot be assessed

Question 49

T0

Answer 49

No evidence of primary tumor

Question 50

Tis

Answer 50

Carcinoma in situ

Question 51

T1

Answer 51

Tumor 2 cm or less in greatest dimension (Tumor < 2cm)

Question 52

T2

Answer 52

Tumor more than 2 cm but not more than 4 cm in greatest dimension (Tumor 2 to 4 cm)

Question 53

T3

Answer 53

Tumor more than 4 cm in greatest dimension (Tumor > 4 cm)

Question 54

T4

Answer 54

Tumor invades deep adjacent structures (e.g., through cortical bone, inferior alveolar nerve, floor of mouth, skin of face)

Question 55

Regional Lymph Nodes (N) Is used to describe

Answer 55

progressive lymph node involvement

Question 56

N0

Answer 56

Regional lymph nodes cannot be assessed (N0 - No palpable nodes)

Question 57

N1

Answer 57

Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension (N1 — single ipsilateral node ≤ 3cm)

Question 58

N2a

Answer 58

Metastasis in single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension (N2A— single ipsilateral node 3 to 6 cm)

Question 59

N2b

Answer 59

Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension (N2B— multiple ipsilateral nodes ≤ 6cm)

Question 60

N2c

Answer 60

Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension (N2C— contralateral or bilateral nodes ≤ 6cm)

Question 61

N3

Answer 61

Metastasis in a lymph node more than 6 cm in greatest dimension (N3 — node > 6cm)

Question 62

Distant Metastasis (M) M describes

Answer 62

whether the cancer has spread to a different part of the body.

Question 63

MX

Answer 63

Distant metastasis cannot be assessed

Question 64

M0

Answer 64

No distant metastasis - Means the cancer has not spread to other parts of the body

Question 65

M1

Answer 65

Distant metastasis - Means cancer has spread to other parts of the body such as the lungs liver, bone, brain, adjacent skin etc.,

Question 66

American Joint Committee on Cancer (AJCC) staging system * The AJCC staging system is a classification system developed by the American Joint Committee on Cancer. * It utilizes * It acts as a guide to appropriate treatment and prognosis.

Answer 66

in part the TNM scoring system and is used to describe the amount and spread of cancer in a patient’s body.

Question 67

American Joint Committee on Cancer (AJCC) Staging System * Stage I

Answer 67

T1, N0, M0

Question 68

American Joint Committee on Cancer (AJCC) Staging System * Stage II

Answer 68

T2, N0, M0

Question 69

American Joint Committee on Cancer (AJCC) Staging System * Stage III

Answer 69

T3, N0, M0 T1, N1, M0 T2, N1, M0 T3, N1, M0

Question 70

American Joint Committee on Cancer (AJCC) Staging System * Stage IVA

Answer 70

T4, N0, M0 T4, N1, M0 Any T, N2, M0

Question 71

American Joint Committee on Cancer (AJCC) Staging System * Stage IVB

Answer 71

Any T, N3, M0

Question 72

American Joint Committee on Cancer (AJCC) Staging System * Stage IVC

Answer 72

Any T, Any N, M1

Question 73

Stage I Cancer

Answer 73

This is tumor of small size (Tumor 2 cm or less in greatest dimension) that has not grown deeply into nearby tissues and has not spread to the lymph nodes or other parts of the body. It is often called locallized or early stage cancer

Question 74

5 year survival rate is --% for Stage I Cancer

Answer 74

85

Question 75

Stage II Cancer

Answer 75

This is a operable primary tumor (2 cm to 4 cm or less in greatest dimension) that has not grown deeply into nearby tissues and has not spread to the lymph nodes or other parts of the body.

Question 76

5 year survival rate is --% for Stage II Cancer

Answer 76

66

Question 77

Stage III Cancer T3, N0, M0 -

Answer 77

The oral tumor is larger than 4 cm across, has not grown deeply into nearby tissues and has not spread to the lymph nodes or other parts of the body

Question 78

Stage III Cancer T1 toT3, N0, M0 -

Answer 78

The oral tumor is any size but has not grown into nearby adjacent structures or spread to distant sites in the body. However, cancer cells are present in one lymph node, which is located on the same side of the head or neck as the primary tumor and is smaller than 3 cm across.

Question 79

5 year survival rate is --% for Stage III Cancer

Answer 79

35-45

Question 80

TNM Clinical Stage IV Cancer

Answer 80

In this situation, the cancer has reached an advanced stage and in stage IVC has distant metastasis

Question 81

5 year survival rate is --% for Stage IV Cancer

Answer 81

9

Question 82

What is Tumor Grading? * Tumor grading is not the same as the TNM staging system of a cancer. * Staging is ...

Answer 82

determining the progression or spread of tumor in the body. However, tumor Grading looks at the tumor cell differentiation and rate of growth under microscopic examination.

Question 83

* In tumor grading,

Answer 83

the pathologist carries out the description of a tumor based on how abnormal the tumor cells are. Grading helps the pathologist determine if there is a degree of dysplastic changes in the tumor and also helps us know how quickly a tumor is likely to grow and spread.

Question 84

Tumor Grading of Squamous Cell Carcinoma Histopathological Grading:

Answer 84

Tumors are graded as 1, 2, 3, or 4, depending on the amount of abnormality

Question 85

Gx: G1: G2: G3: G4:

Answer 85

Grade of differentiation cannot be assessed (undetermined grade) Well differentiated (Low Grade) Moderately well differentiated (intermediate grade) Poorly differentiated (High Grade) Undifferentiated (High Grade)

Question 86

How does tumor grade affect a patient’s treatment options? In Grade 1 tumors, the tumor cells and the organization of the tumor tissue appear close to normal. These tumors tend to grow and spread slowly and indicates a better prognosis. In contrast, the cells and tissue of Grade 3 and Grade 4 tumors do not look like normal cells and tissue and tend to grow rapidly and spread faster and may require immediate or more aggressive treatment. Clinicians use a combination of the (4), to develop a treatment plan and to determine a patient’s prognosis

Answer 86

tumor grade, TNM staging and a patient’s age and general health

Question 87

Definitive Diagnosis of Oral Cancer Biopsy This is the mainstay of tumor diagnosis coupled with high degree of suspicion Incisional Biopsy (3)

Answer 87

- Small portion of the lesion with the adjacent normal tissues to facilitate correct diagnosis. - To visualize the transitional zone between tumor and normal tissue. - Performed at the periphery to avoid the necrotic central area.

Question 88

Biopsy Result

Answer 88

* If your clinical impression does not match the Histopathological diagnosis, then the biopsy procedure must be repeated.

Question 89

Management of Oral Cancer (4)

Answer 89

* Surgery * Radiation * Chemotherapy * Combination Treatment

Question 90

Oral Cancer – Surgical Management (3)

Answer 90

* Surgical resection of Primary tumor * Neck dissection * Surgical reconstruction

Question 91

Surgical Management of Oral Cancer Management of Primary Tumor En bloc resection:

Answer 91

Removal of the Primary tumor along with a cuff of normal tissue around it. 1-2 cm safety margins around tumor tissue

Question 92

Surgical Management of Oral Cancer (4)

Answer 92

Management of Primary Tumor Surgical Management of The Neck Lymph Nodes Functional reconstruction including restoration of esthetics Concurrent Chemotherapy and radiation treatment

Question 93

Surgical Management of The Neck Lymph Nodes

Answer 93

Neck dissection

Question 94

Squamous Cell Carcinoma - Lateral border of tongue TNM Grading Surgical Treatment :

Answer 94

Partial Glossectomy + with Radical Neck Dissection

Question 95

Marginal Resection If cancer has spread into bone, surgery may include removal of the involved bone tissue of the maxilla or mandible. Marginal Resection: Indication:

Answer 95

Resection of a tumor without disruption of the continuity of the bone This type of surgical procedure is performed in patients who have advanced primary tumors adjacent to the mandible.

Question 96

Partial Resection Partial Resection: Indication:

Answer 96

Resection of a tumor by removing full-thickness portion of the jaw. In this situation, the jaw continuity is disrupted. In the mandible, this can vary from a small continuity defect to a hemimandibulectomy. This type of surgical procedure is performed in patients who have advanced tumors that frankly invade the mandible extensively.

Question 97

Partial resection of the Mandible Partial Resection: Indication:

Answer 97

Resection of a tumor by removing full-thickness portion of the jaw. In this situation, the jaw continuity is disrupted. This type of surgical procedure is performed in patients who have advanced tumors that frankly invade the mandible extensively.

Question 98

Total Resection (2)

Answer 98

* Resection of a tumor by removal of the involved bone. * Eg., Hemi-Maxillectomy and Hemi-Mandibulectomy

Question 99

Management of Oral Cancer Neck Dissection

Answer 99

* Lymphatic metastasis to the neck is the most important mechanism of spread of Oral cavity squamous cell carcinoma from primary sites. * The risk of lymph node involvement by metastasis varies depending on the site of origin, size of primary tumor, histologic grade of the primary tumor, perineural invasion, perivascular invasion, and extracapsular spread. * The most important factor in prognosis of Squamous cell carcinoma involving the oral cavity is the status of cervical lymph nodes. * Lymph node metastasis reduces the survival rate of patients with squamous cell carcinoma by half. * Therefore, Neck dissections are performed in the hope of controlling metastatic cancer within cervical lymph nodes from primary cancers in the head and neck region.

Question 100

Management of Oral Cancer Neck Dissection - Indications

Answer 100

* Clinically palpable or radiographic evidence of metastasic submandibular and cervical lymph nodes. * There is secondary involvement of the neck from squamous cell carcinoma of anterior part of the tongue, buccal mucosa and gingiva which gives rise to cervical lymph node metastasis in 30% to 40% of the cases, * There is secondary involvement of the neck from squamous cell carcinoma of of the posterior tongue and hypopharynx which gives rise to cervical lymph node metastasis in 50% to 60% of the cases

Question 101

Surgical Management of Oral Cancer Why is Neck Dissection so critical? * A single ipsilateral metastatic lymph node reduces survival by --%. * A single contralateral metastatic lymph node reduces survival by --%. * Extra-nodal spread reduces survival a further --%.

Answer 101

50 50 50

Question 102

Neck Dissection - Classification The RND is classified according to the Academy’s Committee for Head and Neck Surgery & Oncology into four major types: (3)

Answer 102

1. Radical Neck Dissection (RND) 2. Modified Radical Neck Dissection (MRND) 3. Selective Neck Dissection (SND)

Question 103

Neck Dissection (3)

Answer 103

* Radical Neck Dissection * Modified (functional) Neck Dissection * Selective (functional) Neck Dissection

Question 104

* Modified (functional) Neck Dissection (4)

Answer 104

- Preservation of at least one of the following: - Cranial Nerve XI (Spinal Accessory Nerve) - SCM (Sternocleido Mastoid Muscle) - IJV (Internal Jugular Vein)

Question 105

* Selective (functional) Neck Dissection (2)

Answer 105

- Not all lymph node regions dissected for e.g - Supraomohyoid neck dissection

Question 106

Management of Oral Cancer Adjuvant Therapy

Answer 106

* Additional cancer treatment like Chemotherapy and Radiation treatment after surgery in order to lower the risk of recurrence is called as adjuvant therapy

Question 107

Reconstruction of Oral Cavity Defects following Surgical Resection of Oral Cancer - Rationale * To Restore the:

Answer 107

* Form of the Maxilla and mandible – Maintain correct anatomical relation to the jaws – Important for dental rehabilitation (endosseous implant placement) * Function - Mastication - Speech * Aesthetics

Question 108

Reconstruction of Oral Cavity Defects following Surgical Resection of Oral Cancer (4)

Answer 108

* Soft Tissue Reconstruction * Hard Tissue Reconstruction * Soft and Hard Tissue Reconstruction * Functional Reconstruction including Dental Implant Treatment

Question 109

Soft Tissue Reconstruction (6)

Answer 109

* Primary closure * STSG(Split Thickness Skin Graft)/ dermal graft * Local flaps – Mucosal or skin * Regional flaps * Myocutaneous flaps * Free flaps with microvascular anastomosis

Question 110

Hard Tissue Reconstruction (5)

Answer 110

* No reconstruction * Irradiated bone * Pedicled vascularized flap * Free flap - vascularized bone with microvascular anastomosis * Osteointegrated titanium implants (Functional Reconstruction)

Question 111

Microvascular Flaps Used for Reconstruction of Defects of the Oral Cavity ((4)

Answer 111

* Radial Forearm Flap * Ileum * Scapula * Fibula

Question 112

Oral Cancer - Post-treatment follow-up intervals * Every -- for the first year * Every -- for the second year * Every -- for the third year * Every -- thereafter for life

Answer 112

6-8 weeks 2-3 months 3-4 months 6-12 months