Head and Neck con’t

ORAL CAVITY CANCERS

Anatomy of the Oral Cavity:

• Hard palate
• Anterior 2/3 of the tongue
• Gingiva – tissue that surrounds base of the teeth
• Retromolar trigon
• Floor of the Mouth
• Teeth
• Lips
• Salivary Glands
• Buccal Mucosa

Epidemiology:

30% of all head and neck cancers

• 2000 cases each year
• 95% of all Oral Cavity cancers are Squamous Cell Carcinoma

Natural History:

• Most early mucosal lesions are asymptomatic and present as slightly

     elevated red lesions with ill-defined borders

• Red lesions (erythroplakia) are most likely to be cancerous.
• White lesions (leukoplakia) are present and are less likely to be malignant, but approximately 17.5% are said to become cancerous on long follow-up

Clinical Presentation

• Most patients with early disease present with a
  • Canker sore
  • Denture sore
  • Or a lump in the mouth
• Advanced lesions may be associated with
  • Bleeding
  • Pain
  • Trismus of the jaw with pain radiating to the ear may occur

Age Groups and Risk Factors:

95% of the patients are over 40 and the average age is 60

Also Males outnumber Females 2 to 1

(in females it is on the rise due to the fact that more women are smoking)

• generally found in people who use tobacco or alcohol
• if the person smoke and drinks the tobacco will intensify the effects to the area
• in general people in this group have poor hygiene
• also occurs in younger males (teens) and has been attributed to marijuana smoke
• Very common in India due to Betal Nut chewers (Oral squamous cell carcinoma in India accounts for 50% of all cancers)

Oral Cavity Cancer is usually preceded by :

• luekoplacia – whitish patches in the mouth
• erythroplasia – velvety red patches in the mouth

(these both indicate a degeneration in the mucousa and generally should be treated as cancerous tissue)

Histology:

Squamous Cell Carcinoma represents 95% of all Oral Cavity Cancers

• coverings and linings of the oral cavity
• Uncommon non-squamous cell cancers include

• Malignant tumors of the minor salivary gland, such as
  •  Adenoid cystic carcinoma
  •  mucoepidermoid carcinoma 
•   Adenocarcinoma, which are found most often in the palate, cheek mucosa, and lips.

Natural History (pathology):

1. exophytic type – grows out superficially (later metastasis than other types)
2. infiltrative type – deep extension into underlying tissue
3. ulcerative type – most common form / rapid infiltration

Prognostic Factors :

• stage

• size of lesion
• extension of node
• thickness
• vascular invasion

Surivival :

• For most Head and Neck Cancers if there is no recurrence in 2 years after cure then it will not recur!
• Survival rate is 55% in whites and 34% in blacks

SITES of ORAL CAVITY CANCER:

LIPS :

Location :

• obicularis oris – completely circular muscle
• vermillion border
• commisure of the mouth – usually a very aggressive cancer
• lower lip is most common site

Lesions of the Lower Lip:

              Early Stage Carcinoma (T1, T2, N0)

• patient can have treatment of choice (radiation or surgery)
• Surgery – might be cosmetic concerns
• Radiation (superficial/orthovoltage or electron beam)
• Electron beam – custom cutout is used
• Gum shields are placed
• Usually receive 60Gy
• Brachytherapy is another option (iridium wires that are directed only towards the primary)
• 90% survival rate for 5 years

Local or regionally Advanced Stage (T3 – T4, N0 or T3 – T4, N+)

• Must always assume nodes are involved
• Surgery and radiation (to cover nodes)
• Radiation Alone with neck node irradiation

ORAL TONGUE:

Location:

• Epithelial covered muscle covered with salivary glands
• Lateral aspect of the tongue is the most common site of cancer of the oral tongue
• Underside, blade, tip of tongue

Histology:

Squamous Cell Carcinoma

Signs and Symptoms :

Usually painless so patients do not seek attention

• Often found during a dental exam

Prognosis:

Depth of invasion is prognostically important

Stage is very important to survival:

• N0 has a 75% change of 5 year survival
• N1 and higher is 30% chance of 5 year survival
• Early detection is extremely important!!!

Radiation Therapy plays a big role in Oral Tongue Cancer:

• Surgery is not done that often because a total glosectomy would make be very uncomfortable for the patient (speech is effected)
• Partial Glosectomy is done
• Most patients receive BrachyTherapy to the Oral Tongue
  • Iodine 125 or Irridium 192 is temporarily placed in the tongue
  • HDR is often used because LDR would be uncomfortable for the patient
• 70 Gy (cannot just use External Beam because you would damage the mandible
• Some External Beam can be used
• Bite block is used to position the tongue
• Field angles 3 fields through the mouth
• Must catch the nodes in field