Dr V.RAMKUMAR

CONSULTANT DENTAL&FACIOMAXILLARY SURGEON

REG NO:4118 TAMILNADU-INDIA(ASIA)

INTRODUCTIONINTRODUCTION

The word “cancer” derives from the The word “cancer” derives from the Latin for crab as it adheres to any Latin for crab as it adheres to any part that it seizes upon in an part that it seizes upon in an obstinate manner like the crab. obstinate manner like the crab.

DefinitionDefinition

It is an abnormal mass of tissue, the It is an abnormal mass of tissue, the growth of which exceeds and is growth of which exceeds and is uncoordinated with that of normal uncoordinated with that of normal tissue and persists in the same tissue and persists in the same excessive manner even after excessive manner even after cessation of the stimuli which evoked cessation of the stimuli which evoked the change. (British Oncologist Sir the change. (British Oncologist Sir Rupert Willis).Rupert Willis).

Over 90% of the malignant Over 90% of the malignant neoplasms of the oral cavity are neoplasms of the oral cavity are squamous cell carcinomas.squamous cell carcinomas.

Rest are adeno carcinomas of minor Rest are adeno carcinomas of minor salivary glands and secondaries.salivary glands and secondaries.

Oral cancer is one of the ten most Oral cancer is one of the ten most common causes of death worldwide.common causes of death worldwide.

EPIDEMIOLOGYEPIDEMIOLOGY

Oral cancer accounts for about 40 – Oral cancer accounts for about 40 – 50% of all malignant tumors in Indian 50% of all malignant tumors in Indian sub-continent.sub-continent.

4% in UK & USA.4% in UK & USA.

EPIDEMIOLOGYEPIDEMIOLOGY

Age & Sex: Age & Sex:

98% -r the age of 4098% -r the age of 40

more common in men than in more common in men than in females,females,

due to average increase in lifespan due to average increase in lifespan the incidence rises steeply with age the incidence rises steeply with age and will become more common in and will become more common in aging population.aging population.

ETIOLOGYETIOLOGY

Causative factors operate over a long Causative factors operate over a long period & the process of malignant change period & the process of malignant change is slow & there is a prolonged lag period is slow & there is a prolonged lag period before actual disease appear.before actual disease appear.

Etiological factors:Etiological factors: i) possible carcinogens: i) possible carcinogens: # Tobacco use –# Tobacco use – * cigarette smoking * cigarette smoking * pipe smoking* pipe smoking * smokeless tobacco * smokeless tobacco

# Betel nut & Leaf chewing –# Betel nut & Leaf chewing – * paan, quid, khaini, misri, * paan, quid, khaini, misri, gutka, snuff etc.gutka, snuff etc. # Alcohol # Alcohol ii) Sunlightii) Sunlight iii) Pre-cancerous lesions:iii) Pre-cancerous lesions: - leukoplakia- leukoplakia - erythroplakia- erythroplakia - lichen planus- lichen planus - syphilis- syphilis - oral submucous fibrosis- oral submucous fibrosis - oral hairy leukoplakia- oral hairy leukoplakia

iv) Infections :iv) Infections : Viruses – Viruses – HSV, HPV (TYPES 16/18)HSV, HPV (TYPES 16/18) they induce p53 gene mutationsthey induce p53 gene mutations Chronic candidiasisChronic candidiasis Syphillitic ulcerSyphillitic ulcerv) Genetic disorders:v) Genetic disorders: - dyskeratosis congenita- dyskeratosis congenita - Fanconi’s anemia- Fanconi’s anemiavi) Malnutrition:vi) Malnutrition: - vitamin A deficiency - vitamin A deficiency - Patterson-Kelly syndrome (Iron deficiency)- Patterson-Kelly syndrome (Iron deficiency)vii) Oral sepsis:vii) Oral sepsis:viii) Immunosuppressed patients:viii) Immunosuppressed patients: - AIDS/HIV, TB etc. - AIDS/HIV, TB etc.

Sites of Oral Cancer:Sites of Oral Cancer:

- - lower lip & posterolateral part of lower lip & posterolateral part of tonguetongue

are the most common sites.are the most common sites.

- majority - concentrated in the lower - majority - concentrated in the lower part of the mouth - lateral borders of part of the mouth - lateral borders of the tongue, floor of the mouth, lingual the tongue, floor of the mouth, lingual aspect of the alveolar margin and aspect of the alveolar margin and posteriorly oropharynx.posteriorly oropharynx.

- other sites - lip, tongue, gingiva, - other sites - lip, tongue, gingiva, alveolar ridge, buccal mucosa, palate, alveolar ridge, buccal mucosa, palate, antrum.antrum.

DOTTED AREA – MORE PRONE TO SCC – Floor of mouth, Tongue, tonsillar pillars & lateral soft palate.

SIGNS & SYMPTOMSSIGNS & SYMPTOMS

Initial asymptomatic Initial asymptomatic Discomfort, Dysphagia, odynophagia, otalagia, Discomfort, Dysphagia, odynophagia, otalagia,

limited movements of tongue.limited movements of tongue. Pain & bleeding due to secondary infections.Pain & bleeding due to secondary infections. Loss of weight, anemia, deterioration of general Loss of weight, anemia, deterioration of general

health, malignant cachexia.health, malignant cachexia. Early cancer presents with a asymptomatic red or Early cancer presents with a asymptomatic red or

white lesion and a small indurated lump or erosion white lesion and a small indurated lump or erosion or ulceration.or ulceration.

Later carcinomas appear as ulcers with prominent Later carcinomas appear as ulcers with prominent rolled edges and induration which may become rolled edges and induration which may become painful.painful.

LYMPH NODESLYMPH NODES LYMPHATIC SPREAD of oral carcinoma usually LYMPHATIC SPREAD of oral carcinoma usually

involves the submandibular, digastric and involves the submandibular, digastric and cervical lymph nodes which may become cervical lymph nodes which may become enlarged, firm to hard in texture, non-tender enlarged, firm to hard in texture, non-tender unless associated with secondary infection.unless associated with secondary infection.

Fixation of nodes to adjacent tissue, Fixation of nodes to adjacent tissue, overlying bone suggests involvement of overlying bone suggests involvement of periosteum or bone.periosteum or bone.

Spread of tumor is critical for prognosis and Spread of tumor is critical for prognosis and selection of treatment.selection of treatment.

PATHOLOGICAL CHANGESPATHOLOGICAL CHANGES The essential features of carcinoma is invasion of The essential features of carcinoma is invasion of

surrounding tissues by malignant epithelial cells.surrounding tissues by malignant epithelial cells. Invading cells grow into tissues forming irregular Invading cells grow into tissues forming irregular

branching processes and islands of tumors.branching processes and islands of tumors. In more infiltrative high grade carcinomas single In more infiltrative high grade carcinomas single

cell and small cluster of cells detach along the cell and small cluster of cells detach along the invasive front of the lesion.invasive front of the lesion.

Tumors cells invade deeper tissues like muscle, Tumors cells invade deeper tissues like muscle, fat, nerves and eventually bone are infiltrated fat, nerves and eventually bone are infiltrated and destroyed.and destroyed.

Invading cancer cells exert inflammatory reaction Invading cancer cells exert inflammatory reaction and become surrounded by lymphocytes and and become surrounded by lymphocytes and plasma cells.plasma cells.

Cont…Cont…

Squamous cell carcinomas are graded Squamous cell carcinomas are graded according to the degree of differentiation, according to the degree of differentiation, that includes, changes in cell size, that includes, changes in cell size, morphology, increased mitotic figures, morphology, increased mitotic figures, hypochromatism, alteration in normal hypochromatism, alteration in normal cellular orientation and maturation.cellular orientation and maturation.

Degree of differentiation are:Degree of differentiation are: - Well differentiated- Well differentiated - Moderately differentiated- Moderately differentiated - Poorly differentiated- Poorly differentiated

MOLECULAR CHANGESMOLECULAR CHANGES

Carcinogenesis is a genetic process that leads to Carcinogenesis is a genetic process that leads to change in morphology and cellular behaviour.change in morphology and cellular behaviour.

Major genes involved in head & neck squamous Major genes involved in head & neck squamous cell carcinoma are PROTO-ONCOGENES, TUMOR cell carcinoma are PROTO-ONCOGENES, TUMOR SUPPRESSOR GENES, epigenetic changes such as SUPPRESSOR GENES, epigenetic changes such as DNA METHYLATION or HISTONE DE-ACETYLATION.DNA METHYLATION or HISTONE DE-ACETYLATION.

Others – cytokine growth factors, angiogenesis, Others – cytokine growth factors, angiogenesis, cell adhesion molecules, immune function.cell adhesion molecules, immune function.

Proto-oncogenes : RAS (rat sacrcoma), cyclin D1, Proto-oncogenes : RAS (rat sacrcoma), cyclin D1, myc, erb-B, blc-1, blc-2, int-2, ck-8 and ck-19.myc, erb-B, blc-1, blc-2, int-2, ck-8 and ck-19.

SPREAD OF CARCINOMASPREAD OF CARCINOMA

Carcinoma spreads by direct invasion.Carcinoma spreads by direct invasion. Metastatic spread by lymphatics to Metastatic spread by lymphatics to

regional lymph nodes.regional lymph nodes. Submandibular and jugulodigastric lymph Submandibular and jugulodigastric lymph

nodes are frequently involved.nodes are frequently involved. Ca. of lip and floor of the mouth spread Ca. of lip and floor of the mouth spread

bilaterally.bilaterally. Tip of the tongue - submental - jugulo-Tip of the tongue - submental - jugulo-

omohyoid.omohyoid. Dorsum and lateral parts of the tongue – Dorsum and lateral parts of the tongue –

submandibular lymph nodes – jugulo-submandibular lymph nodes – jugulo-digastric lymph nodes.digastric lymph nodes.

Regional lymph nodesRegional lymph nodes

PATTERNS OF LYMPHATIC SPREAD

PROGNOSISPROGNOSIS

American Joint Committee on Cancer (AJCC): American Joint Committee on Cancer (AJCC): - has developed tumor, node, metastasis - has developed tumor, node, metastasis

(TNM) system of cancer classification.(TNM) system of cancer classification. - it is principally a clinically description of - it is principally a clinically description of

disease.disease. TNM Staging:TNM Staging: T – size of primary tumorT – size of primary tumor N – indicates presence of tumor N – indicates presence of tumor in lymph nodein lymph node M – distant metastasisM – distant metastasis

TNM classificationTNM classification T1s: Carcinoma in situT1s: Carcinoma in situ T1 < 2cmT1 < 2cm T2 > 2cm < 4cmT2 > 2cm < 4cm T3 > 4cmT3 > 4cm T4 > 4cm with invasion of adjacent structures.T4 > 4cm with invasion of adjacent structures.

N0 no node involvementN0 no node involvement N1 single ipsilateral node < 3cmN1 single ipsilateral node < 3cm N2a single ipsilateral node < 6cmN2a single ipsilateral node < 6cm N2b multiple ipsilateral > 3cm < 6cmN2b multiple ipsilateral > 3cm < 6cm N2c bilateral or contralateral < 6cmN2c bilateral or contralateral < 6cm N3a ipsilateral more than > 6cmN3a ipsilateral more than > 6cm N3b bilateal more > 6cmN3b bilateal more > 6cm

Mo no known metastasisMo no known metastasis M1 metastasis presentM1 metastasis present

TNM – LYMPH NODAL CLASSIFICATION

Staging:Staging:

# Stage I: T1 N0 M0# Stage I: T1 N0 M0 # Stage II: T2 N0 M0# Stage II: T2 N0 M0 # Stage III: T3 N0 M0;# Stage III: T3 N0 M0; T1, T2 or T3 N1 M0T1, T2 or T3 N1 M0 # Stage IV: T4 any N M0# Stage IV: T4 any N M0 any T N2 or N3 M0any T N2 or N3 M0 any T or N with M1any T or N with M1

The staging system has combined The staging system has combined the T, N & M to classify the lesions as the T, N & M to classify the lesions as stages I to IV.stages I to IV.

There be may difference in biology There be may difference in biology and response to treatment between and response to treatment between a stage III tumor i.e classified as T1 a stage III tumor i.e classified as T1 N1 M0 & a stage III tumor which is T3 N1 M0 & a stage III tumor which is T3 N0 M0.N0 M0.

INVESTIGATIONSINVESTIGATIONS

IMAGING:IMAGING: Routine radiology - OPG, PNS view etcRoutine radiology - OPG, PNS view etc CT, MRICT, MRI UltrasonographyUltrasonography Nuclear scinti scanning – gives evidence Nuclear scinti scanning – gives evidence

of bone involvement of tumor and bony of bone involvement of tumor and bony necrosis following radiotherapy.necrosis following radiotherapy.

BIOPSY:BIOPSY:

Incision, ExcisionIncision, Excision FNAFNA Acridine – binding method.Acridine – binding method. Oral screening – Oral screening –

exfoliative cytologyexfoliative cytology

toludine blue testtoludine blue test