Examination. PMDs & Oral cancer. Examination. History taking. Potentially malignant disorders. Review of the patient s medical and dental history

Transcription

1 Examination Examination PMDs & Oral cancer 1. Review of the patient s medical and dental history 2. Oral examination รศ.ทพญ.ดร. พรพรรณ พ บ ลย ร ตนก จ ผศ.ทพ.ดร. ชาญว ทย ประพ ณจ าร ญ ภาคว ชาเวชศาสตร ช องปาก คณะท นตแพทยศาสตร จ ฬาลงกรณ มหาว ทยาล ย 3. Extraoral examination 4. Additional investigations 5. Staging (in case of oral CA.) and prognosis History taking Potentially malignant disorders Review of the patient s medical and dental history Warning lesions commonly appear as White lesion White & red lesion Risk behavior, parafunctional habits and lifestyle Tobacco use and alcohol consumption Hyperkeratosis Pale mucosa Red lesion Ulcerative lesion

2 Clinical appearance Clinical appearance Courtesy Prof. Isaäc van der Wall Kumar P, et al, South Asian J Cancer, 2013 Regezi JA, et al,oral patho;ogy clinical pathologic correlation, 2012 Langlais RP, et al,color atlas of common oral diseases, 2009 White lesion Pale mucosa Red lesion Red & white lesion Clinical appearance Extraoral examination Ulcerative lesion Regezi JA, et al,oral patho;ogy clinical pathologic correlation, 2012

3 Head & Neck examination Visual assessment of the H&N - asymmetry, color and textural changes Head & Neck examination Palpation of the regional cervical LN - metastasis of cancer to LN in the neck - tenderness and mobility Bates' guide to physical examination and history taking. 10 th edition Lymph node 12 Lymph nodes Submandibular node Submental node Supraclavicular node Preauricular node Submandibular node / Submental node Bates' guide to physical examination and history taking. 10 th edition JADA 2001;132:36S-40S.

4 Cervical lymph nodes Intraoral examination Superficial / Deep cervical lymph node Intraoral examination Intraoral examination Oral cavity Tuberosity Attached gingiva Retromolar pad Vestibule (mucobuccal fold) Buccal mucosa Labial mucosa Tongue Floor of mouth Hard palate Submandibular & sublingual salivary gland The ADA Practical Guide to Soft Tissue Oral Disease, 2014 Oropharynx Soft palate Tonsillar pillars & fossa Base of tongue Pharynx The ADA Practical Guide to Soft Tissue Oral Disease, 2014

5 Oral examination Oral examination Additional investigations 19 Additional investigations Cytological smear Vital tissue staining Toluidine blue Lugol s iodine Autofluorescence visualization Biopsy Imagings

6 21 Cytological smear ล กษณะเซลล ปกต 23 เซลล มะเร ง ม ร ปร างหลากหลาย น วเคล ยสม ขนาดใหญ

7 26 Vital tissue staining Toluidine blue Lugol s iodine 25 Limitations of vital tissue staining Ulcerative / inflamed areas Early stage of dysplastic change Experience to interpretation Neville BW, et al, Oral & Maxillofacial Pathology, Toluidine blue 28 Toluidine blue Basic metachromatic dye (tolonium chloride) that stains nuclear material of malignant lesion Dysplastic tissues appear as Blue color For lesions not clinically detectable Guide for biopsy site selection The limitations Ulcerative / inflamed areas Early stage of dysplastic change Experience to interpretation ม อาการมากกว า 3 เด อน ล างส ด วย 1% acetic acid ทา 1% toluidine blue sensitivity = 95.0% specificity = 71.4%

8 29 Toluidine blue 30 Lugol s iodine A solution of elemental iodine and potassium iodine Healthy oral tissues appears brown color while dysplastic tissues appear as pale Apply restrictively to non-keratinized mucosa only The same limitations in application as to use of toluidine blue Ulcerative / inflamed areas Early stage of dysplastic change Experience to interpretation Gandolfo S, et al, Oral Oncol Jan;42: Lugol s iodine 32 Lugol s iodine sensitivity = 94.7% specificity = 83.8% Fatima S, et al, Ann Maxillofac Surg Jul-Dec;6:

9 33 Vinegar 34 Vinegar application (น าส มสายช ) sensitivity = 87.93% specificity = 86.36% SCC = Squamous Cell Carcinoma Mild CI = Mild Chronic Inflammation 35 Autofluorescence Visualization 36 Autofluorescence Visualization The major endogenous fluorophores Neoplastic changes alter the tissue structure and the concentration of fluorophores; oral neoplasia is associated with a loss of fluorescence. Healthy oral tissue emits a pale green fluorescence while altered tissues, which attenuate the passage of light, appear dark brown to black. The Velscope( )system The Velscope( )system

10 37 Biopsy Scalpel biopsy: Gold standard Punch biopsy Excisional biopsy with Incisional biopsy Biopsy site

11 42 Imagings Imagings Inadequate clinical data - The anatomy involved in lesion - Metastasis information 41 Treatment plan 43 Imagings 44 Computed tomography (CT) Computed tomography (CT) Magnetic Resonance Imaging (MRI) Positron Emission Tomography (PET) Ultrasonography White SC, et al, Oral Radiology Principles and Interpretation, 2009

12 45 Computed tomography (CT) 46 Computed tomography (CT) White SC, et al, Oral Radiology Principles and Interpretation, Computed tomography (CT) 48 Magnetic Resonance Imaging (MRI) Marco Antonio Portela Albuquerque et al. Braz. oral res. vol.23 no.2 São Paulo Apr./June 2009 White SC, et al, Oral Radiology Principles and Interpretation, 2009

13 49 Magnetic Resonance Imaging (MRI) 50 Magnetic Resonance Imaging (MRI) T1 T Positron Emission Tomography (PET) 52 Positron Emission Tomography (PET) White SC, et al, Oral Radiology Principles and Interpretation, 2009 Schöder H, et al. J Nucl Med May 2006 vol. 47 no

14 53 Positron Emission Tomography (PET) 54 Ultrasonography Kisansa ME, et al. Int J Case Rep Images 2017;8(1): year survival rate 5-year survival rate depends on Stage Type of cancer Site of cancer 56 Staging 5-year survival rate in Thai ~ 31.9% Seenuanlae L, et al. KKU Journal for Public Health Research 2013; 6: 61-70

15 57 Staging Most popular : TNM by Union for International Cancer Control (UICC) 1. Primary tumor 2. Regional Lymph Nodes metastasis 3. Distant metastasis 58 Primary tumor TX T0 Tis T1 T2 T3 T4a (lip) T4a (oral cavity) T4b (lip and oral cavity) Primary tumor cannot be assessed No evidence of primary tumor Carcinoma in situ Tumor 2 cm or less in greatest dimension Tumor more than 2 cm but not more than 4 cm in greatest dimension Tumor more than 4 cm in greatest dimension Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin (chin or nose) Tumor invades through cortical bone, into deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face Tumor invades masticator space, pterygoid plates, or skull base; or encases internal carotid artery Regional Lymph Nodes metastasis NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis as specified in N2a, 2b, 2c below Distant metastasis N2a N2b N2c N3 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension Metastasis in a lymph node more than 6 cm in greatest dimension Lung Liver Bone MX M0 M1 Distant metastasis cannot be assessed No distant metastasis Distant metastasis

16 61 TNM staging 62 Staging Stage T N M Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 T3 N1 N0, N1 M0 M0 Stage IV A T1, T2, T3 T4a N2 N0, N1, N2 M0 M0 The staging of oral cancer affects to Treatment plan Prognosis 5 year survival rate Stage IV B Any T T4b N3 Any N M0 M0 Stage IV C Any T Any N M year survival rate 5 year survival rate depends on Stage Type of cancer Site of cancer 5 year survival rate in Thai ~ 30%