OROPHYRENGEAL CANCERS

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1 OROPHYRENGEAL CANCERS

2 INTRODUCTION 2 % 4 % of all malignant Tumors in west Asia India 40% Men ^ Age :Over 60 yrs 90% of all oral cancers results from Tobacco and Alcohol Pan (Betel Leaf,Nut, Lime), Reverse smoking Incidence in Women increasing Survival remains 55% at 5 years, despite treatment Multiple primary cancer Distant metastasis 20 % of cases Systemic disease from early stage

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4 Resection Technique of access and reconstruction Lip splitting mandibulotomy Rim resection to mandibulectomy Skull base surgery using oral approach and facial osteotomy

5 Reconstruction Primary reconstruction is the role Past staged procedures no longer used Simple or composite flap cover Pectoralis, Latissimus Micro vascular flaps

6 Radiotherapy Linear Accelrator, computerised planning reduced the morbidity Teeth need not be removed Radio necrosis rare Brachytherapy T1 & T2 Lesions, mobile organ Irridium wire Hyperfractionation

7 Chemotherapy Only palliative, Cisplatin, 5 FU Fungating painful lesions

8 Pre malignant conditions a) Lesions carry risk of malignant change 1. Leucoplakia 2. Erythroplakia 3. Chronic candidiasis

9 b) Pre malignant conditions 1. Oral submucous Fibrosis 2. Syphilitic Glossitis 3. Siderophinic Dysphagia c) Doubtful Lesions 1. Oral Lichen planus 2. Discoid lupus erythematosis

10 Leucoplakia WHO S Definition Any white patch or plaque cannot be characterised clinically or pathologically as any other disease.

11 Clinical Features Varied sizes, white plaque, yellow, grey. Surface smooth or wrinkled, cracks.fissured Homogenous or nodular Induration Malignancy Long duration increases malignancy 2.5 % in 10 years Age in 70 & 80 years 7.5 % Site: Floor of mouth, Tongue Pooling of saliva

12 Etiology Tobacco Smoking, Chewing 20% Risk Non smokers 1 % Alcohol doubtful Management Any indurted or ulcerated area HPE Patient advised stop smoking alcohol at 1 year 60% reduction Carcinoma in situ, Epithelial Hyperplasia Co2 laser excision Excision and suture or skin grafting Follow up at 4 months interval

13 Erythroplakia Oral mucosa bright red velvety plaque Irregular outline, nodular Malignant change 17 times more than leucoplakia Carcinoma in situ,epithelial hyperplasia Biopsy and excision with laser

14 Chronic Hyperplastic Candidiasis Chalky plaques keratin, thicker Immunological defect Miconozole, nystatin, Amphotericin Surgical excision

15 Oral Submucous Fibrosis Fibrous strands in the sub mucosa of oral cavity Mouth opening progressively reduced Asians, juxta epithelial fibrosis epithelial dysplasia Squmaous cell carcinoma Arecoline Alkaloid, Collagenases may be responsible Treatment : Intralesional Steroids Surgical Excision

16 Syphilitic Glossitis Leukoplakia Interstitial Glossitis with atrophic epithelium Regular follow up for cancer

17 Sideropenic Dysphagia Plummer Vinson Syndrome Sweden, Women ^ 25 % oral cancer occurs in sideropenics Atrophic Epithelium Vulnerable to carcinogenic irritants

18 Other Lesions Oral Lichen planus 1.2 % erosive, steroids topically b) Discoid lupus erythematosus: Circumscribed,elevated, white patches with erythematous halo, labia, Men ^ uv protection cream

19 Table 17-3 TNM Staging for Oral Cavity Carcinoma Primary tumor TX T0 Tis T1 T2 T3 Unable to assess primary tumor No evidence of primary tumor Carcinoma in situ Tumor is <2 cm in greatest dimension Tumor >2 cm and <4 cm in greatest dimension Tumor >4 cm in greatest dimension T4 (lip) Primary tumor invading cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (e.g., nose or chin) T4a (oral) T4b (oral) Tumor invades adjacent structures (e.g., cortical bone, into deep tongue musculature, maxillary sinus) or skin of face Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid artery Regional lymphadenopathy NX N0 N1 N2a N2b N2c N3 Distant metastases MX M0 M1 Unable to assess regional lymph nodes No evidence of regional metastasis Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension Metastasis in single ipsilateral lymph node, >3 cm and <6 cm Metastasis in multiple ipsilateral lymph nodes, all nodes <6 cm Metastasis in bilateral or contralateral lymph nodes, all nodes <6 cm Metastasis in a lymph node >6 cm in greatest dimension Unable to assess for distant metastases No distant metastases Distant metastases

20 Clinical Features Tongue Middle third, lateral margin may extend to floor of mouth Ulceration, leucoplakia, exophytic, Hard, induration, areas of necrosis Infiltration of tongue muscles Difficulty in swallowing, speech with pain severe, constant, radiating to neck and ears Lymph node metastasis common early

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22 Buccal Mucosa Extends from upper alveolar ridge to lower alveolar ridge From commissure anteriorly to retromolar Squmous cell CA,mostly posteriorly Exophytic, Ulcerative, Verrucous Occlusal Trauma, ulceration, infection Insidious onset Trismus with infiltration of muscle Posterior extension worse prognosis Skin infiltration occurs sinuses

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25 Nodes involvement Verrucous Superficial, Exophytic minimal invasion, soft, velvety low grade

26 Carcinoma Lip Vermilion border of lower lip 80 % upper lip 5 % Central third only 15 % Initially spread laterally than deeply Later may invade mandible Node Metastasis

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29 Investigations 1)Radiography OPG of jaws Assess the alveolar ridge, antrum Limited value 2) CT Scan Antral, Pterygoid regions Nodal assessment,liver, lung,bones

30 3) MRI Investigation of choice Soft Tissue Imaging, Infiltration USG, Nuclear Imaging, not useful 4) FNAC Neck nodes To find out metastasis Technique 23G needle, LA

31 Biopsy Incisional Biopsy at selected site, away from necrosis and infection Histology 1. Squemous cell grade 2. Adeno carcinoma 3. Malignant melanoma 4. Verrucous carcinoma

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35 Management Surgical a) Carcinoma Tongue Intra oral excision with margin 0.5 to 1 cm Advanced lesions Radio, Chemo Brachy therapy Upto 1 /3 of tongue excision no reconstruction needed allow to granulate Split skin graft Co2 laser used to excise

36 2 cms or more Hemiglosectomy For advanced lesions Lip split mandibulotomy Neck dissection Mandibular rim excision Composite resection, reconstruction with radial forearm microvascular free flap One hypoglossal nerve preserved

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40 19) Carcinoma Lip Surgical : 1) Upto 1/3 of lip wedge excision and Primary closure under LA 2) Local Flaps : Johansen step ladder Flap Bernard Flap

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43 Carcinoma Cheek T1 Lesions Confined to mucosa wide excision with split skin grafting Extensive lesions composite excision and Free radial forearm micro vascular flap McGregor s fore head flaps Axial Superficial temporal artery Temporal Flap

44 Neck Node Management Supra hyoid node dissection Ipsilateral neck node dissection

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47 THANK YOU