Finding Dangerous Mucosa

Transcription

1 Finding Dangerous Mucosa 2

2 Oral Cancer Squamous Cell Carcinoma Salivary Gland Adenocarcinoma Malignant Lymphoma Metastatic Carcinoma Sarcoma 4

3 Incidence of Cancer in the United States For Oral and Oropharyngeal Cancer: USA: 35,000 cases per year 50% 5-year survival rate 93 people develop oral cancer every day 1 person dies from oral cancer every hour 5

4 Etiologic Agents of Head and Neck Squamous Cell Carcinoma EBV Actinic Radiation Alcohol Tobacco HPV Alcohol Tobacco 2003 American Society of Clinical Oncology 6

5 What Does Oral Squamous Cell Carcinoma Look Like Clinically? Exophytic Mass-forming Fungating Papillary Verruciform Endophytic Invasive Burrowing Ulcerated Leukoplakic a white patch Erythroplakic a red patch Erythroleukoplakic a red-and-white patch 7

6 Early Diagnosis of Oral Cancer Identify precursor lesions Leukoplakia Erythroplakia Be suspicious - biopsy clinically suspicious lesions 9

7 Hidden Pathology

8 Hidden Pathology Soft Palate Uvula Dorsal Tongue 1

9 Components of an Oral Cancer Examination Extraoral examination Inspect head and neck. Bimanually palpate lymph nodes and salivary glands. Lips Inspect and palpate outer surfaces of lip and vermilion border. Inspect and palpate inner labial mucosa. Buccal mucosa Inspect and palpate inner cheek lining. Gingiva/alveolar ridge Inspect maxillary/mandibular gingiva and alveolar ridges on both the buccal and lingual aspects. Tongue Have patient protrude tongue and inspect the dorsal surface. Have patient lift tongue and inspect the ventral surface. Grasping tongue with a piece of gauze and pulling it out to each side, inspect the lateral borders of the tongue from its tip back to the lingual tonsil region. Palpate tongue. Floor of mouth Inspect and palpate floor of mouth. Hard palate Inspect hard palate. Soft palate and oropharynx Gently depressing the patient s tongue with a mouth mirror or tongue blade, inspect the soft palate and oropharynx. Neville and Day, CA Cancer J Clin 2002;52:

10 Leukoplakia A white patch or plaque that can t be characterized clinically or pathologically as any other disease. Rule of thumb: 20% of Leukoplakia will be dysplastic 13

11 Erythroplakia A red patch that can t be characterized clinically or pathologically as any other disease. Rule of thumb: 90% of Erythroplakia will be dysplastic 14

12 Classic Articles on Leukoplakia and Erythroplakia 15

13 Leukoplakia A Clinical Diagnosis

14 Erythroplakia - Erythroplasia A Clinical Diagnosis

15 Epithelial Dysplasia a Histologic Diagnosis Normal

16 Severe Epithelial Dysplasia Normal

17 Carcinoma-in-Situ Normal

18 Squamous Cell Carcinoma Normal

19 Infiltrating Squamous Cell Carcinoma Skeletal muscle Nests of tumor cells

20 Grading Epithelial Dysplasia Mild - Lower 1/3 Moderate - Middle 1/3 Severe - Upper 1/3 Carcinoma in situ Full thickness change 23

21 Diagnostic Biopsy

22 Diagnosis of Oral Squamous Cell Carcinoma Incisional or excisional biopsy is required for definitive diagnosis Get a manly biopsy!

23 Scalpel Biopsy

24 Scalpel Biopsy - Incisional Fixation in 10% neutral, buffered formalin

25 Punch Biopsy

26 Punch Biopsy

27 Punch Biopsy

28 Punch Biopsy - Incisional

29 Punch Biopsy

30 Punch Biopsy

31 Excisional Biopsy

32 Biopsy Artifacts

33 Local Anesthetic Injection Site with Fibrin Clot

34 Minor Salivary Gland Biopsy

35 Crush Artifact

36 Crush Artifact

37 Cautery Artifact

38 Cautery Artifact

39 Cautery Artifact

40 Cautery Artifact

41 Forceps Squeeze

42 Forceps Squeeze

43 Forceps Squeeze

44 Saline Artifact

45 Pemphigus vs Saline Artifact

46 Suction Artifact

47 Suction Artifact

48 Air knot Suture Artifact

49 Freezing Artifact 53

50 Requirements for a Good Biopsy Representative Manly Orientable Undistorted

51 Staging of Oral Cancer 55

52 Oral Squamous Cell Carcinoma Staging: TNM Classification Tumor size Metastasis Regional lymph nodes Distant sites Stage determines: Treatment Prognosis 56

53 Primary Tumor (T) Size Tis CIS T1 <2 cm T2 2 to 4 cm T3 > 4 cm T4 Invades adjacent structures 57

54 Nodal Involvement (N) N0 No regional node metastasis N1 Metastasis - single ipsilateral node, < 3 cm N2 Metastasis - 3 to 6 cm N3 Metastasis > 6 cm 58

55 Distant Metastasis (M) M0 No distant metastasis M1 Distant metastasis 59

56 TNM Staging T 2 N 1 M 0 T 3 N 3 M 1 T 4 N 0 M 0 60

57 Stage Grouping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 T1 or T2 or T3 N1 M0 Stage IV Any T4 lesion Any N2 or N3 lesion Any M1 lesion 61

58 Clinical Stage and Survival Rates for Oral Cancer N0 N1 N2-N3, M+ T1 T2 80% 60-80% I II T % III T % IV 62

59 Tumor Stage Determines Prognosis Treatment Higher stage -> worse prognosis Higher stage -> more aggressive treatment 63

60 Five Year Survival by Stage 64

61 Histologic Grading of Squamous Cell Carcinoma Well differentiated Moderately differentiated Poorly differentiated 65

62 Treatment of Head and Neck Squamous Cell Carcinoma Surgery Radiation Combined surgery and radiation 66

63 Multidisciplinary Head and Neck Tumor Board for Treatment Planning Surgical oncology Medical oncology Radiation oncology Radiology Pathology Dentistry oral surgery, maxillofacial prosthodontics Speech pathology Social work Physical therapy Occupational therapy 67

64 Oral Cavity Cancer Five Year Survival by Stage - ACS All stages combined 59% Local disease 81% Regional metastasis 51% Distant metastasis 30% 68

65 31F Cigarette Smoker with Painful Red and White Lesion of Ventral Tongue 69

66 Adjunctive Diagnostic Procedures

67 Adjunctive procedures Vital staining toluidine blue Exfoliative cytology Reflectance Fluorescence Transepithelial brush biopsy

68 Adjunctive Diagnostic Techniques Elective aids to incisional biopsy Not substitutes for biopsy Delays in obtaining biopsy Delays in referral Patient resistance Medical reasons Low index of suspicion

69 Toluidine Blue Vital Staining

70 Tolonium Chloride binds to DNA A positive result means that there may be dysplastic cells present A negative result does not exclude dysplasia May be useful to accelerate biopsy or to identify an area to biopsy Toluidine Blue Vital Staining

71 Toluidine Blue Vital Staining

72 Toluidine Blue Vital Staining

73 Toluidine Blue Vital Staining

74 Toluidine Blue Vital Staining

75 Toluidine Blue Vital Staining

76 Toluidine Blue Vital Staining

77 Oral Exfoliative Cytology 83

78 Exfoliative Cytology of Uterine Cervix 84

79 Percent Reliability of Oral Exfoliative Cytology Folsom, Journal of Oral Surgery; 33: 61, Gingiva Lip Buccal M ucosa Ventral Soft Palate Floor of Tongue Mouth 85

80 Exfoliative Cytology 86

81 Exfoliative Cytology 87

82 Exfoliative Cytology 88

83 Exfoliative Cytology 89

84 Exfoliative Cytology 91

85 Exfoliative Cytology 92

86 Oral Exfoliative Cytology Contraindications Keratotic surface Suspicious for malignancy Indications Herpetic lesions Candidiasis 93

87 Oral Exfoliative Cytology for Diagnosis of Viral Infections Herpes Viral Cytopathic Effect (CPE) Normal Squames 94

88 Oral Exfoliative Cytology for Diagnosis of Fungal Infections Candidal Yeast Forms

89 Oral Exfoliative Cytology for Diagnosis of Fungal Infections Candidal Pseudohyphae 96

90 Evidenced-Based Clinical Recommendations for Screening for Oral Squamous Cell Carcinoma JADA, May

91 Adjunctive Screening Aids Devices intended to assist in lesion detection Devices based on tissue reflectance MicroLux/DL (AdDent, Danbury, CT) Orascoptic DK (Orascoptic, Kerr, Middleton, WI) ViziLite Plus (Zila, Phoenix, AZ) Device based on autofluorescence VELscope (LED Dental, Burnaby, BC, CA) Device based on autofluorescence and tissue reflectance Identifi 3000 (Trimira, Houston, TX) Device intended to assist in lesion assessment Device based on transepithelial cytology OralCDx BrushTest (OralCDx Laboratories, Suffern, NY)

92 Adjunctive Screening Aids There is insufficient evidence that commercial devices based on autofluorescence enhance visual detection of potentially malignant lesions beyond that achieved through a conventional visual and tactile examination (III) There is insufficient evidence that commercial devices based on tissue reflectance enhance visual detection of potentially malignant lesions beyond that achieved through a conventional visual and tactile examination (III) There is insufficient evidence to assess the validity of transepithelial cytology of seemingly innocuous mucosal lesions (III) In suspicious mucosal lesions with high potential for malignancy, transepithelial cytology has validity in identifying disaggregated dysplastic cells (III) (A conclusion of insufficient evidence does not necessarily mean that the intervention is or is not effective, but instead means that the panel did not find sufficient evidence to support a recommendation)

93 Acetic Acid Under blue-white illumination, abnormal squamous epithelium is reported to be distinctly white (acetowhite)

94 MicroLux/DL

95 MicroLux/DL DL = Diagnostic Light 1% Acetic acid rinse Blue-white (440nm) LED light source Tranlumination tip Lighted mirror

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97 Orascoptic DK

98 Orascoptic DK DK = Diagnostic Kit 1% Acetic acid rinse Blue-white (440nm) LED light source Tranlumination tip Lighted mirror

99 Orascoptic DK

100 Vizilite Plus

101 Vizilite Plus Plus = Toluidine Blue 1% Acetic acid rinse Blue-white (440nm) LED light source

102 Visilite - Plus

103 Visilite - Plus

104 Visilite - Plus

105 Visilite - Plus

106 Velscope Tissue Fluorescence

107 VELscope - Tissue Fluorescence c

108 VELscope - Tissue Fluorescence

109 VELscope - Tissue Fluorescence

110 VELscope Tissue Fluorescence

111 VELscope - Tissue Fluorescence

112 VELscope - Tissue Fluorescence

113 Transition from Normal Epithelium to Dysplastic Epithelium 120

114 Leukoplakia Mild Epithelial Dysplasia

115 Leukoplakia Mild Epithelial Dysplasia January 2007

116 Leukoplakia Recurrence - February 2008

117 Leukoplakia Recurrence - February 2008

118 Leukoplakia Retreatment- 6 Weeks Postop

119 Leukoplakia Retreatment- 6 Weeks Postop v

120 Leukoplakia Retreatment- 6 Weeks Postop

121 Leukoplakia Retreatment- 6 Weeks Postop

122 Identafi 3000

123 Identafi 3000 Press Release -Trimira LLC : Identafi 3000 uses white, violet, and amber wavelengths of light to excite oral tissue in distinct and unique ways. Biochemical changes can be monitored with fluorescence, while morphological changes can be monitored with reflectance. This multiple wavelength technology identifies abnormal tissue with more accuracy than the single color approaches currently on the market. The ability to read metabolic and physiologic differences makes it easier to distinguish between normal and abnormal tissue. The combined system of fluorescence and reflectance uses the body's natural tissue properties as an adjunctive tool for oral mucosal examination.

124 Fine Needle Aspiration Biopsy

125 Fine Needle Aspiration Biopsy

126 Fine Needle Aspiration Biopsy Fine Needle Aspiration Biopsy

127 Fine Needle Aspiration Biopsy

128 Fine Needle Aspiration Biopsy

129 Transepithelial Brush Biopsy

130 Transepithelial Brush Biopsy Oralscan Laboratories, Suffern, NY OralCDx test kit Computer assisted oral brush biopsy analysis

131 Transepithelial Brush Biopsy Complete transepithelial sample Adequate sample

132 Transepithelial Brush Biopsy No anesthesia required Moisten brush and place either the side or the tip of brush on lesion Apply firm pressure and rotate 5 to 10 times Assess full thickness harvest by observing micro-bleeding

133 Transepithelial Brush Biopsy

134 OralCDx Brush Biopsy Report Negative - no cellular abnormalities Positive epithelial dysplasia or carcinoma - Scalpel biopsy indicated Atypical - abnormal epithelial changes - Scalpel biopsy indicated

135 OralCDx Transepithelial Brush Biopsy Drore Eisen, DDS, MD, Medical Director Oralscan Laboratories The brush biopsy is used to test benign-appearing lesions that have been either watched or ignored in the past. These are lesions that dentists do not find sufficiently suspicious to warrant referral for scalpel biopsy, not those distinguished by signs and symptoms of malignancy, clear indications for scalpel biopsy.

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150 Squamous cell carcinoma of left soft palate - radiation therapy 2006 Carcinoma-in-situ right soft palate - excised 2009 Bit right tongue in January, seen in March

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158 Acute myelogenous leukemia Bone marrow transplant Graft versus host disease Scleroderma Leukoplakia

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165 Bone marrow transplant Graft vs Host disease

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168 Verrucous Carcinoma 202

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172 Verrucous Carcinoma 206

173 Verrucous Carcinoma 207

174 Proliferative Verrucous Leukoplakia 208

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179 Proliferative Verrucous Leukoplakia 213

180 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia 214

181 Proliferative Verrucous Leukoplakia High-risk, aggressive type of oral leukoplakia High potential for malignant transformation Not associated with tobacco use Women outnumber men 215

182 Proliferative Verrucous Leukoplakia Slow-growing Begins as hyperkeratosis Spreads to become multifocal and verruciform Resistant to therapy - recurs Malignant transformation Diagnosis often retrospective 216

183 Proliferative Verrucous Leukoplakia Oct

184 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakiac Oct

185 Proliferative Verrucous Leukoplakia 219

186 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia Oct

187 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia Jan

188 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia 222

189 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia 223

190 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia 224

191 Proliferative Verrucous Proliferative Leukoplakia Verrucous Leukoplakia 225