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  1. 1. OROPHARYNGEAL CANCER Dr Tareq Gharaibeh, BDS, M.Med.Sc, FDS RCS Assistant professor,Faculty of Dentistry Consultant in Oral & Maxillofacial Surgery, King Abdullah Teaching Hospital
  2. 2. ORPHARYNGEAL CANCER <ul><li>Introduction </li></ul><ul><li>Epidemiology </li></ul><ul><li>Aetiology </li></ul><ul><li>Clinical presentation </li></ul><ul><li>Workup and staging </li></ul><ul><li>Treatment modalities </li></ul><ul><li>Prognosis </li></ul>
  3. 3. Introduction <ul><li>The 6 th most common malignancy within the EC ailthough the 3 rd in men (4 th in women) of developing countries </li></ul><ul><li>The most common malignant tumour in south east asia. </li></ul><ul><li>40% of all malignancies in parts of India </li></ul><ul><li>Commoner in males </li></ul>
  4. 4. Introduction <ul><li>The prognosis for cure improves the earlier the diagnosis is made and appropriate treatment started </li></ul><ul><li>treatment for a small early lesion is likely to be less mutilating and have a lower morbidity than treatment for a large advanced lesion </li></ul>
  5. 5. Introduction <ul><li>Unlike many malignant lesions occurring elsewhere in the body oral scc can be readily observed in its‘ early stages. There are few places in the oral cavity that a lesion can genuinely progress unnoticed by patient and clinician. </li></ul>
  6. 6. Introduction <ul><li>The fact that so many patients still continue to present late with advanced disease is a sad indictment of the state of medical and dental care in Jordan and even the UK </li></ul>
  7. 7. Epidemiology <ul><li>Squamous cell carcinoma (scc) accounts for about 90% of all oral malignancy the remainder include salivary gland neoplasms, lymphomas and sarcomas. </li></ul>
  8. 8. Epidemiology <ul><li>The rate of new oral cancers would appear to be falling from its' peak in 1920 to the present levels. However, there is disturbing evidence that cancers of all types including oral cancer are on the increase. </li></ul>
  9. 9. Epidemiology <ul><li>there is a strong clinical impression as yet unsubstantiated that we are seeing a rise in incidence of aggressive oral scc in young patients with no accepted risk factors </li></ul>
  10. 10. Aetiology <ul><li>Actinic Radiation </li></ul><ul><li>Epithelial atrophy </li></ul><ul><li>Viruses </li></ul><ul><li>Immunosuppression </li></ul><ul><li>Candida infection </li></ul><ul><li>Smoking </li></ul><ul><li>Chewing habits </li></ul><ul><li>Alcohol </li></ul><ul><li>Poor diet </li></ul><ul><li>Industrial hazards </li></ul><ul><li>Dental factors </li></ul>
  11. 11. Aetiology <ul><li>Smoking: </li></ul><ul><li>Cigar and pipe smoking Vs cigarette smoking </li></ul><ul><li>Reverse smoking </li></ul><ul><li>Chewing habits: </li></ul><ul><li>Pan chewing -> Leukoplakia -> SCC </li></ul><ul><li>Alcohol: </li></ul><ul><li>Unclear mechanism </li></ul><ul><li>Type and quality more important than quantity </li></ul>
  12. 12. Aetiology <ul><li>Smoking and Alcohol synergism </li></ul><ul><li>Smoking alone: 9 times greater risk </li></ul><ul><li>Alcohol alone: 8 times greater risk </li></ul><ul><li>Smoking and alcohol consumption: </li></ul><ul><li>9+8=40!! </li></ul>
  13. 13. Aetiology <ul><li>Industrial hazards: </li></ul><ul><li>Higher incidence in textile workers </li></ul><ul><li>Dental factors </li></ul><ul><li>Actinic Radiation: </li></ul><ul><li>SCC more common in lower lip than upper lip </li></ul><ul><li>Lip cancer is rare in dark-skinned people </li></ul><ul><li>Epithelial atrophy: </li></ul><ul><li>May enhance the absorption of carcinogens </li></ul>
  14. 14. Aetiology <ul><li>Viruses: </li></ul><ul><li>HSV-2 implicated in carcinoma of uterine cervix </li></ul><ul><li>Immunosuppression: </li></ul><ul><li>Increased incidence of certain cancers in patients with renal transplants or HIV </li></ul><ul><li>Candidal infection: </li></ul><ul><li>Chronic hyperplastic candidosis is premalignant </li></ul>
  15. 15. Jordan <ul><li>Your average Mo </li></ul><ul><li>Male with carious teeth </li></ul><ul><li>Smokes 40-60 since Tany e3dady!! </li></ul><ul><li>Drinks cheap local spirits </li></ul><ul><li>Eats shawerma or falafel on the road while Ferrarying in his Kia mini-van </li></ul>
  16. 16. Indications for urgent referral <ul><li>Any unhealed ulcer for more than two weeks </li></ul><ul><li>Any unexplained oral bleeding </li></ul><ul><li>Any area of induration </li></ul><ul><li>Any unexplained white patch </li></ul><ul><li>All-red or red/white patches </li></ul><ul><li>Cervical nodes </li></ul>
  17. 17. Clinical presentation <ul><li>Can affect any part of the oral mucosa </li></ul><ul><li>Sites particularly at risk vary according to aetiological factors: </li></ul><ul><li>Europe: Tongue and lip </li></ul><ul><li>India: Buccal mucosa </li></ul>
  18. 18. SCC of lower lip
  19. 19. SCC on alveolar ridge
  20. 20. SCC in the FOM
  21. 21. Clinical presentation <ul><li>Early lesions are usually asymptomatic </li></ul><ul><li>May present as: </li></ul><ul><li>a white patch </li></ul><ul><li>a red patch </li></ul><ul><li>an ulcer </li></ul><ul><li>an exophytic growth </li></ul>
  22. 22. Clinical presentation <ul><li>Pain may be a late feature </li></ul><ul><li>Advanced lesions have a very variable presentation </li></ul><ul><li>Bone destruction may be evident on radiographs </li></ul><ul><li>Teeth may become mobile </li></ul><ul><li>There may be altered sensation </li></ul>
  23. 23. Role of the medics <ul><li>Patient education </li></ul><ul><li>Elimination of risk factors </li></ul><ul><li>Thorough examination </li></ul><ul><li>Be safe.. refer if in doubt </li></ul>
  24. 24. Pre-malignant conditions
  25. 25. Leukoplakia <ul><li>Idiopathic white patch that cannot be wiped off the mucosa </li></ul><ul><li>Up to 4% risk of malignant change in 5 years </li></ul><ul><li>Very variable clinical presentation (homogeneous, speckled, verrucous, nodular,..etc) </li></ul><ul><li>Management include biopsy, conservative treatment, excision, and laser ablation </li></ul>
  26. 26. Erythroplasia (erythroplakia ) <ul><li>Red velvety pathches </li></ul><ul><li>Idiopathic </li></ul><ul><li>Very high risk of </li></ul><ul><li>malignant change </li></ul><ul><li>70% are carcinomas </li></ul><ul><li>in situ on first biopsy </li></ul><ul><li>Same management as leukoplakias </li></ul>
  27. 27. Candidal leukoplakia <ul><li>Rough adherent </li></ul><ul><li>white plaque </li></ul><ul><li>Typical site is buccal </li></ul><ul><li>mucosa behind the </li></ul><ul><li>commissures </li></ul><ul><li>Variable risk of malignant change </li></ul><ul><li>Management is with vigorous systemic antifungals </li></ul>
  28. 28. Lichen planus <ul><li>Chronic inflammatory mucocutaneous disease </li></ul><ul><li>Unclear pathogenesis </li></ul><ul><li>Two distinctive clinical types (non-erosive and erosive) </li></ul><ul><li>Usually bilateral distribution </li></ul><ul><li>Only erosive type is premalignant </li></ul><ul><li>Management includes biopsy and steroids </li></ul>
  29. 29. Prognosis of oral cancer <ul><li>STNMP system: </li></ul><ul><li>Site </li></ul><ul><li>Tumour size </li></ul><ul><li>Node involvement </li></ul><ul><li>Metastasis </li></ul><ul><li>Pathology </li></ul>
  30. 30. Staging <ul><li>T1 <2cm. T2 >2cm<4cm. T3 >4cm. T4 massive tumour with invasion </li></ul><ul><li>N0: No nodes </li></ul><ul><li>N1: ipsilateral <3cm </li></ul><ul><li>N2a: ipsilateral >3cm<6cm </li></ul><ul><li>N2b: ipsilateral multiple <6cm </li></ul><ul><li>N2c: Bilateral/Contralateral: <6cm </li></ul><ul><li>N3: any node >6cm </li></ul>
  31. 31. Investigation <ul><li>Surgical biopsy, Incisional </li></ul><ul><li>FNA, for neck and parotid lumps </li></ul><ul><li>Radiographs </li></ul><ul><li>CT </li></ul><ul><li>Ultrasound esp for abdomen and liver mets. </li></ul>
  32. 32. Treatment <ul><li>CURATIVE </li></ul><ul><li>LOCAL DISEASE CONTROL </li></ul><ul><li>PALIATIVE ONLY </li></ul>
  33. 33. Team Approach <ul><li>Maxillofacial Surgeon </li></ul><ul><li>Plastic/Neuro surgery </li></ul><ul><li>Chemotherapist </li></ul><ul><li>Radiotherapist </li></ul><ul><li>Nutritionist </li></ul><ul><li>Speech therapist </li></ul><ul><li>Dentist </li></ul><ul><li>Maxillofacial prosthodontist </li></ul>
  34. 34. Treatment <ul><li>Treatment modalities: </li></ul><ul><li>Surgical excision </li></ul><ul><li>Radiotherapy </li></ul><ul><li>Chemotherapy?? </li></ul><ul><li>Surgery and radiotherapy </li></ul>
  35. 35. Surgery <ul><li>Excision of the tumour with a safety margin </li></ul><ul><li>1-2cm 3D margin for SCC </li></ul><ul><li>Intra-bony lesions require bigger margin </li></ul><ul><li>Partial mandibulectomy or maxillectomy with soft tissue and L.Ns </li></ul>
  36. 36. Management of the neck <ul><li>Neck divides into seven levels </li></ul><ul><li>Only levels I to V need consideration </li></ul>
  37. 37. Management of the neck <ul><li>Therapeutic neck dissection: When disease is obviously present in the neck and the dissection is undertaken to ablate the disease </li></ul><ul><li>Elective neck dissection; No obvious clinical disease in the neck but a high chance of occult disease or neck opened for access </li></ul>
  38. 38. Management of the neck <ul><li>Many confusing terms for dissection in use: ‘Functional’, ‘Supra-omohyoid’, ‘Lateral’, ‘Radical’, ‘Extended radical’ and ‘Modified radical’ </li></ul>
  39. 39. Management of the neck <ul><li>Two simpler terms: </li></ul><ul><li>Comprehensive neck dissection, if all 5 levels are removed </li></ul><ul><li>Selective neck dissection, anything less 5 levels </li></ul>
  40. 40. Management of the neck <ul><li>Controversy regarding the (No) neck </li></ul>