Oral cancers evaluation & staging-modified


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  • This exam is abstracted from the standardized oral examination method recommended by the World Health Organization. The method is consistent with those followed by the Centers for Disease Control and Prevention and the National Institutes of Health. It requires adequate lighting, a dental mouth mirror, two 2" x 2" gauze squares, and gloves; it should take no longer than 5 minutes. The examination is conducted with the patient seated. Any intraoral prostheses are removed before starting.
  • The extraoral and perioral tissues are examined first, followed by the intraoral tissues. The extraoral assessment includes inspection of the face, head, and neck. The face, ears, and neck are observed, noting any asymmetry or changes on the skin such as crusts, fissuring, growths, and/or color change. The regional lymph node areas are bilaterally palpated to detect any enlarged nodes. If enlargement is detected, the examiner should determine the mobility and consistency of the nodes. A recommended order of examination includes the preauricular, submandibular, anterior cervical, posterior auricular, and posterior cervical regions.
  • The perioral and intraoral examination procedure follows a seven-step systematic assessment of the lips; labial mucosa and sulcus; commissures, buccal mucosa, and sulcus; gingiva and alveolar ridge; tongue; floor of the mouth; and hard and soft palate. Lips Begin examination by observing the lips with the patient's mouth both closed and open. Note the color, texture and any surface abnormalities of the upper and lower vermilion borders.
  • With the patient's mouth partially open, visually examine the labial mucosa and sulcus of the maxillary vestibule and frenum and the mandibular vestibule. Observe the color, texture, and any swelling or other abnormalities of the vestibular mucosa and gingiva.
  • Retract the buccal mucosa. Examine first the right then the left buccal mucosa extending from the labial commissure and back to the anterior tonsillar pillar. Note any change in pigmentation, color, texture, mobility, and other abnormalities of the mucosa, making sure that the commissures are examined carefully and are not covered by the retractors during the retraction of the cheek.
  • First, examine the buccal and labial aspects of the gingiva and alveolar ridges (processes) by starting with the right maxillary posterior gingiva and alveolar ridge and then move around the arch to the left posterior area. Drop to the left mandibular posterior gingiva and alveolar ridge and move around the arch to the right posterior area. Second, examine the palatal and lingual aspects as had been done on the facial side, from right to left on the palatal (maxilla) and left to right on the lingual (mandible).
  • With the patient's tongue at rest, and mouth partially open, inspect the dorsum of the tongue for any swelling, ulceration, coating, or variation in size, color, or texture. Also note any change in the pattern of the papillae covering the surface of the tongue and examine the tip of the tongue. The patient should then protrude the tongue, and the examiner should note any abnormality of mobility or positioning.
  • With the aid of mouth mirrors, inspect the right and left lateral margins of the tongue.
  • Grasping the tip of the tongue with a piece of gauze will assist full protrusion and will aid examination of the more posterior aspects of the tongue's lateral borders.
  • Then examine the ventral surface. Palpate the tongue to detect growths.
  • With the tongue still elevated, inspect the floor of the mouth for changes in color, texture, swellings, or other surface abnormalities.
  • With the mouth wide open and the patient's head tilted back, gently depress the base of the tongue with a mouth mirror. First inspect the hard and then the soft palate.
  • Examine all soft palate and oropharyngeal tissues.
  • Bimanually palpate the floor of the mouth for any abnormalities. All mucosal or facial tissues that seem to be abnormal should be palpated.
  • T1 weighted,. T2 weighted and Gadolinium enhanced MRI of metastatic node
  • Oral cancers evaluation & staging-modified

    2. 2. Evaluation and staging of oral cancer Dr Sujay Susikar PG in Surgical Oncology Professor Dr R Rajaraman unit Government Royapettah Hospital
    3. 3. Initial head and neck examination Standard and complete head and neck examination All 12 cranial nerves examined Otoscopy and anterior rhinoscopy Examination of oral cavity Palpation of tongue and tongue base Mirror and flexible laryngoscope examination Examination under anaesthesia in patients with trismus, SMF, ankyloglossia, uncooperative patients
    4. 4. WHO Format – oral cavity examination Exam abstracted from WHO standardized oral examination method Consistent with CDC and NIH method Requirements:  Adequate lighting  Dental mouth mirror  Two 2" x 2" gauze squares  Gloves  Seated patient  Removal of intraoral prostheses Should take no longer than 5 minutes
    5. 5. Extraoral Examination Face
    6. 6. Perioral and Intraoral Soft Tissue Examination – Lips
    7. 7. Perioral and Intraoral Soft Tissue Examination – Labial Mucosa
    8. 8. Buccal Mucosa
    9. 9. Buccal Mucosa
    10. 10. Gingiva
    11. 11. Tongue Dorsum
    12. 12. Tongue Left Margin
    13. 13. Tongue Right Margin
    14. 14. Tongue Ventral
    15. 15. Floor
    16. 16. Hard Palate
    17. 17. Oropharynx
    18. 18. Palpation
    19. 19. Histological confirmation of diagnosis Wedge Biopsy for infiltrating lesions Punch Biopsy for Proliferative lesions Transoral under LA if possible Taken from edges Adequate depth of tissue Anaesthesia in Trismus, Ankyloglossia, SMF, Infiltrative & Posteriorly placed lesions
    20. 20. Staging  MetastaticTumor-  Nodal –•Examination • Clinical workupunder • X ray Chestanesthesia • Ultrasound • Chest CT / PET•X Rays, • CT in•Panorex extensive in patients with•CT Scan nodal N2 disease and•MRI N2 adenopathy disease below thyroid • PET notch • Symptom directed
    21. 21. Investigations for Staging Examination under Anesthesia in selected cases X Ray Mandible, PNS, Maxilla
    22. 22. Orthopantamogram Orthopantomogram for involvement of mandible & maxilla Assessment of the entire dentition and early evaluation of erosions Mentum & lingual cortex difficult to assess
    23. 23. ULTRASOUND NECK Highly operator dependent Sensitive in picking up nodes in clinical N0 disease Useful for image guided biopsy Ultrasound criteria: Size min axial diameter 7mm- submental, 8mm for other nodes Roundness index ratio of transverse to longitudinal diameters Absence of an echogenic hilus Presence of necrosis – coagulative or cystic within a node Extracapsular spread Colour doppler- disorganised peripheral flow pattern
    24. 24. Coagulative Cystic necrosis necrosisExtracapsular Disorganiseddisease peripheral flow
    25. 25. ULTRASOUND NECKIndications for Ultrasound neck: Patients with clinical N0 neck with primary in areas with high possibility of lymphatic spread Clinically insignificant nodes ?
    26. 26. CT scan Standard practise now Evaluates site and location of primary Assessment of Metastatic adenopathy Scans done prior to biopsy to avoid confusion by changes from biopsy
    27. 27. CT scan
    28. 28. CT scan
    29. 29. CT scanIndications for CT: For evaluation of primary situated adjacent to bone Evaluation of extent of spread in large primaries To decide on management of the mandible Evaluation of neck
    30. 30.  Malignant node criteria for CT :  LN > 15 mm. in level II  LN > 10 mm. in other levels  Group of ≥ 3 nodes ( 1-2 mm.)  Central necrosis  Loss of tissue planes ( fat plane)
    31. 31. CT ScanADVANTAGES: Increased speed Bony framework – better evaluated Small calcifications more apparentDISADVANTAGES: Requires ionizing radiation And iodinated contrast agents
    32. 32. Dentascan DentaScan performs real time image reformation specific to CT dental imaging: oblique and panorex reformation. Assessment of Bone involvement No motion artifact in Bulky tumors
    33. 33. Dentascan
    34. 34. MRI – In Selected cases Better Soft tissue contrast Multiplanar – better assessment of Primary Useful additional information in previously treated patients (recurrence and residues) and in lesions with skull base involvement No dental amalgam artifact
    35. 35. MRIIndications for MRI: In primaries with possible perineural spread For evaluation of possible skull base involvement To evaluate exact soft tisue spread of the tumor to plan conservative resections
    36. 36. MRI
    37. 37. MRI
    38. 38. MRIAdvantages: More sensitive for subtle spread along nerves and into the skull base Better evaluation of cartilage or marrow invasionDisadvantages: Lower patient tolerance Dangers with metallic implants, pacemakers and other hardware Increased expense Patient motion always a concern
    39. 39. PET scanInherent limitations of conventional imaging: Poor sensitivity for detection of disease < 1cm Limited ability to distinguish residual or recurrent tumor from scar Inability to biologically characterize disease Inability to provide early prognostic information regarding treatment outcome
    40. 40. PET scanAdvantages : Useful in detection of additional disease not seen on routine staging and altering TNM staging Detection rate of occult primary higher Less reliant on size for detection of nodal disease Can detect distant metastasis and synchronous second primary malignancies not seen on routine work up, therefore avoiding inappropriate aggressive treatments
    41. 41. PET scan
    42. 42. PET scan
    43. 43. PET scan
    44. 44. PET scanUses of PET: Staging Thereupetic planning Post therapy restaging Thereupetic monitoring and outcome Restaging and relapseDilemmas : Management of equivocal PET? Cost effectiveness?
    45. 45. Pre Anaesthetic Assessment General medical evaluation Routine pre op lab Investigations To rule out Co-morbid conditions
    46. 46. Intra operative Frozen Section For margins For nodes if selective node dissection doneOptimal frozen section reporting: guidelines: Confirmation of malignancy Closest margins – exact length Positivity of closest margins
    47. 47. Pre operative assessment of Speech & swallowing – Baseline for rehabilitation Spectrogram – intensity frequency , resonance & format of speech Modified Barium Swallow – premature spillage into hypopharynx & vestibule of larynx
    48. 48. Screening for Second Primary 4% annual incidence Pan endoscopy ( triple endoscopy), sputum & saliva cytology, Xray Chest
    49. 49. T - Staging TX – Primary cannot be assessed T0 – No evidence of primary Tis – Ca. in situ T1 – 2 cm or less T2 – more than 2 cm but not more than 4 cm T3 – more than 4 cm
    50. 50. T - Staging T4a (lip) - Invading through cortical bone, inferior alveolar nerve, floor of mouth or skin of face(chin or nose) T4a (Oral cavity) – Invading adjacent structures eg,. cortical bone, deep extrinsic muscle of tongue, maxillary sinus or skin of face T4b – Invading masticator space, pterygoid plates, skull base or encases Internal carotid artery (Superficial erosion alone of bone/ tooth socket by gingival primary is not T4 )
    51. 51. N - Staging NX - Nodes cannot be assessed N0 – No nodes N1 – single ipsilateral node 3 cm or less in greatest dimension N2a – single ipsilateral node more than 3 cm but not more than 6 cm N2b – multiple ipsilateral nodes none more than 6 cm N2c – bilateral or contralateral node none more than 6 cm N 3 – node more than 6 cm (Midline nodes are ipsilateral nodes)
    52. 52. M - Staging MX – metastasis cannot be assessed M0 – No metastasis M1 – Distant metastasis
    53. 53. Stage Grouping Stage 0 – Tis N0 M0 Stage I – T1 N0 M0 Stage II – T2 N0 M0 Stage III – T1-3 N1 M0 T3 N0 M0 Stage IV A - T4a N0-1 M0 T1-4a N2 M0 Stage IV B – Any T N3 M0 T4b Any N M0
    54. 54. Fallacies of TNM staging Depth of Primary not included < 2mm - 13% nodes & 3% death 2 to 9 mm – 46% nodes & 17% death > 9mm – 65% nodes & 35% death Extracapsular involvement in node not considered No provision for molecular markers, IHC
    55. 55. Molecular staging Molecular assays detect occult cancer cells previously missed by physical examination and standard histopathologic techniques. Provide more objective analyses with fewer sampling errors
    56. 56.  Intra operative gene probe – Pilot study showed 12 out of 30 patients with negative margin were disease free at 2 years To predict response to RT – Breakpoints on 1p22, 3p21, 8p11, distal 14q were resistant
    57. 57. “Biological staging” - Biological behavior Useful in assessing cycling cells Precancerous lesions Surgical tumor margins Predicting aggressive behavior Invasion front Metastatic potential
    58. 58. “Biological staging” - Biological behavior Biomarker Predictors in Oral Precancerous & Cancerous Lesions