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Case presentation Carcinoma oral cavity
- 1. Case presentation on Ca- Buccal mucosa Presenter: Dr Aakansh Jain, 3rd year MCh resident
- 2. History • 55 yrs old lady, • resident of lucknow • Home maker by occupation Chief complaint • Swelling in the right side of cheek inner aspect x 5-6 months • Ulcer over this swelling for 1 month
- 3. HOPI • Noticed a small swelling near right lower 1st molar over gingival region 5-6 months back • Not associated with pain • Sudden onset, rapidly progressed to current size of approx. 4x3 cm with in last 3 months • Involved inner aspect of cheek and molar gingiva • Swelling got visible on outer aspect of cheek for last one month • An ulcer developed over swelling for last one month • Sought medical help one month back for same . Ulcer was not healed for two weeks treatment then patient was referred to higher Centre for further management
- 4. • Swelling was associated with difficulty in chewing so patient developed habit of chewing from left side. • H/o tobacco chewing (1 packet daily ) for last 5 years • h/o use of tobacco based toothpaste 3-4 times daily for last 10 years • Non alcoholic • H/o of dental caries and tooth extraction (lower molars both side) with in one year • H/o recurrent trauma to cheek due sharp edges of tooth x 1yr
- 5. • No h/o bleeding on touch • No h/o Halitosis , increased salivation • No h/o sensory loss or hypoesthesia over face • weight loss approx. 7- 8 kgs in last 6 month Metastatic history- • No neck swelling • No h/o chest pain, breathing difficulty • No h/o Abdominal lump / swelling, • H/o sleeplessness for 6 months • No H/o bone pain / headache • No h/o hoarseness of voice
- 6. Past history Known case of hypothyroidism – taking 25 mcg eltroxin irregularly Not a k/c/o DM/ HTN/ Asthma/ TB Family history No other family members had h/o head and neck cancer Obstetric and gynecology history Attained menopause – 19 years back , had 4 children all born by NVG, No h/o menorrhagia Dietary History Mixed diet, Nonalcoholic, tobacco chewer for past 5 years
- 7. CLINICAL EXAMINATION General physical examination • Conscious ,co-operative, oriented to time, place and person • Averagely built, adequately nourished , BMI – 26.66, MAC - 17 cm • Well hydrated • Pulse rate- 80/min, regular in rhythm, normal in volume and character • BP – 126 /88 mmHg , RR- 18 / min • ECOG - 1 , kernofsky- 90 • No Pallor / icterus / cyanosis / pedal edema / clubbing / lymphadenopathy • Poor oral dental hygiene – nicotine stained teeth
- 8. Systemic examination – Respiratory system/CVS/CNS - WNL P/a – abdomen was soft, no organomegaly present
- 10. INSPECTION Extra oral examination • Facial symmetry was distorted • There was fullness present in the region of adjacent to ulcer in the mouth which was around 5x 4 cm • No skin erythema, scar / sinus / fistula • Mouth opening was adequate • No fullness seen in neck • Possible flap donor sites inspected and found adequate
- 12. Intra oral – an Ulcero-proliferative growth of size approx 6x5 cm irregular shape present in right vestibule involving cheek mucosa and extending to gingiva of right lower canine and premolars. • extent- 3 cm below upper gingiva buccal sulcus and abutting lower GB sulcus 1.5 -2 cm behind the right commissure uptil the 2nd molar • Ulcer - Everting edges, irregular margins, floor formed by unhealthy granulation tissue with slough present • Dentition was incomplete with absent teeth • Teeth absent – B/l upper and lower 2nd premolars , B/l lower 1st molars, left lower canine • Dental caries present in the remaining teeth and upper premolars had sharp edges, remaining molars were displaced
- 13. • Poor orodental hygiene - Nicotine stained teeth and palate • Patches of leucoplakia , erythroplakia present • Melanoplakic patch over palate • No other synchronous lesion • Tongue was freely mobile • Retromolar trigone free • Grade 2 trismus
- 14. PALPATION • Non- Tender swelling • No increase in local temperature • Ulceroproliferative growth of size 5x4 cm present In the right gingivosulcus region, irregular surface, firm in consistency, everted margin, surrounding skin of around 1 cm was indurated, lesion was fixed to underlying buccinator muscle. • Masseter and pterygoid muscles were free . • Cheek Skin over the swelling was pinchable and free from ulcer • No fixity to underlying bone • Sensation over tongue was normal , and taste sensation was preserved • Sensations present in infraorbital and inferior alveolar nerve territory • Mouth opening ( inter incisor distance- 3 cm) • No loose teeth however the edges of teeth were pointed
- 15. • Cranial nerves 5,7,9,10 ,11 and 12 examination done and was found to be normal Examination of neck • Trachea appeared to be central • No clinical neck lymphadenopathy • Common Carotid pulsation was felt at normal site in both side • Examination of cervical spine normal • Examination of ear, nose ,throat and scalp was normal
- 16. Diagnosis • 55 years old lady with ulcero-proliferative growth of lower right gingivobuccal sulcus for 6 months probably SCC of cT3 N0 M0 of stage III without complications
- 17. Investigations • To confirm my diagnosis • To stage the disease • To treat the patient
- 18. To confirm my diagnosis • Edge / punch biopsy • USG of neck then USG guided FNAC of lymph nodes to confirm neck metastasis
- 19. To stage the disease • OPG • CT contrast face and neck to evaluate precise extent of involvement • CXR PA – lung metastasis • Indirect laryngoscopy for synchronous malignancies • USG abdomen • Bone scan for possible bony involvement
- 20. To treat the patient • PAC fitness investigations • Doppler for perforators for flap
- 21. Management • Three dimensional WLE + segmental mandibulectomy + functional neck dissection and reconstruction with Free fibula bone graft with skin paddle
Editor's Notes
- 6 s of ulceration- spirit , sharp tooth ,syphilis , spices, smoking and sepsis
- Significant ??? More than 10% in 3 months dhili kapdhe
- Examined in well lighted room , after taking informed consent and in presence of female attendant 80/min in right radial artery , which Kernofsky level of Functional Capacity Able to carry on normal activity and to work; no special care needed. No complaints; no evidence of disease 100% Able to carry on normal activity; minor signs or symptoms of disease 90% Normal activity with effort; some signs or symptoms of disease 80% Unable to work; able to live at home and care for most personal needs; varying amount of assistance needed Cares for self; unable to carry on normal activity or to do active work 70% Requires occasional assistance but is able to care for most personal needs 60% Requires considerable assistance and frequent medical care. 50% Unable to care for self; requires equivalent of institutional or hospital care; diseases may be progressing rapidly Disabled; requires special care and assistance 40% Severely disabled; hospital admission indicated although death not imminent 30% Very sick; hospital admission necessary; active supportive treatment necessary. 20 Moribund; fatal processes progressing rapidly. 10% Dead. 0%
- Vestibule- the space between the soft tissue (lips and cheeks), and the teeth and gums
- Synchronous metachronus lesion - Synchronous cancers were defined as those occurring within 6 months of the first primary cancer, while metachronous cancers were defined as those occurring more than 6 months later (12). Erythroplakia , Leukoplakia
- Lingual nerve The inferior alveolar nerves supply sensation to the lower teeth, and, via the mental nerve, sensation to the chin and lower lip.
- Cortical bone involvement Under anaesthesia