how to manage oral cancer cases

1. Dr. REVATHY MOHAN
Lecturer
Malabar Dental College &
Research Centre

2. INTRODUCTION
 There are three recognized treatment
modalities for managing head and neck
cancer
surgery
radiotherapy
chemotherapy
 Stage I & Stage II cancers – surgery or
radiotherapy
 Stage III & Stage IV cancers – combination
of radiation therapy and surgery
 Treatment modalities are chosen based on
nature of tumor

3. Factors Influencing Choice Of
Treatment
1. Site and location of the primary
2. Size of tumor
3. Proximity to the bone
4. Status of nodal involvement
5. Histological typing of tumor
6. Ability to achieve adequate surgical
margins and preserve functions
7. Physical and mental status of patient
8. History of any treatment

4. I.SURGICAL MANAGEMENT
 Surgical treatment aims at complete
removal of the primary as well as the
metastatic nodes
 Never used as a palliative mode of
treatment
 The extent of resection of primary
lesion depends upon size and the
adjacent structures that may have
been infiltrated

5. Criteria For Choosing Surgical
Management:
 Tumors which are non-sensitive to radiation
 Tumors involving bone
 Recurrent tumors in sites that have been previously
irradiated
 To reduce bulk of tumor prior to radiation therapy
 Where side effects of surgery are expected to be less
significant than those associated with radiation
 When nodes are to be removed
 In palliative cases to reduce the bulk of the tumor and
to promote drainage from a blocked cavity

6. NECK DISSECTION(CERVICAL
LYMPHADENECTOMY)
 All lymph nodes are removed beginning from the
lower border of the mandible superiorly, to the
clavicular region inferiorly , and from the trapezius
muscle posteriorly and to the midline anteriorly
 Sternocleidomastoid muscle ,omohyoid muscle,
jugular vein and submandibular salivary gland are
resected
 Based on clinical involvement of lymph nodes,
neck dissections are categorized as;
Prophylactic – clinically non-palpable nodes
-may or may not be microscopically
involved
Therapeutic -clinically palpable nodes
-presumed to be microscopically
involved

7. COMMANDO SURGERY
 A combined resection wherein the primary
tumor , affected lymphatics and involved
adjacent structures are removed
MICROSCOPICALLY FROZEN SECTION
ORIENTED HISTOLOGIC SURGERY
(MOHS) TECHNIQUE
 Surgically resected specimens are
immediately frozen and histologically
analyzed to assess for clear margins
 Aid in removing all tumor cells

8. II . RADIATION THERAPY
 Plays an important role in the management of head
and neck cancer
MECHANISM:
 Normal tissue function depends primarily on cell
integrity and viability , as well as on the ability of
cells to replace and maintain their structure and
organization
 Radiation disrupts the electron orbital structure of
tissue atoms
 Ionizing radiation displace electrons from
molecules and atoms which they collide ,causing
ionization
 This induce cascade of events that may alter cells
transiently or permanently

9.  Cells are most vulnerable to injury when
they are in process of dividing and
multiplying
 Most important target of ionizing
radiation is DNA
 Radiation may damage the DNA:
- directly (Direct Target Theory)
- indirectly(Indirect Target Theory)
 Lipids in cell membrane and proteins that
function as critical enzymes are damaged
 Affected cells may die or remain incapable
of division
 A differential effect is achieved due to
- greater potential for cell repair in
normal tissue than in malignant cells
- higher growth fraction of cancer
cells

10.  Central tumor cells are less susceptible to
radiotherapy since they are relatively hypoxic
 When peripheral cells are affected by radiation
central cells become oxygenated and become
susceptible to subsequent fractions of radiation
Variations in response to radiotherapy
 More differentiated the tumor less will be the
response to radiotherapy
 Exophytic and well oxygenated tumors are more
radiosensitive
 Large invasive tumors with small growth
fractions are less responsive
 Tumors with bone involvement ,less probability
of cure

11. TYPES OF RADIOTHERAPY
RADIOTHERAPY
CURATIVE THERAPY
PALLIATIVE THERAPY
•Curative therapy : to eradicate the disease permanently
in the treated area.
•Palliative therapy: to achieve temporary improvement
in the patient’s condition when cure is rarely possible.

12. RADIATION DOSE
 Radiation dose needed for cancer is based on:
-Location of malignancy
-Type of malignancy
- Whether radiotherapy is used alone or in
combination with other modalities
 Head & neck carcinomas
– dose between 50 and 70 Gy
-over a 5 – 7 week period ,once a day,5 days a week,2 Gy
per fraction
 Low dose for preoperative radiotherapy or radiotherapy
for malignant lymphomas

13. FRACTIONATED RADIATION
-Helps to minimize normal tissue reaction
-Used because there is a difference in the responses of tumor
tissue and normal tissue
Clinical effects of fractionated radiotherapy are influenced
by;
- Ability to repair sublethal damage
- Reoxygenation of the tumor during course of radiation
- Repopulation of normal tissues and normal tissues
between fractions
- Redistribution of cells into a more sensitive phase in
cell cycle treatment

14. Various types of fractionation
 Conventional Fractionation
 Hyperfractionation
 Accelerated fractionation
 Accelerated hyperfractionation
 Concominant –Boost technique
 Hypofractionation
 Split course therapy

15. RADIATION TECHNIQUES
RADIATION TECHNIQUES
EXTERNAL BEAM
RADIATION
LOCAL IRRADIATION
(BRACHYTHERAPY)
SURFACE
IRRADIATION
INTRACAVITARY
IRRADIATION
INTERSTETIAL
IRRADIATION
DIRECT
ROENTGEN
THERAPY
INTERNAL
IRRADIATION

16. EXTERNAL BEAM IRRADIATION
 Irradiation from sources at a distance
from the body
 X-ray, teletherapy with radium-
226,cobalt-60,cesium-60
 SOURCES:
Low energy – orthovoltage : 50 –
300 kVp
High energy – cobalt 60 ; linear
accelerators (4 million electron volts)

17. LINEAR ACCELERATOR

18.  low energy beams – small sized intra oral tumors ,lip and skin
cancers
 high energy radiation –provides variable penetration due to its
ability to vary the energy of photons
-spares bone and skin
 Three principle field arrangements;
wedged pair fields
parallel opposed fields
three field technique
 Wedged pair fields
-allows therapeutic dose to unilateral disease while sparing a
high dose to opposite side
 Parallel opposed field and three field set up
-large tumor or midline lesion
-provides relatively uniform exposure for midline diseases

19. LOCAL IRRADIATION
(BRACHYTHERAPY)
 Irradiation from source in direct contact with
the tumor
1)SURFACE IRRADIATION
with applicators loaded with radioactive material
2)INTRACAVITARY IRRADIATION
with radioactive material in removable
applicators which are inserted into body
cavities,such as uterus ,
vagina,nasopharynx,maxillary sinus etc

20. 3)INTERSTETIAL IRRADIATION
 By ;
removable needles contain radium 226,
cobalt 60 , cesium 137
non removable seeds – radioactive gold
198 or radon
small radioactive irridium sources in
nylon suture
radioactive tantalum 182 wire
 The radioisotope are implanted into the
tumor
4)DIRECT ROENTGEN THERAPY
 to epithelial lesions by means of cones
 transvaginal , intraoral

21. 5)INTERNAL / SYSTEMIC IRRADIATION
 Radioactive sources administered intravenously or
parentrally
 Radioactive iodine – thyroid cancer
 Phosphorus 32 – polycythemia vera

22. SELECTION CRITERIA
 Easily accessible lesions
 Early stage diseases
 Well localised tumor
 No nodal or distant metastasis
 No local infection/inflammation

24. ADVANTAGES
 High biological efficiency
 Tolerable acute reaction
 Decreased risk of tumor population
 Better cosmesis
 Minimal radiation morbidity
DISADVANTAGES
 Difficult for inaccessible regions
 Limited for small tumors
 Invasive procedure
 Small errors in placement of sources lead to extreme changes
from intended dose distribution
 Costly

25. ADVANTAGES OF RADIOTHERAPY
 1) no tissue or functional loss
 2)better cosmetic outcome
 3)can simultaneously treat multiple
primaries
 4)control of subclinical disease in regional
nodes is possible without added morbidity
 5)better surgical salvage of radiotherapy
failures than radiotherapy of surgical failures
 6)lesion can be treated in situ and need for
tissue removal is avoided
 7) primary tumors of posterior third of the
tongue,oropharynx,and tonsillar pillars can
be easily treated

26. DISADVANTAGES OF RADIOTHERAPY
 1)undesirable acute side effects such
as painful mucositis, loss of taste,
dryness of mouth etc
 2)potential late complications of soft
tissues and bone
 3)development of secondary tumors
 4)protracted treatment cause
 5)requires good infrastructures

27. EFFECTS OF RADIATION THERAPY
 Hyperpigmentation of skin
 Transient loss of hair
 Mucositis
 Loss of taste
 Salivary dysfunction
 Radiation caries
 Candidiasis
 Fungal infections
 Pain
 Osteoradionecrosis

28. RECENT DEVELOPMENTS IN
RADIOTHERAPY
 IMRT
 IGRT
 Combined radiation and chemotherapy
IMRT(INTENSITY MODULATED
RADIATION THERAPY)
 Employs a computer directed radiation
source that targets the cancer more
accurately than conventional radiation
therapy
 Maximise dose to tumor targets while
limiting dose to normal structures

29.  Advantage – significantly limit dose deposition to
normal structures
 Disadvantage – increased volume of normal tissue
exposure
IGRT(Image Guided Radiotherapy)
 Additional ability to modify dose , fields and radiation
 Integrated CT guides the changes in radiation
throughout course of treatment
Combined radiation and chemotherapy
 Administering drugs prior to treatment

30. III. CHEMOTHERAPY
 Used as an induction therapy prior to local
therapies
 Adjuvant after local treatment
 Objective : to promote initial tumor reduction
:to provide early treatment of
micrometastases
 Goal : to eradicate rapidly growing cells of
tumor or modify their growth
 Affects rapidly dividing cells of target tumor
and lining epithelium, the oral ecology and
vascular ,inflammatory and healing responses
of oral cavity

31. DRUGS USED IN ORAL CANCER
CHEMOTHERAPY
 Methotrexate
 Bleomycin
 Taxol and derivatives
 Platinum derivatives (cis platin &
carboplatin )
 5- flurouracil

32. METHOTREXATE
 Antimetabolic chemotherapeutic agent
 Inhibitor of folic acid metabolism
 Prolonged contact of tumor cell population
with antimetabolite will result in sequential
death of cells
 Administered either intra arterially or per orally
 Systemic methotrexate is given in intermittent
weekly or semiweekly IV injections of 40 – 60
mg/m2 of body surface area

33. Adverse effects:
 Gastric erosion
 Alopecia
 Bone marrow depression
 Renal toxicity
 Hepatic toxicity
 Seizures and meningitis

34. BLEOMYCIN
 Group of antibiotics
 Isolated from Streptomysis verticillus
 Acts by interfering with DNA function of the cell
 Ideal dose- 0.25 – 0.50 unit /kg ,weekly /twice weekly
 Do not exceed a dose of 400 units since it cause
pulmonary toxicity and death
 Advantage- lack of causing myelosuppression
 Adverse effects : skin rashes
:erythema

35. CISPLATIN
Relatively new drug
Acts by altering DNA structure
Given IV ,80- 120 mg/m2,for 3 weeks
Causes dehydration and renal impairement
Therefore it is important to maintain adequate
hydration before administration

36. 5- FLUROURACIL
 Usually administered along with
cis platin
 Inhibit enzyme Thymidilate
synthetaserequired for thymidine
synthesis
 Standard dosage – 1000
mg/m2/day
 Adverse effects – stomatitis
-bone marrow
suppression

38. TOXIC EFFECTS OF CHEMOTHERAPY
 Mucositis
 Nausea
 Vomiting
 Alopecia
 Bone marrow suppression

39. BIBLIOGRAPHY
 Textbook of Oral Medicine Oral Diagnosis & Oral
Radiology – Ravikiran Ongole,Praveen B N
 Burket’s Oral Medicine
 Textbook of Dental & Maxillofacial Radiology – Freny
R. Karjodkar
 Essentials for Pharmacology for Dentistry –
K.D.Tripathi
 Internet