the important matter in covered in oral cancer

1. ORAL CANCER

2. • • 1.6 % of all malignancies in women (usa, 15th) – in 2006 it was the
12th most common
• • 3 % of all estimated new cases of cancer in men (usa, 8th) – in 2006
it was the 6th most common – india: most common malignancy •
• 2008: 25,310 new cases in men – less than 3% of expected deaths •
• 94% of malignancies are scca

3. • • middle aged and older individuals – disturbing number of younger
adults •
• three categories – oral cavity proper, lip vermilion, oropharynx •
• male: female=2:1 • incidence: 8/100,000 •
• cau males 65 or older have the highest incidence – afram middle-
aged males have the highest incidence rate of oral cavity proper and
oropharynx – cau males highest of lip vermilion – afram increasing
incidence; cau decreasing

4. • tobacco smoking (squamous cell carcinoma)
• • indirect evidence – 80% of patients are smokers – chance for 2nd
primary of upper aerodigestive tract is 2x to 6x greater in patients
who continue smoking after treatment – pipe and cigar carries
greater risk – reverse smoking (50% of palatal scca in such cultures)
– risk is dose dependent

6. • smokeless tobacco
• • users have increased risk • most cancers develop at the site of
placement •
• • scca of the placement location more common among women than men
in geographic areas where more women than men use dry snuff •
• much lower cancer risk than smoked

7. • betel quid (paan)
• • areca palm nuts, betel leaf, slaked lime, tobacco leaf • oral
submucous fibrosis • 600,000,000 people use it • 8% lifetime risk

8. • Alcohol
• • Consumption and abuse •
• Association with tobacco • Alcohol and tobacco abuse •
• One third of oral cancer patients are heavy users •
• 20% of oral cancer patients have cirrhosis

9. • phenols
• • workers in the wood product industry • nasal and nasopharyngeal
carcinoma
• Radiation
• • Actinic radiation •
• X-irradiation: therapeutic & dental

10. • iron deficiency
• • plummer-vinson syndrome •
• cancer of the upper aerodigestive tract • esophageal webs •
• analysis of last english language case reports published in the
literature during the last 7 years (1999–2005) revealed that 25 out
of the 28 adult patients with plummer-vinson syndrome were women
(89 %)

11. • oncogenic viruses
• • hpv: 16, 18, 31, 33 •
• hsv: most likely not •
• hiv : indirectly – immunosuppression •
• ebv: lymphoma, nasopharyngeal carcinoma

12. • squamous cell carcinoma
• • tongue – more than 50% of cases – posterior lateral border and
ventral surfaces • floor of mouth (more common in men than women) •
extension to soft palate/tonsils; “horseshoe” area • less common:
gingiva, buccal mucosa, labial mucosa, hard palate

13. • • white •
• red •
• white and red •
• exophytic (fungating, papillary, verruciform) – indurated •
• endophytic (ulcerated, invasive, burrowing) – rolled border

14. • • pain is not a reliable indicator •
• small carcinomas are usually painless •
• larger often painful due to infiltration •
• lesions may mimic reactive processes •
• lesions may appear innocuous

15. SIGNS AND SYMPTOMS
Initially may be asymptomatic and patients are most often identified
only after development of symptoms …main problem is that of
discomfort can be diagnosed in 85% of the patients.. Patient may also
present with awareness of mass in mouth or neck
the oral cavity should ne examined after carefully examining cervical
submandibular lymph nodes

16. • lymphatic spread usually involves uppermost nodes ,the
submandibular and digastric nodes ,upper cervical lymph
nodes
• the nodes are usually non tender unless secondarily
infected

17. STAGING OF ORAL CANCER
TNM CLASSIFICATION

18. • tumor size –
• x cannot be assessed –
• 0 no evidence of primary tumor –
• 1s ca in situ at primary site –
• 1-primary tumor=2cm
• 2 >2and=4
• 3 >4 cm –not fixed to underlyng structures)
• 4 primary tumor; ( fixed to other structures)
• 4a invasion through cortical bone
• 4b invasion in to masticatory space,pterygoid plates or skull base or encompasses
ICA

19. nodal involvement (regional)
• •–
• 0 no clinically positive nodes –
• 1 clinically positive homolateral node = 3cm – •
• 2a single homolateral node =3cm but <6cm
• • 2b multiple homolateral node or nodes all < 6cm
• 3a homolateral node or nodes one >6cm •
• 3b bilateral •
• 3c contralateral

20. metastases
• –
• 0 no evidence of distant metastasis –
• 1 distant metastasis present

21. CLINICAL STAGING
• STAGE I T1N0M0
85%
• STAGE II T2N0M0
66% •
• STAGE III T3N0M0
41% •
• STAGE III T1N1M0 •
• STAGE III T2N1M0 •
• STAGE III T3N1M0 •
• STAGE IV A T1,T2,T3,N2,M0 OR T4A,ANY N,M0
9%

22. metastasis
• • metastatic nodes are firm and feel “fixed” •
• extracapsular spread •
• homolateral and contralateral •
• lower lip, floor of mouth-submental nodes •
• posterior mouth -superior jugular and digastric
• • oropharynx-jugulodigastric node

23. EVALUATION OF THE
SUSPECTED CA LESION

24. • exfoliative cytology
• toluidine blue staining
• toluidine blue + lugol’s iodine
• incisional/excisional biopsy
• FNAB
• brush biopsy/Oroscan
• vizilite

25. toluidine blue
• topical application is followed by 1.0% acetic acid.
• the dye retained predominantly in the abnormal nuclei of the tumor
cells , produces area of uptake seen as directly blue stained tissue.
rinsing is performed to remove dye retained by debris or within
irregularities of the mucosal surface
• biopsy must be performed in those areas where uptake is positive.

26. • smear techniques have a good screening utility and normally
do not have much application in dental clinics because they
are non conclusive and negative smear report does not have
much value .
• if positive still biopsy needs to be done.

27. • toluidine blue stains the abnormal cells and lugols iodine
stains the normal area brown the colour contrast makes it
easier to identify biopsy site. Once the lesion is identified
• Following method can be used

28. BIOPSY PROCEDURE
• suitable block –lignocaine 2-4cc
• 000 silk suture introduced in the tissue
• than suture is elevated and an elliptical incision made around this
tissue so that 33% of normal area can be included.
• specimen to be gently washed under water and than kept in 10%
formalin, which should be 10 times the tissue mass.

29. TREATMENT

30. • surgery
• radiation therapy
• combination of surgery and radiation
• Chemotherapy
• Gene therapy
• Immunotherapy/biotherapy
• Lasers
• Cryosurgery and hyperthermia

31. RADIOTHERAPY
• radiotherapy kills cancer cells because it damages dna.
cancer cells are more prone to damage than normal cells
because of their high multiplying rate and their reduced
ability to repair themselves. radiotherapy is usually given
using x-rays;
•

32. • radiotherapy beams are usually x-rays given at a higher dose than
normal x-rays and are pointed directly at the cancer.
• a radiotherapy treatment session is where a number of radiotherapy
beams are
• given one after the other, each pointing at the cancer from a
different angle.
• radiotherapy treatment session usually takes around 10-30 minutes.
• .

33. • a radiotherapy treatment course is the number of radiotherapy
treatment sessions
• required to complete the curative radiotherapy course. in a typical
radiotherapy
• course, there are around 20 - 40 daily radiotherapy treatment
sessions spread over 4 - 8 weeks

34. • for most epithelial malignancies ,radiation is delievered in 1.8 to 2 gy
per fraction for 5 weeks to a total dose of 6000 to 6500cgy in 3
weeks.
• lymphomas a re usually ttd in the head and neck to a total dose of
3500 to 5000cgy

35. EXTERNAL BEAM RADIOTHERAPY (EBRT)
•
• external beam radiotherapy is the traditional method of giving
radiotherapy and still the best treatment in many cases.
• the patient lies on a radiotherapy bed in the same position every day
for a radiotherapy treatment session. in each session, between 2-4
radiotherapy beams are given.

36. • A radiotherapy beam is switched on to deliver the beam.
Then the radiotherapy machine moves into a different
position before giving the next beam from a different
angle. The machine that gives the radiotherapy is called a
linear accelerator (or a “linac”).

37. BRACHYTHERAPY
• interstitial and intracavitary implants are used to treat primary
cancers in head and neck
• they may be used as a primary tt modality for tumors localized to ant
2/3rds of oral cavity, to boost dose to a site, tt following recurrence
.
• isotopes used are cesium, iridium,and gold seeds.

38. • INTENSITY-MODULATED RADIATION THERAPY (IMRT)
•
• intensity-modulated radiation therapy (imrt) is a way of
giving radiotherapy that enables doctors to precisely shape
the radiation beam around the cancer while keeping the
dose away from normal cells

39. • 2 VOLUMETRIC MODULATED ARC THERAPY (VMAT)
•
• volumetric modulated arc therapy (vmat) treatment is very similar to
imrt it produces the same result as imrt but is up to eight times
faster.
•
• vmat is also known as rapidarc. .
•
•

40. • IMAGE GUIDED RADIOTHERAPY (IGRT)
•
• image guided radiotherapy (igrt) is the use of different types of
pictures to help improve the number of times we hit the cancer and
to make sure we miss the normal cells.

41. • STEREOTACTIC ABLATIVE BODY RADIOTHERAPY
(SABR)
• stereotactic ablative body radiotherapy (sabr) is also known as
stereotactic body radiotherapy (sbrt).
• sabr is different to normal radiotherapy because instead of giving a
little radiotherapy everyday over four to eight weeks, we give a big
dose over only three to five days. this adds up to a much bigger dose
overall so it is better at killing the cancer and cures more people

42. • PROTON THERAPY
•
• proton therapy is a form of radiotherapy that does not use
traditional x-rays. proton beams are different because they do
not go all the way through the body, they stop at the area of
the cancer and deliver most of the dose to that area.

43. • INTRA-OPERATIVE RADIOTHERAPY (IORT)
• intra-operative radiotherapy (iort) is usually for patients who have
had their cancer removed with an operation where there is a small
chance of left over cancer cells. usually patients will get ebrt to get
rid of these left over cancer cells.
• with iort, the radiotherapy is given while the patient is under
anaesthetic usually at the time of their cancer operation (although it
can be given at a separate operation).

44. • MOLECULAR RADIOTHERAPY
• cancer cells take up different molecules to help them grow
or develop. molecular radiotherapy takes advantage of this
by creating either a ‘copy cat’ molecule that looks like the
one the cancer needs or by making the actual molecule the
cancer needs. we then make these molecules radioactive so
that they produce radiotherapy.

45. • this can be done by making the molecule unstable so it
breaks down. these molecules are then injected into the
patient and the cancer cells take them up. the molecules
that have been taken into the cancer cells then produce
radiotherapy and cause the cancer cells to die.

46. advances in radiotherapy currently
• include use of heavy charged particles(neutrons) which provide
more focussed distribution of cellular damage and are less
sensitive to hypoxia than conventional radiation sources.
• hyperfractionation is the use of more than one fraction of
radiation each day of therapy. improved tumor control may be
achieved and late complications may be reduced. but chances of
mucositis increases.

47. SURGERY
• small lesions are excised leaving 1 cm margin around and larger type
may need a commando like operation. Surgery is indicate for
• Tumor involving bone when side effects are less of surgery
• Tumors that lack senstiviy to radiation
• Recurrent tumor that earlier was treated with radiotherapy.

48. COMBINED RADIATION AND SURGERY
• THE ADVANTAGES OF PREOPERATIVE RADIATION ARE DESTRUCTION OF
PERIPHERAL TUMOR CELLS
• POTENTIAL CONTROL OF SUBCLINICAL DISEASE
• CONVERSION OF INOPERABLE TO OPERABLE.
• DISADVANTAGES INCLUDE
• EXACT TUMOR EXTENT, DELAYED SURGERY AND POST SURGICAL HEALING.

49. • pre radiation surgery can be used to remove the bulk of tumor
containing hypoxic cells
• in extensiive carcinoma post operative radiotherapy is chosen

50. CHEMOTHERAPY
• SEVERAL DRUGS ARE EFFECTIVE WHEN USED SINGLY BUT RESPONSE RATES ARE
LOW AND RESPONSE RATES SHORT
• DRUGS
• METHOTREXATE
• CISPLATIN
• BLEOMYCIN
• 5-FLUOROURACIL

51. LASERS IN CANCER THERAPY
• advantages of co2 laser include precise excision with microscopic
control,minimal blood cells, the sealing of lymphatics,possibly
decreasing the tumor cell spread and decreased post operative
oedema.
• photodymanic therapy kills the cancerous tissue and the precancerous
tissue , but not the normal tissue. photodynamic therapy used a laser
to produce a chemical reaction that kills the cancer cells without
harming healthy tissue.

52. CRYOSURGERY AND HYPERTHERMIA
• they are infrequently used as primary treatment measures
in management of oc.
• cryosurgery involve use of liquid nitrogen in the sudden
death of tumor cells. it is most frequently used for control
of early lesions in debilitated or in a palliation of non
resectable lesions.

53. GENE THERAPY
• gene therapy for oral cancer is currently under
investigation in clinical trials . the goal of cancer gene
therapy is to introduce new genetic material into target
cells without toxicity to non target tissues.
• adenovirus vectors are commonly used in gene therapy
trials because of their efficiency in gene transfer.

54. • immunotherapy/biotherapy
it is designed to repair,stimulate,or enhance body’s own
immune responses. treatments such as interferon and colony
stimulating factor are used either alone or in conjunction
with other modalities such as surgery radiation, chemo for
beter prognosis.

55. • BIOTHERAPY MAY BE USED
• to control ,stop or suppress processes that permit ca growth
• make ca cells more recognizable, more susceptible to obstruction by our
immune system
• boost the killing power of immune system cells , such as t cells, nk cells and
macrophages.
• Enhance body’s ability to repair or replace normal cells damaged or
destroyed by other forms of ca treatment; such as chemotherapy.

56. COMPLICATION OF CANCER TREATMENT
• MUCOSITIS
• XEROSTOMIA
• CANDIDIASIS
• CARIES
• TISSUE NECROSIS
• SPEECH,MASTICATION,NUTRITION
• MANDIBULAR DYSFUNCTION
• DENTOFACIAL ABNORMALITIES
• PAIN