Oral cancer ppt oncology

1. ORAL CANCER

2. • Oral cancer is cancer that develops in the tissues
of the mouth or throat.
• Oral cancer, which includes cancers of the lips,
tongue, cheeks, floor of the mouth, hard and soft
palate, sinuses, and pharynx (throat), can be life
threatening if not diagnosed and treated early.

3. Epidemiology
• Men have twice the risk of developing oral
cancer as women, and men who are over age
50 face the greatest risk.

4. Types of oral cancer
PREMALIGNANT
• Leukoplakia :Leukoplakia appears as thick, white patches on
the inside surfaces of your mouth
MALIGNANT
• Squamous cell carcinoma: most common type of mouth
cancer .Malignant growth arising from tiny, flat,
squamous cells that lines mucous membrane. Mostly
affects lower lip, tongue
• Basal cell carcinoma : 2nd most common inoral cancer.
Occurs on lips. Caused by excessive exposure to
sunlight

5. Less common types of mouth cancer include:
Oral malignant melanoma – where the cancer starts in cells
called melanocytes, which help give skin its color
Adenocarcinomas – cancers that develop inside the salivary
glands

6. Risk factors for the development of oral
cancer
• Smoking
• Smokeless tobacco users
• Excessive consumption of alcohol
• Family history of cancer.
• Excessive sun exposure
• Human papillomavirus (HPV).
• Weakened immune system
• Poor nutrition

7. Pathophysiology of oral cancer
ETIOLOGY AND PRECIPITATINGFACTORS
MUTATION OF PRO ONCOGENE
CHANGES IN CELLULAR STRUCTURE AND
FUNCTION
ABNORMAL PROLIFERATION
FORMATION OF MASS TUMOR
INVADE SURROUNDING TISSUES/LYMPHNODES

8. Symptoms of Oral Cancer
• Many oral cancers produce few or no symptoms
in the early stages
• Swellings/thickenings, lumps or bumps, rough
spots/crusts/or eroded areas on the lips, gums,
or other areas inside the mouth
• The most common and frequent symptom is
persistent painless sore or mass that does not
heal with in 2 weeks.

9. Symptoms of Oral Cancer
• Lesions in oral cancer is painless,
indurated(hardened)ulcer with raised edges
• Erythroplakia,leukoplakia
• In advanced stages
 Bleeding in the mouth
 Numbness, pain/tenderness in any area of
the face, mouth, or neck

10. Symptoms of Oral Cancer
A soreness or feeling that something is caught in
the back of the throat
Difficulty chewing or swallowing, speaking, or
moving the jaw or tongue
Hoarseness, chronic sore throat, or change in
voice, coughing of bloodtinged sputum
 Ear pain
 Changes in position of teethor ill fitting dentures
 Dramatic weight loss

11. STAGING OF ORAL CANCER
Stage 0
Stage 0 is also called carcinoma in situ, and this is the very
beginning of the scale. It describes abnormal cells in the lining
of the lips or oral cavity, which have the potential to become
cancer.
Stage I
Stage I describes a very early stage of cancer. The tumor
is not more than 2 centimeters, and the cancer has not
reached the lymph nodes.

12. Stage II
Stage II describes a tumor that is larger than 2 centimeters
but not more than 4 centimeters. Stage II cancer has not
reached the lymph nodes.
Stage III
Stage III mouth cancer describes cancer that either is
larger than 4 centimeters or has spread to a lymph node in the
neck.

13. Stage IV
Stage IV is the most advanced stage of mouth cancer. It
may be any size, but it has spread to:
Nearby tissue, such as the jaw or other parts of the oral
cavity
One large lymph node (more than 3 centimeters in size) and
on the same side of the neck as the tumor, multiple lymph
nodes of any size on the same side of the neck as the tumor,
or one lymph node of any size on the side of the neck opposite
the tumor
Distant parts of the body beyond the mouth, such as the
lungs

14. Staging of oral cancer – TNM CLASSIFICATION
Tumor (T)
• Using the TNM system, the "T" plus a letter or
number (0 to 4) is used to describe the size
and location of the tumor.
.

15. TX Primary tumor cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1 Tumour 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 Tumour more than 4 cm in greatest dimension
T4a (lip) Tumour invades through cortical bone, inferior alveolar nerve, floor
of mouth, or skin (chin or nose)
T4a (oral
cavity)
Tumor invades through cortical bone, into deep/extrinsic muscle
of tongue (genioglossus, hyoglossus, palatoglossus, and
styloglossus), maxillary sinus, or skin of face
T4b (lip
and oral
cavity)
Tumor invades masticator space, pterygoid plates, or skull base;
or encases internal carotidartery

16. Node (N)
• The “N” in the TNM staging system stands for
lymph nodes.
• When cancer has spread through a lymph
node and into the tissues directly surrounding
it, it is called Extra Nodal Extension (ENE).

17. N
X
Regional lymph nodes cannot be
assessed
N0 No regional lymph node
metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
N2
a
Metastasis in a single ipsilateral lymph node, more than 3 cm but
not more than 6 cm in greatest dimension
N2b Metastasis in multiple ipsilaterallymph nodes, none more than 6 cm
in greatest dimension
N2
c
Metastasis in bilateral or contralateral lymph nodes, none more than
6 cm in greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest
dimension

18. M0 No distant metastasis
M1 Distant metastasis
M - Distant metastasis

19. Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N0, N1 M0
Stage IVA T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1
STAGING

20. SIGNS AND SYMPTOMS
Many oral cancers produce few or no symptoms in the early
stages
Later, the most frequent symptom is a “ painless sore or
mass that will not heal.
A lip or mouth sore that doesn't heal
A white or reddish patch on the inside of your mouth
Loose teeth
A growth or lump inside your mouth
Mouth pain
Ear pain
Difficult or painful swallowing

21.  Voice changes
 Lump or mass in the neck
 Weight loss
 Persistent bad breath
 It can go unnoticed it can be painless
 lymphadenopathy

22. Diagnosis of oral cancer
• History collection
• Physical examination
• X-ray
• Toluidine blue test
• Magnetic resonance imaging (MRI) scan
• Computerized tomography (CT) scan
• Positron emission tomography (PET) scan
• Biopsy
Remove a small sample of affected tissue to
check for the presence of cancerous cells.

23. PUNCH BIOPSY
• A punch biopsy may be used if the suspected affected area of tissue
is in an easily accessible place, such as your tongue or the inside of
your mouth. The area is first injected with a local anesthetic to
numb it. The doctor will then cut away a small section of affected
tissue and remove it with tweezers. The procedure is not painful, but
can feel a little uncomfortable.

24. FINE NEEDLE ASPIRATION (FNA)
• A fine needle aspiration (FNA) is a type of biopsy used if it is
suspected that a swelling in neck is the result of mouth cancer.

25. PAN ENDOSCOPY
• A pan endoscopy is a procedure used to obtain
a biopsy when the suspected tissue is at the
back of throat or inside nasal cavities.

26. Management of oral cancer
• Early-stage (I and II) oral carcinoma can be treated
with surgery or radiation.
• In advanced stage (III and IV) oral squamous cell carcinoma,
a combination of surgery and radiation therapy

27. SURGERY
• Surgery is often the first treatment used for these cancers.
It's most commonly used for early stage cancers, those that
are small and haven't spread.
• After cancer is removed, reconstructive surgery can be
done to help restore the appearance and function of the
areas affected by the cancer or cancer treatment.

28. Tumor resection
• In a tumor resection, the entire tumor and a margin (edge)
of normal-looking tissue around it is removed (resected).
• The margin of normal tissue is taken out to reduce the
chance of any cancer cells being left behind.
• The main (primary) tumor is removed using a method
based on its size and location. For example, if a tumor is in
the front of the mouth, it might be relatively easy to remove
it through the mouth.

29. Mandibulotomy .In case of larger tumor (especially when it
has grown into the oropharynx) may need to be removed
through an incision (cut) in the neck or by cutting the jaw
bone with a special saw to get to the tumor.

30.  Mandibulectomy (mandibular resection) Removes all ( total
Mandibulectomy) or part of the jaw bone (partial thickness
mandibular resection or marginal mandibulectomy).
• This operation may be needed if the tumor has grown into
the jaw bone.

31. Mohs (micrographically oriented histographic
surgery)
Mohs surgery, is a precise surgical technique in which the
complete excision of skin cancer is checked by microscopic
margin control. It offers the highest cure rates while maximizing
preservation of healthy tissue.
Some cancers of the lip may be removed by Mohs surgery. The
tumor is removed in very thin slices. Each slice islooked at right
away under the microscope to see if there are cancer cells. Slices are
removed and examined until no cancer cells are seen.

32. Glossectomy (removal of the tongue)
Glossectomy may be needed to treat cancer of the tongue.
partial glossectomy -For smaller cancers, only part of the
tongue (less then 1/3) may need to be removed.
Total glossectomy-For larger cancers, the entire tongue may
need to be removed

33. Maxillectomy
• If cancer has grown into the hard palate all
(maxillectomy) or part of the involved bone (partial
maxillectomy )is removed.

34. Laryngectomy (removal of the voice box)
Very rarely, surgery to remove large tumors of the tongue or
oropharynx may require removing voice box (larynx).
When the voice box is removed, the windpipe (trachea) is
attached to a hole (stoma) made in the skin in the front of the
neck. This is called tracheostomy or trach (trake).

35. Neck dissection
• Cancers of the oral cavity and oropharynx often spread
to the lymph nodes in the neck. Removingthese lymph
nodes (and other nearby tissues) is calleda neck
dissection or lymph node dissection and is done at the
same time as the surgery to remove the main tumor.

37. There are several types of neck dissection procedures
• In a partial or selective neck dissection only a fewlymph
nodes are removed.
• For a modified radical neck dissection, most lymph nodes
on one side of the neck between the jaw bone and
collarbone are removed, as well as some muscle and nerve
tissue.
• In a radical neck dissection, nearly all nodes on one side, as
well as even more muscles, nerves, andveins are removed.

38. RECONSTRUCTIVE SURGERY
 Operations may be needed to help restore the
structure of areas affected by more extensive
surgeries to remove the cancer.
SPLIT THICKNESS
Split-thickness skin grafts are composed of full-
thickness epidermis and partial-thickness
dermis, and they most commonly range in
thickness between 0.015 inches and 0.20
inches

39. SKIN GRAFT
A cutaneous flap
A skin flap consists of skin and subcutaneous tissue that
survives based on its own blood supply.
A myocutaneous flap
A skin flap consists of subcutaneous tissue, muscle and skin.
A microvascular free flap
Microvascular free-tissue transfer to the head and neck has
become an accepted method of reconstruction owing to
increased success rates. The large number of arteries and
veins in the neck make free-flap revascularization easier than
in other recipient sites of the body

40. NON SURGICAL THERAPY

41. chemotherapy
• 5 flurouracil
• Methotrexate
• Cisplastin
• Carboplatin
• Paclitaxel
• bleomycin

42. Radiation therapy
• Combination of interstitial implants and external
beam radiation

43. BRACHYTHERAPY
Brachytherapy is a type of internal radiation therapy in which
seeds, ribbons, or capsules that contain a radiation source are
placed in your body, in or near the tumor.

44. Pre operative nursing management
GENERAL PREOPERATIVEASSESSMENT
• Obtain surgical consent
• Obtain a thorough medical history and perform a physical
examination.
• Specific diagnostics
▫ Laboratory tests
▫ Preoperative cardiac assessment
▫ Preoperative pulmonary assessment
▫ Preoperative nutritional statusassessment
▫ Pre anesthetic consent

45. Pre operative nursing diagnosis
• Chronic pain related to tumor
invasion to surrounding tissues
• Imbalanced nutritional status less than
body requirement related to dysphagia
• Impaired oral mucous membrane related to
cancer of oral cavity

46. 1)Maintain adequate nutrition
 NG tube feeding
 Enteral feeding
 Parenteral feeding
2)Promote verbalcommunication
 Use of paper and pen
 Use of pictures
 Use of gestures
3)Pain management
 Analgesics to reducepain
 Comfortable position
 Use topical anesthetics, either painted or sprayed onto the
painful areas or swished over the mucosa’s surface. Two topical
anesthetics used are dyclonine and benzocaine.
 Systemic analgesics include aspirin, acetaminophen,
propoxyphene, and codeine.
4)Promote oral hygiene

47. Pre operative teaching
• Informed about the type of surgery, type of unit,health
care team
• Airway maintenance after surgery. Emphasis about need
for stoma care, humidification,suctioning
 Provide communication training- teach alternative forms of
communication and use of laryngeal communication
devices
 Educate regarding enteralnutrition
 Preventing constipation
 In case of emergency alerting healthcare personnel
 Get access to information resources and support groups

48. Nursing Diagnosis
• Chronic pain related tosurgery
• Risk for ineffective airway clearance relatedto surgery
• Imbalanced nutritional status less than body
requirement related to oral surgery
• Impaired oral mucous membrane related to surgery of oral
cavity
• Impaired verbal communication related to excision of
tongue
or larynx
• Ineffective coping related to hospitalization
• Ineffective health maintenance related to hospitalisation
• Disturbed body image related to surgical excision
• Risk for bleeding related to surgery
• Risk for infection related to surgical incision/low
immune status

49. Post operative nursing management
Pain management-
▫ pain assessment and medication administration.
▫ Comfortable position
▫ Promote drainage of
secretions
Ensure airway patency
o Assess airway patency and respiratory status every hour
until stable
o Propped up position with supporting arms
o Deep breathing and coughing exercises as tolerable every 2
to 4 hours
Control of postoperative bleeding
Prophylactic antibiotic
administration

50. Post operative nursing management
• Nutritional management
 NPO Usually 7 to 10 days after surgery-To allow mucosal suture line
and surgical sites to heal by preventing stress or pressure during
eating or swallowing and reduce risk of infection
 Nasogastric tube feedings
 Diet that’s high in protein and calories, small frequent diet and
supplemented with vitamins and minerals. Avoid foods that are
coarse, rough, acidic, orspicy.
• Wound management
 Wound care 2 to 4 times per day as ordered by physician to keep
incisions clean and help preventinfection.
 Care of drainage tubes

51. Post operative nursing management
Tracheostomy
 care of tracheostomy
 suctioning
 prevention of infection
Ensure graft viability
normally pink and warm
Blue color indicates venouscongestion
White color indicates arterial congestion
 Assess for presenceof pulse
Oral care
 Rinses/ gentlebrushing
 Oral suctioning
 Avoid vigorous brushing
 No oral care if intraoral resection until approved by
physician

52. Intravenous (iv) solutions/medications
▫ IV is necessary to administer fluids until oral or NG intake
is adequate
▫ IV will be used to administer antibiotics as needed and to provide
access for administration of other medications including
analgesics

53. Neck dissection
Provide comfort care and airway management
Skin flap will be assessed for adequate circulation.
Avoid constrictive clothing around neck.
Neck may have a sunken or depressed appearance on side
of dissection. Promote positive self image.
Patient may experience loss of sensation to posterior
scalp, neck, and shoulder. Reinforce safety measures to
protect skin from injury.
Promote airway clearance
Elevate head of bed 30 degree
Encourage coughing deep breathing and use of incentive
spirometry
Monitor vitals every 4 hours

54. Assess the wound and proper care
If hemorrhage apply direct pressure suction airway reassure patient
Care of suture lines as ordered
Maintain drainage output colour and consistency
Maintain suction to drain
Milk tubing every 1-2hrs for 24 hours then every 4 hours is needed
Assess skin flap every shift drain patency or infection
Monitor intake and output and record every shift

55. Prevent complication
Monitor shoulder droop secondary to loss of nerve supply to
trapezium muscle and inability to raise hand over head
Reinforce need to do shoulder strengthening exercise three times per
day
Manage nutrition
Monitor patients ability to inject food
Weight daily at same time
Consult with dietitian
Provide patient and family support

56. To maintain physical mobility
Diagonal neck stretch: Up
Gently turn your head so you’re looking up and to the right. Place
your right hand on your left cheek and jaw.
Apply mild pressure to give yourself a deeper stretch

57. Repeat this in the other direction.
Hold each stretch for 30 seconds, then relax. Take 1 full breath
between each repetition. Repeat this 5 times on each side

58. Side neck stretch
Sit or stand and point your right arm downward.
Place your left hand on top of your head.
Gently pull down your head toward your left shoulder, to stretch
the muscles on the right side of your neck
Repeat this in the other direction.
Hold each stretch for 30 seconds, then relax.
Take 1 full breath between each repetition. Repeat this 5 times
on each side.

59. Pectoral stretch using doorway
Stand in a doorway.
 Place your hands and forearms at shoulder level on the sides of the
doorway
Gently step forward until you feel a gentle stretch across your chest
and in front of your shoulders.
Keep your back straight, and your neck and shoulders relaxed.
Hold for 30 seconds, then relax.
Return to the starting position with your arms at your sides. Take 1
full breath between each repetition. Repeat this 5 times

60. Chin tuck
Sit or stand with your back and head leaning against the wall. Tuck
your chin in and try to flatten the back of your neck against the wall
Hold this position for 5 seconds, then relax.
Return to the starting position.
 Take 1 full breath between each repetition. Repeat this 10
times.

61. Arm circles
Sit or stand with your arms at your sides.
Have your palms facing forward and your thumbs pointing to the
ceiling.
 Lift your arms up and circle them backward
Return to the starting position.
Take 1 full breath between each repetition. Repeat this 10
times.

62. Arm and shoulder retraction
Sit or stand with your arms in front of you and your palms facing
forward.
Push your shoulders down and away from your ears.
 This stops you from shrugging. Move your arms out to the sides,
while squeezing your shoulder blades together.
Hold this position for 5 seconds, then relax.

63. Monitoring and managing potential complications
Hemorrhage
Chyle fistula
Chyle fistula is defined as a leakage of lymphatic fluid from the
lymphatic vessels, typically accumulating in the thoracic or
abdominal cavities
Nerve injury

64. promote Communication
• Discuss patient's inability to speak until edema
decreases.
• Determine ability to read and write and discuss
appropriate communication methods (i.e., writing
materials, picture board).
• Use call bells .
Provide psychologicalsupport
• Promote mental health
• Improves self esteem

65. CONCLUSION
Oral cancer is cancer that develops in the tissues of the mouth or
throat. It belongs to a larger group of cancers called head and neck
cancers. Most develop in the squamous cells found in your mouth,
tongue, and lips.