Second part of oropharyngeal malignancies for MBBS teaching

1. Oropharyngeal Carcinoma
DR. AMAL MARIYADAS K BOOBILY
JR GENERAL SURGERY
RMC ORAI

2. RECAP

3. Premalignant lesions of the oral cavity
 High risk lesions –
 Leukoplakia
 Erythroplakia
 Chronic hyperplastic candidiasis due to Candida albicans

4. Premalignant lesions of the oral cavity
 Moderate risk lesions –
 OSMF
 Syphilitic glositis
 Plummer Vinson syndrome

5. Premalignant lesions of the oral cavity
 Equivocal risk lesions –
 Oral lichen planus
 Dyskeratosis congenital
 Discoid Lupus

6. Oral and Upper aerodigestive tract
Cancers
 One of the commonest cancers in Asia and India
 Etiology
 Tobacco
 Smoking
 Quid
 Arecanut
 Alcohol
 HPV
 EBV
 Vit A deficiency
 Plummer Vinson Syndrome
 Bad dental hygiene
 Improper dentures
 Family history
 Premalignant conditions

7. Oral and Upper aerodigestive tract
Cancers
 Common features
 Hard irregular lump
 Trismus
 Dysphagia
 Ear pain
 Hoarseness of voice
 Ankyloglossia
 Bronchopneumonia
 Aspiration

8. Anatomic extent of Lip
 Lips begins at the vermillion border.
 Upper lip, lower lip and oral commissure

9. Anatomic extent of Lip
• Lips begins at the vermillion border.
• Upper lip, lower lip and oral commissure

10. Benign lesions of lip
 Mucous retention cyst
 Papilloma
 Cheilitis
 Herpes labialis

11. Mucous retention cyst
 Can occur in upper or lower lips.
 Retention cyst of minor salivary glands.
 Bluish, soft, fluctuant, well localized often trans-illuminant swelling.
 Often resolves on its own.
 If it does not resolve it can be excised under LA.

12. Mucous retention cyst

13. cyst

14. Papilloma
 Benign lesion
 Lipoma, Pyogenic granuloma, keratoacanthoma, minor salivary tumors can occur
on lip

15. Pappiloma
 Benign lesion
 Lipoma, Pyogenic granuloma, keratoacanthoma, minor salivary tumors can occur
on lip

16. Pappiloma
 Benign lesion
 Lipoma, Pyogenic granuloma, keratoacanthoma, minor salivary tumors can occur
on lip

17. Pappiloma
 Benign lesion
 Lipoma, Pyogenic granuloma, keratoacanthoma, minor salivary tumors can occur
on lip

18. Pappiloma
 Benign lesion
 Lipoma, Pyogenic granuloma, keratoacanthoma, minor salivary tumors can occur
on lip

19. Cheilitis
 A/w stomatitis
 Vitamin C deficiency
 Malnutrition, Radiotherapy induced, Drug induced, sepsis.
 C/C – Redness, painful swelling of lips.
 In chronic cases linear ulcers will be present at the commissure.
 Treatment – Treat the cause

21. Neoplasm of lip
 SCC is the commonest in lower lip
 BCC is the common CA in upper lip

22. CA LIP
 Incidence 15 % of all oral cancers
 May arise from vermilion border or from mucosa
 Common after 40 yrs.
 Khaini, a mixture of Tobacco and slaked lime kept under the lip, is called Khaini
chewers are at high risk.
 All previously discussed RF are applicable in Ca lip.
 Common in men 15:1
 Common in lower lip 90%, lower lip is exposed to the harmful UV radiations
 Common in pipe smokers

23. CA LIP
 Presentation – Starts as a red granular dry lesion
 Lesion gets ulcerated
 Ulcero-proliferative lesion
 Submental and Submandibular nodes L1

24. CA LIP - Etiology
 Cheilitis – actinic type
 Solar keratosis
 Papilloma
 Leukoplakia
 Smoking, UV rays, pipe smoking
 Smoking, Reverse smoking
 Khaini
 Countryman man’s lip – Agriculturalist who are exposed to sunlight get CA lip

25. CA LIP – Clinical Features
 Non-healing progressive ulcer
 Initially painless, becomes painful if it involves nerve, periosteum or bone
 Everted edge with induration
 Growth moves with the lip
 Submandibular or submental swelling
 Fungation, bleeding, halitosis

26. Differential Diagnosis
 Keratoacanthoma
 BCC
 Minor salivary gland tumors
 Extension from CA Cheek
 Pyogenic granuloma
 Malignant melanoma if the primary lesion is pigmented

27. TNM Staging for Oral cavity cancers
 T – Tumor size
 N – Nodal involvement
 M – Distant metastasis

30. Investigations
 Wedge biopsy
taken from 2 sites
has to be taken from the edge as it contains the active cells
Malignant squamous cells with epithelial pearls are the features

31. Investigations
 FNAC from Lymph nodes
 CT scan – used to asses the extent of tumor
 MRI – useful in assessing soft tissues, base of skull and perineural spread.
 Orthopantomogram – looks for mandibular involvement
 PECT – CT to look to metastasis
 Oral brush biopsy
 Sentinel Lymph node biopsy

32. Management
 Curative or palliative
 Basic treatment strategy
 Surgery – WLE, Mandibulectomy -segmental, Addressing the neck nodes,
reconstruction.
 Radiotherapy – Curative or palliative, EBRT or Brachytherapy
 Chemotherapy
 Chemoradiotherapy
 Neoadjuvant chemotherapy
 Palliative therapy

33. CA LIP - Treatment
 If lesion < 2 cm
 Curative radiotherapy
 Brachytherapy or External beam radiotherapy
 Good cure

34. CA LIP - Treatment
 If tumor > 2 cm
 Wide local excision is done
 Up to 1/3rd of lip can be excised and sutured primarily in layers while keeping
vermillion border in apposition.
 Excision of > 1/3rd of lip requires reconstruction using flaps

35. CA LIP - Treatment
 Lymph nodes –
 Radical neck dissection on one side
 Functional block dissection on other side or Supra-omohyoid dissection
 For central N0 tumor – prophylactic bilateral elective supra-omohyoid block
dissection is done
 For lateral N0 tumor – prophylactic ipsilateral supra-omohyoid block dissection is
done

36. CA LIP - Treatment
 Postoperative RT
 Segmental resection if mandible is involved

37. CA LIP - Reconstruction
 ABBE – Estlander’s rotation flap
 Frie’s modified Bernard flap
 Microvascular flaps
 Nasolabial flaps
 Cheek flap
 Free radial artery flap
 W flap plasty
 Gilliesfan flap

38. Tongue
• ANATOMY
• ULCERS
• BENIGN LESIONS
• GLOSSITIS
• TONGUE TIE
• CA TONGUE
• CA BASE OF TONGUE

39. Tongue - Anatomy
 Parts –
 Tip – Anterior free end
 Root – Attached to mandible and hyoid bone
 Body – Rough dorsal surface with papillae
 Ventral smooth, attached to floor of mouth by frenulum with deep lingual vein on
both sides.
 Dorsal part divided into anterior 2/3rd and post 1/3rd by sulcus terminalis.

40. Tongue - Anatomy
 Parts –
 Tip – Anterior free end
 Root – Attached to mandible and hyoid bone
 Body – Rough dorsal surface with papillae
 Ventral smooth, attached to floor of mouth by frenulum with deep lingual vein on
both sides.
 Dorsal part divided into anterior 2/3rd and post 1/3rd by sulcus terminalis.

41. Tongue - Anatomy
 Parts –
 Tip – Anterior free end
 Root – Attached to mandible and hyoid bone
 Body – Rough dorsal surface with papillae
 Ventral smooth, attached to floor of mouth by frenulum with deep lingual vein on
both sides.
 Dorsal part divided into anterior 2/3rd and post 1/3rd by sulcus terminalis.

42. Tongue - Anatomy
 Parts –
 Tip – Anterior free end
 Root – Attached to mandible and hyoid bone
 Body – Rough dorsal surface with papillae
 Ventral smooth, attached to floor of mouth by frenulum with deep lingual vein on
both sides.
 Dorsal part divided into anterior 2/3rd and post 1/3rd by sulcus terminalis.

43. Tongue - Anatomy
 Muscles of the tongue
 Intrinsics – Superior and inferior longitudinal, transverse and vertical
 Extrinsic – Genioglossus, Hyoglossus, Palatoglossus, styloglossus

44. Tongue - Anatomy
 Muscles of the tongue
 Intrinsics – Superior and inferior longitudinal, transverse and vertical
 Extrinsic – Genioglossus, Hyoglossus, Palatoglossus, styloglossus

45. Tongue - Anatomy
 Muscles of the tongue
 Intrinsics – Superior and inferior longitudinal, transverse and vertical
 Extrinsic – Genioglossus, Hyoglossus, Palatoglossus, styloglossus

46. Tongue - Anatomy
 Lymphatic drainage
 Tip – Submental nodes
 Margin – Submandibular nodes and deep cervical nodes
 Midline – lymphatics freely crosses to both sides
 Posterior 3rd – Pharyngeal nodes

47. Tongue - Anatomy
 Lymphatic drainage
 Tip – Submental nodes
 Margin – Submandibular nodes and deep cervical nodes
 Midline – lymphatics freely crosses to both sides
 Posteror 3rd – Pharyngeal nodes

48. Tongue - Ulcers
 Dental ulcers – Painful
 Aphthous ulcers – Painful
 Tuberculous ulcer – Painful
 Syphilitic ulcer – Painless
 Malignant ulcer – Painless
 Ulcer in Lichen planus - Painless

49. Tongue – Benign lesions
 Papilloma
 Fibroepithelial polyp
 Hemangioma
 Lymphangioma
 Neurofibroma
 Lipoma
 Granular cell myo-blastoma

50. CA Tongue - Introduction
 Incidence is equal in both sexes
 Incidence in females is increasing due to increased tobacco use by females.

51. CA Tongue - Aetiology
 As discussed for pervious oral malignancies

52. CA Tongue - Types
 Gross
 Papillary
 Ulcerative or Ulcero-proliferative
 Fissure with induration
 Lobulated, indurated mass – Frozen tongue
 Histologic
 SCC
 Adenocarcinoma
 Melanomas
 Transitional cell CA and lymphoepithelioma ( rare)

56. CA Tongue - Sites
 Lateral margin > Posterior third > Dorsum > Ventral surface > Tip

57. CA Tongue – Clinical Features
 Painless ulcer – Which may later become painful due to involvement of lingual
nerve – Referred pain in ear
 Pain during swallowing in posterior tongue CA
 Swelling over tongue
 Excessive salivation-blood tinged
 Dysphagia –
 Fixed tongue
 Genioglossus involvement
 Posterior third growth

58. CA Tongue – Clinical Features
 Visible ulcer in anterior 2/3rd -
 Surrounding induration
 Everted edges
 Irregular margin
 Bleeds on touch
 Invades surrounding structures
 Posterior growth is usually not visible

59. CA Tongue – Clinical Features
 Ankyloglossia
 Articulation difficulty
 Halitosis
 Change in voice
 Palpable lymph nodes
 Features of bronchopneumonia

60. CA Tongue – Spread
 Local Spread
 Ant 2/3rd
 Genioglossus
 Floor of mouth
 Opposite side
 Mandible
Posterior 3rd
Tonsil
 Soft palate
 Epiglottis
 Larynx
 Cervical spine

61. CA Tongue – Spread
 Lymphatic spread
 Tip of tongue – Submental nodes
 Lateral margin – Submandibular and Deep cervical nodes
 Bilateral neck involvement due to free lymphatic crossing in central area of tongue
 Posterior 3rd – Pharyngeal nodes and Deep cervical nodes

62. CA Tongue – Investigation
 Edge Wedge Biopsy
 FNAC from Lymph nodes
 Indirect or direct laryngoscopy to visualize posterior part of tongue
 CT scan – used to asses the extent of tumor
 MRI – useful in assessing soft tissues, base of skull and perineural spread.
 Orthopantomogram – looks for mandibular involvement
 PECT – CT to look to metastasis
 CXR for Bronchopneumonia
 Oral brush biopsy
 Sentinel Lymph node biopsy

63. CA tongue
TNM staging
SAME FOR ALL ORAL
MALIGNANCIES
DISCUSSED EARLIER

64. CA Tongue – Treatment
 Surgery
 Radiotherapy
 Chemotherapy

65. CA Tongue – Treatment - Surgery
 Tumor < 1 cm – WLE with 1cm clearance in margin and depth
 Tumor 1-2 cm – Partial glossectomy with 2 cm clearance
 Tumor > 2 cm Hemi-glossectomy
 Same side palpable lymph nodes – Radical Neck Lymph node dissection RNLND
 Bilateral Lymph nodes – Same side RNLND with opposite side modified RNLND
with sparing of internal jugular vein or same side RNLND with contralateral supra
omohyoid block dissection

66. CA Tongue – Treatment - Surgery
 Posterior third growth can be approached by lip split incision with mandible
resection f/b total glossectomy – not done commonly due to significant morbidity
 Mandible involvement – Mandibulectomy done
 Hemi-glossectomy + Hemi-mandibulectomy + RNLND = Commando operation

67. CA Tongue – Treatment - Radiotherapy
 Small primary tumor – Curative RT
 Large primary tumor – Initial RT to downsize the tumor
 Advanced primary tumor – Palliative
 Post operative RT for preventing recurrence

68. CA Tongue – Treatment - Chemotherapy
 Prince – Hill regimen – Methotrexate, Vincristine, Adriamycin, Bleomycin and
Mercaptopurine
 Intra arterial or locally through External Carotid artery
 Neoadjuvant therapy done to downstage the tumor.

69. CA Tongue – Terminal events
 Inhalational bronchopneumonia
 Torrential hemorrhage
 Cancer cachexia
 Asphyxia

70. CA Tongue – Poor prognostic factors
 Size > 4cm
 Posterior 3rd tumor
 Tumor crossing midline
 Lymph node involvement
 Poor differentiation
 Bone involvement

71. Complications a/w Oral cancers
 Upper airway obstruction and bronchopneumonia.
 Feeding difficulties and severe malnutrition
 Immunosuppression
 Secondary sepsis, uncontrollable bleeding
 Orocutaneous fistula – CA Cheek - with dribbling and social out casting

72. Thank you