Tumors of maxillofacial areas

1. TUMORS OF MAXILLOFACIAL AREA
CANCER of lip, mucous oral cavity,
tongue and salivary glands

2. Lip cancer (LC) – rather frequently met disease comprises 3-8% among
all malignant tumors
Prevalence in Ukraine comprises 5 cases out of 100 thousand of
population. Its frequency is higher in southern regions of the country, up
to 9%ооо in Odessa and Kherson regions.
Anatomic peculiarities of the structure of lower lip red contours that are
favourable for the cancer appearance are the following:
Corneal and nitid layers of the pavement epithelium of lip red contours
are thinner,
Cells of granular layer instead of keratohyalin synthesize eleidin, that
creates favourable conditions for translucence of sucking papillary layer
capillary. This can explain the difference in colour of lip contours from
skin.
Besides, lip contours do not contain hair follicles, sudoriferous glands and
fatty tissue.

3. Risk factors of the appearance of lip cancer and mouth
tunica mucosa cancer (MTMC)
а) physical : - constant work under the influence of sun
and wind,
- mechanical injury caused by carious teeth
- poor dental prosthetics
- parodontosis,
- thermal injury (burns) (glassblower,
metallurgical manufacture, hot
food),
- strong alcohol usage.
б) chemical: - chewing of tobacco, betel.
- influence of ПАВ (surface active substances)
and other carcinogens,
- smoking.

4. Pretumor lip diseases:
productive:
•leukoplakia
•papilloma (small pappilary excrescences with the cornified
tips),
•skin horn
•keratoacanthoma contour loses its glitter (gloss), becomes
destructive:
•erythroplakia – is a focuses of ulcer of red lip contours that are
not intended to heal
•diffusive hyperkeratosis – a red dry, cracks and becomes
erosive
•Destructive ulcers, erythroplakia, productive leukoplakia and
papilloma are referred to and considered as obligatory pre-
tumors, as the possibility of their malignant transformation is
rather high

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6. Treatment of pre-tumor lip diseases:
1. Elimination of unfavourable influence factors,
2. Giving up smoking,
3. Searing of lips by vitamin А and solcoseryl.
Papillomas, keratoacanthomas and skin horn
could be treated with the help of surgery and
leukoplakia – with the help of cryodestruction.

7. Lip cancer (LC)
Clinical forms of LC:
- exophytic: - pappilary andі
- verruciform
- endophytic: - ulcerative and
- ulcerative-infiltrative.
The characteristic feature of the papillary cancer form is the
presence of the indolent tumor, which is risen over the red
contour of irregular shape. This tumor is usually dense by
touch and has base filtration. When there is ulcerative form of
lip cancer we can find indolent tumourous blunt-edged ulcer
which is situated over the surface of red contour in the form of
a protuberance (as a protuberance). When there is ulcerative-
infiltrative form, except all the characteristic features of
ulcerative form we can find clearly evident tissues infiltration.
Lip cancer metastasizes into lymphogenous-mental (chin),
submaxillary (N2), and cervical (N3) areas.

9. Classification of lip cancer
Т1 - <2 cm N1 - < 3 с
Т2 - < 4 сm N2 - < 6 сm or
bilateral lesion
N3 - > 6 сm
Т3 - > 4 сm
Т4 – spreads on neighboring structures
Grouping according to the stages:
I – Т1N0M0
II – T2N0M0
III – T1-3N1M0
IV – T1-4 N2-3
T1-4N2-3M1

10. Differential signs of “ulcer” on the lip and mucous oral
cavity:
•tuberculosis - ulcer floor has caseation mass, “ulcer” is
painful, bleeds and on the chest organs roentgenogram there
is pulmonary tuberculosis.
•syphilis - “ulcer” is of small size, but in the submмаxillary
area there is a bib node (bubo),
- positive Wassermann reaction and other
sediment reactions
•cancer -“ulcer” with sphacelous bottom, undetermined (dug)
edges as a cauliflower, it is indolent!
Incisional biopsy determines diagnostics – excision of tumor
tissue piece on the border with healthy tissue adhering to
ablastics principle (it is better to fulfill on the background of
the preliminary tumor freezing by liquid nitrogen or preliminary
biopsy of close-focus roentgenotherapy (400 roentgens).

11. Treatment of lip cancer
I stage: - cryodestruction (CD),
- close-focus roentgenotherapy – 7000 roentgens,
- lip resection as an exception (scienter unreasonable anatomic
disfigurement).
II and III stages: - first step - joint radiation therapy,
- second step – CD or lip resection according to Brunts
- third step – Vanah operation – fascial
cervical lymphodenectomy or Krajl operation at N3/
IV stage А: - the first step is chemoradiation therapy (catheterization of the
temporal or external carotid artery on the lesion side) + 40 Gr.
The next two steps are similar to the treatment of the III stage and conducted
only in cases when there is tumor regression for more than 50%.

13. Cancer of mucous oral cavity
General disease incidence in Ukraine comprises 7
cases per 100 thousands of population. The highest
disease incidence rates is:
24%ооо registered in Odessa region and
5%ооо registered in Ivano-Frankivsk region.
Lesion frequency of different parts of
mucous oral cavity:
- tongue – 5%
- oral cavity bottom – 20%,
- buccal region of mucous oral cavity – 12%.

14. Pretumor diseases
Productive: - leukoplakia
- leukokeratosis
- papillomatosis
Destructive: - decubital ulcers
- lichen ruber planus
A very rare form of pre-tumor is Bowen's disease. It is practically cancer in
situ.
Leukoplakia is flat albescent areas of the mucous tunic, which are smooth
and soft during palpation.
Leukokeratosis is the enlargement of pavement epithelium, the superficial
layers of which have the tendency to become horny. At the same time the
deep layers have the tendency to the enlargement of polymorphous cells
with mitoses. Clinically leukokeratosis is different by size and form albescent
areas that overhang the mucous surface, has wartlike shape. Later, on the
surface there appeared cracks and erosions.
Papillomatosis is the papillary enlargement of connective tissue covered by a
laminated pavement epithelium. Papillomas epithelium is inclined to become
horny, has albescent colour and often ulcerate.

15. TONGUE CANCER
In 75% cases tongue cancer is appeared in the
middle of the third part of the tongue side surface..
Lesion of tongue root could be observed in each forth
patient with tongue cancer.
Clinical forms: - papillary,
- ulcerative,
- infiltrative.
Symptoms: early – feeling of extraneous body,
- heartburn,
- pain,
- excessive salivation;
late - difficulties swallowing,
- speech difficulties,
- halitosis,
- irradiation of pain to temple.

16. DIAGNOSTICS OF MUCOUS ORAL CAVITY CANCER:
- Obtaining of anamnesis including risk factors and symptoms
dynamics.
- Examination of mucour oral cavity keeping to the examination
sequence.
- Description of the tumor process, indicating localization, sizes and
relation to the circumflex tissues with the application of shoemaker’s
stirrup and digital bimanual examination.
- Examination of submaxillary and cervical lymph nodes groups.
- Samples collection for the cytological examination when there is an
ulcerative cancer form (impression (touch) smears, scrapes).
- Incisional biopsy when there is a papillary cancer form.
- Laryngoscopy, which is frequently conducted with the application
of fibrolaryngoscope.
- Roentgen examination of dentofacial area including the application
of tomography.

17. Treatment of mucous oral cavity cancer (tongue included)
The selection of the method for mucous oral cavity cancer treatment is
determined by tumor localization and its stage.
At the initial treatment oral cavity sanation should predominate. Metallic
crowns that are situated in the place of irradiation should be removed.
Despite localization and stage therapy of mucous oral cavity should be
combined. In all the cases the treatment should be started from radiation therapy –
remote. And when there is Т1 a combined radiation therapy should be applied.
СВД radiation during this process should be 50-60 grays. After the 3-4 weeks
break doctors estimate the possibility of surgery or cryodestruction when there are
Т1-Т2 tumors.
When there is mucous oral cavity cancer of the III-IV stages it is necessary to
apply internal-arterial regional chemotherapy (cisplatin, 5-FU(fluorouracil),
bleomycine, prospidinum) in combination with the radiation therapy, then to make
a break and consider extended operations (sometimes including maxilla (jaw)
rejection) and Krayl’s operation.
Mucous oral cavity cancer prognosis depends on the tumor localization, its
stage and growth form. The most favourable prognosis is in the case of papillary
cancer form of the I-II stages. Tumor location in the tongue root has always
unfavourable prognosis regardless of treatment methods. The latter is connected
with direct and quick extension of cancer on internal jugular lymph nodes.

18. CANCER OF SALIVARY GLANDS
In 90% cases tumor are appeared in the parotid salivary glands.
In salivary glands there are frequently revealed
Benign tumors:
- polymorphous adenoma (mixed tumor)
- adenoma,
- adenolymphoma.
Malignant tumors: - mucoepidermoid adenocarcinoma
- adenocarcinoma,
- adenocystic carcinoma – cylindroma
- epidermoid cancer.
Polymorphos adenoma. Among benign tumors of salivary glands 50%
falls on mixed tumors. It has a form of a node with unchanged skin over
it. It is movable together with parotis and during operation it is resected
together with the thin-walled capsule.
Adenoma. It has homogenous structure and looks like a node with
smooth surface. This kind of benign tumor is rarely appeared.
Adenolymphoma. This tumor could be found I men of advanced age.
Unlike other benign tumors, it is localized in the parotis gland thickness.

19. MALIGNANT TUMORS OF SALIVARY GLANDS
These tumors have common symptoms such as progressive
dissemination, increasing pain followed by paresis of facial nerve
branch and mimic paresis.
Classification according to the ТNM system is similar to all
tumors of maxilla-facial localization (lips), the difference is only in the
characteristics of Т3 tumor process – node is from 4 to 6 cm and Т4
– node is more than 6 cm.
Treatment of salivary glands malignant tumors depend
on cancer stage:
I-II – treatment should be combined with the preoperative
radiation therapy (50-60 Gy), then followed by a break and after that
parotidectomy operation without preserving integrity of facial nerve.
Operation of Krayl (Kraal) type should be conducted when there are
lymph nodes of the 2-nd and 3-d stages of metastasizing.
III – In case of distant metastases absence, treatment of tumor
extension on the bone of visceral cranium can have a radical type if
extended combined operation will be preceded by chemoradiation
therapy and provide tumor regression to more than 50%.

20. CONCLUSION
Tumors of maxilla-facial area are referred to the visual
cancer forms.
-That is why the solution death rate reduction during these diseases
depends on the state of early diagnostics.
-Cure possibility of patients with cancer of these localizations
having T1 tumors reaches 95%.
-If the tumor process is more extended then such a possibility has
only third or fourth patient.
-The treatment complexity of extended cancer forms of such
localization is determined by the peculiarity of their structure and
functions, which favour quick extension of cancer cells even at the
initial disease stages.
-Constant information of the population about the necessity to
consult immediately a doctor when there appeared any lump (node,
ulcer) on the face, lip or mouth tunica mucosa as well as direct
diagnostics conducted by the doctors (frequently dentists) who has
found these formations is the real way to solve the problem organs
cancer of maxilla-facial localization.