Oral Cancer: "The Forgotten Disease"

The Forgotten Disease
Oral cancer
oral carcinoma is one of the most prevalent cancers and is one of the 10 most common causes of death. Oral cavity cancers account for 30% of head and neck cancers. Oral cancer is a disease of increasing age: approximately 95% of cases occur in people older than 40 years, with an average age at diagnosis of approximately 60 years. The majority of oral cancers involve the tongue, oropharynx, and floor of the mouth ( High risk oval)
Tobacco Tobacco contains potent carcinogens, including nitrosamines (nicotine), polycyclic aromatic hydrocarbons, nitrosodicthanolamine, nitrosoproline, and polonium. One study demonstrated that 80% of patients with cancer were smokers. In parts of Asia where the use of tobacco, betel nuts, or lime to form a quid is widespread (e.g., India), the incidence of oral cancer is high. Alcohol All forms of alcohol have been implicated in the etiology of oral cancer. The combined effects of tobacco and alcohol result in a synergistic effect on the development of oral cancer. Due to dehydrating effects of alcohol on the mucosa, increasing mucosal permeability, and the effects of carcinogens contained in alcohol or tobacco.
TNM Classification of Tumors of the Oral Cavity T (Size of Primary Tumor) N (Cervical Lymph Node Metastases) M (Distant Metastases) Staging T1s: carcinoma in situ N0: no node involvement detected M0: no known metastases Stage 1: T1 N0 M0 T1: tumor < 2 cm N1: single ipsilateral node < 3 cm M1: metastases present Stage 2: T2 N0 M0 T2: tumor > 2 cm and < 4 cm N2a: single ipsilateral node < 6 cm Stage 3: T3 N0 M0; T3: tumor > 4 cm N2b: multiple ipsilateral nodes > 3 cm and < 6 cm T1,T2, or T3 N1 M0 T4: tumor > 4 cm with invasion of N2c: bilateral or contralateral lymph nodes < 6 cm Stage 4: T4 any N M0; any T N2 adjacent structures (ie, through N3a: ipsilateral node > 6 cm or N3 M0; any T or N, with M1 cortical bone; deep into extrinsic N3b: bilateral nodes > 6 cm muscles of tongue, maxillary sinus, and skin)
A thorough clinical examination is the first line of defence in the detection of oral cancer Prognosis is directly dependent on the tumor stage at diagnosis Nearly one-half of all oral cancers are not detected until they are in advanced stages.
Toluidine Blue a metachromic dye that has been used as a nuclear stain. Biopsy The traditional biopsy, whether incisional or excisional (for small lesions), is the gold standard.
Brush cytology has gained acceptance in the dental community as a safe, minimally invasive technique for use in the screening of clinically suspicious lesions. Brush cytology differs from exfoliate cytology in that it removes an entire transepithelial layer for cytologic evaluation as opposed to the sloughing surface layer of the mucosa. The brush cytology is only a screening tool, and any atypical or positive results must be confirmed by an incisional biopsy Results negative when no epithelialabnormality is noted. positive when definite cellular evidence of dysplasia or carcinoma is found. atypical when abnormal epithelial changes of uncertain diagnostic significance are observed inadequate when an incomplete transepithelial specimen was submitted.
Treatment
Early detection and appropriate treatment of cancers remain the most effective weapons against cancers of the oral cavity. Incidence and mortality for oral cancer is nearly double that of cancer of the cervix. The choice of treatment depends on such factors as cell type and degree of differentiation; the site, size, and location of the primary lesion; lymph node status; the presence of bone involvement; the ability to achieve adequate surgical margins; the ability to preserve speech; the ability to preserve swallowing function; the physical and mental status of the patient; a thorough assessment of the potential complications of each therapy; the experience of the surgeon and radiotherapist; and the personal preferences and cooperation of the patient.
Surgery may be the primary treatment or may be part of combined treatment with radiation therapy. Surgery is indicated (1) for tumors involving bone, (2) when the side effects of surgery are expected to be less significant than those associated with radiation, (3) for tumors that lack sensitivity to radiation, (4) for recurrent tumor in areas that have previously received a maximum dose of radiotherapy. (5)Surgery also may be used in palliative cases to reduce the bulk of the tumor and to promote drainage from a blocked cavity (e.g., antrum).
Preoperative Issues in Oral Cavity Cancer Treatment The decision to operate on a patient with head and neck cancer must involve consideration of potential complications. Airway If there is any doubt concerning the ability of a patient to maintain an airway in the preoperative period, a tracheotomy is advisable. Preoperative Antibiotics Operations on the oral cavity are considered clean contaminated, and therefore, preoperative antibiotics are indicated. Alcohol Withdrawal Appropriate prophylaxis with benzodiazepines is recommended if the patient drinks daily. Deep Venous Thrombosis
Surgery may fail due to incomplete excision, inadequate margins of resection, tumor seeding in the wound, unrecognized lymphatic or haematogenous spread, neural invasion, or perineural spread
Radiation can cause reproductive cell Death as well as Apoptosis and also slows cellular division. Classically radiation is discussed in terms of the four Rs: repair, reoxygenation, redistribution, and regeneration. The radiation particle-cell interaction may be either direct, or more commonly impact with H2O molecules to create secondary particles that interact with cellular DNA. Absorbed dose is reported as a gray (Gy) Previously rad (1 cGy = 1 rad). Radiation therapy is typicallygiven in daily doses of 200 cGy Radiation is delivered to a specific target area that is limited by shielding (defined as radiation portals or ports)
Indications for postoperative radiation therapy: Two or more lymph nodes containing metastatic disease in a neck dissection (many clinicians contend that one positive node is an indication) Extracapsular extension (ECS) of cancer beyond the confines of a node Poor histologic factors: extensive perineural or perivascular invasion, positive (close) soft tissue margins Large (T3 or T4) primary cancers
Chemotherapy The immune system in general is not inherently competent to destroy the cancer. Chemotherapeutic agents kill a constant fraction of cancer cells leaving behind a certain amount of resistant cells. Multidrug protocols have been developed to counter the development of resistant cell lines in cancer. Cell cyclespecific and Non cell cyclespecific agents Measurements are obtained at the beginning of treatment and at completion. Complete response: Defined as the disappearance of all evidence of disease Partial response: At least a 50% reduction in size as defined by the formula above Stable disease: Less than a 50% reduction in tumor size Progression: An increase of 25% or appearance of new lesions
Chemoprevention chemoprevention agents - agents that reverse or suppress premalignant carcinogenic progression to invasive malignancy. The role of such agents would be two fold: (1) to treat premalignant lesions to prevent their evolution to invasive carcinoma, and (2) to prevent development of second primary squamous cell cancers in patients who have already undergone treatment of cancer.
Palliative chemotherapy is given to patients with incurable disease to temporarily reduce tumor volume in the hope of improving quality of life and lengthening survival. Adjuvant chemotherapy is given to patients who have undergone treatment of their primary cancer site with surgery and/or radiation. Neoadjuvant chemotherapy (also known as induction chemotherapy) is given to patients prior to definitive treatment of the primary cancer site. Chemotherapy in combination with radiation treatment can be given in a sequential or a concurrent strategy.

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The Forgotten Disease

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