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8/3/2019 Buccal Cancer
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Tobacco and alcohol use are the main etiologic agents associatedwith the development of buccal carcinoma.
In Asia, betel nut is a significant etiologic agent, in addition to
tobacco and alcohol.
In India, over 90% of patients with buccal carcinoma have a historyof using betel nut.
Other suspected but not confirmed etiologic agents include:
human papilloma virus,
poor oral hygiene,
and chronic irritation.
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It occurs more often in men, male:female ratio of 3-4:1most commonly in the 7th or 8th decade of life.
incidence of buccal carcinoma is much higher in Asia. In Southeast
Asia, the disease is the most common form of oral cavity
cancer.In India, buccal carcinoma is the most common cancer in men and
the third most common cancer in women.
widespread practice of betel nut chewing.
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Betel nut, composed
mainly of the fruit of the
Areca Palm and often
mixed with tobacco, is
placed along the buccal
mucosa to induce a
feeling of euphoria.Buccal carcinoma
related to betel nut
chewing tends to
develop at an earlierage, with most cases
occurring between the
ages of 40-70.
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No symptoms in the early stageWhite or red lump in the mouth that does not go away aftertwo weeks (Leukoplakia)
A red, raised patch in the mouth that bleeds easily
A lump or thickening in the mouthPain increases when eating or drinkingSoreness or a feeling that something is caught in the throatDifficulty chewing or swallowing
Severe ear painDifficulty moving the jaw or tongueHoarsenessNumbness of the tongue or other areas of the mouthDentures fit poorly or become uncomfortable because the
jaw is swollen
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Buccal carcinoma commonly presents as a slow-growing mass on the buccal mucosa. Smalllesions tend to be asymptomatic and are often
noted incidentally on dental examination.
Pain commonly occurs as the lesion enlarges andulceration develops. Oral intake may worsen the
pain and lead to malnutrition and dehydration.Associated symptoms include bleeding, poordenture fit, facial weakness or sensory changes,dysphagia, odynophagia, and trismus.
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A doctor will examine the inside of the mouth and back of thethroat to check the location and size of the tumor. Examination
of the ears, nose and neck are needed to help determine if the
tumor has spread.
CBC count,electrolytes, BUN and creatinine
Prothrombin time (PT), Partial thromboplatin time
Liver function test: used to increased for alcoholic liver
damage
Blood typing and cross matching
X-rays to determine if the tumor has spread to the lung.Fine Needle Aspiration Biopsy (FNAB)
Computerized tomography (CT) scan.
Magnetic resonance imaging (MRI).
Positron emission tomography (PET) scan.
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ANATOMY & PHYSIOLOGY
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1.Mouth (oral cavity, buccal cavity)Histology: stratified squamous epithelium, except on gums, hard palate, tongue dorsum (these are keratinized);
bound by lips anteriorly, cheeks laterally, palate superiorly, tongue inferiorly functions:
ingestion: intake of food
mechanical digestion: chewing of food
chemical digestion: enzymatic breakdown of food
2. Teeth (will be covered in lab) grinding of foodincisors blade shaped; function in clipping and cutting
cuspids (canines) conical with sharp ridgeline and pointed tip; function in tearing and slashing
bicuspids (premolars) 1-2 roots with flattened crowns and prominent ridges; function to crush, mash, and grind
molars flattened crowns with prominent ridges with 3+ roots; function in crushing and grinding
3. Tongue - functions to manipulate food while chewing & swallowing
4. Salivary glandstypes: (will be studied further in lab)
parotid glands anterior to ear; between masseter muscle and skin; contain only serous glands (water secretion with
little mucus)
submandibular glands along the mandibular body; equal numbers of serous and mucus gland cells
sublingual glands anterior to submandibular gland and under tongue; equal numbers of serous and mucus gland
cells
Saliva contents and their functions:
mucus and water coating and putting food into solution
salivary amylase digests complex carbohydrates
antibacterial proteins lysozymes and defensins; inhibit bacterial growth
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The American Joint Commission on Cancer
defines the buccal mucosa as the membrane lining of
the inner surface of the cheeks from the line of contact
of the opposing lips anteriorly to the line of thepterygomandibular raphe (lateral to retromolar trigone)
posteriorly. The medial boundary is the line of
attachment of the buccal mucosa to the upper and
lower alveolar ridges.
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The layers of the cheek from medial to lateral include themucosa, pharyngobasilar fascia, buccinator muscle,
buccinator fat pad, subcutaneous tissue and skin. Sensory
innervation of the buccal mucosa and cheek skin is from the
maxillary and mandibular branches of the trigeminal nerve.
The buccinator muscle is innervated by the facial nerve. The
parotid duct (Stenson duct) pierces the buccinator muscle
and buccal mucosa opposite the maxillary second molar.
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The buccal region lacks anatomic barriers beyond the
buccinator muscle and its fascia to prevent the spread ofcancer. Buccal cancer can spread laterally to extend through
the skin of the cheek; medially to involve the alveoli, palate,
tongue, and floor of the mouth; posteriorly to involve the
retromolar trigone mucosa, the ascending ramus of the
mandible, and the masseter and pterygoid muscles; andanteriorly to involve the oral commissure and lips.
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The primary-echelon lymphatics of the buccal mucosa drain to
the facial and submandibular lymph node basins prior to theupper jugular nodes. The lymphatics may occasionally drain to
the upper jugular nodes via the parotid nodes.
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PATHOPHYSIOLOGY
PREDISPOSING FACTORS
-age
-gender
-race
PRECIPATING FACTORS
-Smoking,
-Chewing betel nut,
-Alcoholism,
-poor oral health
-HPV and chronic irritation
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Radiation therapyIndications for radiation orchemoradiation therapy inthe postoperative setting
include large or deeplyinvasive tumors, close orpositive margins, multiple
lymph nodes with
metastatic cancer, lymphnode extracapsularspread, or perineural
invasion.
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Chemotherapy
The role of induction
chemotherapy in the
treatment of advanced stage
head and neck squamouscell carcinoma is
controversial and is often
recommended for clinical
trials.Chemotherapy may also be
indicated in the palliative
setting for recurrent or
distantly metastatic disease.
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CHEMOTHERAPY PROCEDURE
Once IVF inserted, please give pre medications
and may start chemotherapy.
PRE-MEDS:
Diphenhydramine 50 mg
Ranitidine 50 mg
Dexamethasone 5mg
Gravisetron (Sancuso) 1 amp IV push
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Run the following as side drips:1. Carboplatin 450mg in 250cc D5W x 30mins.
2. Docetaxel 100 mg in 250cc D5W x 1hr.
then discontinue.
Once docetaxel drip is consumed please request MROD tocorporate Nimotuzumab 50 mg, 4 vials in 60 cc PNSS in soluset.Run soluset content (100ml)
Gravisetron patch (Sancuso) attached.
PRN drugs:
Hydrocortisone 100mg for allergic reaction.
Give Neulastyl(Pegfilgastrim) 1 pre filled syringe SQ
24 hours after the end of nimotuzumab infusion.
-CBC with WBC and platelet count monitoring was ordered.
-Continue Erythropoietin 10,000 U SQ 3x a wk
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DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONSNURSING
RESPONSIBILITIES
CARBOPLATIN
(Naproplat)
450 mg
Cytotoxic
Chemotherapy
Carboplatin is second-
generation platinum
compound that may be
classified as a non-
classical alkylating agent
and is cell-cycle
nonspecific. It is cytotoxic
platinum complex that
reacts with nucleophilic
sites of DNA. This causes
interstrand and
interstrand cross links
and DNA protein cross
links, which inhibit DNA,
RNA and protein
synthesis.
Treatment of advanced
ovarian cancer, small-
cell lung cancer, head
and neck cancer and in
genito-urinary cancer,
particularly in testicular,
bladder and cervical
cancers. Antitumor
activity of carboplatin
has also been observed
in pediatric brain tumor
(meduloblastoma).
Patients with a history
of severe allergic
reaction to cisplatin or
other platinum
containing compounds
and patients with
severe bone marrow
depression or significant
bleeding.
Hematologic Toxicity: Bone
marrow suppression is the dose-
limiting toxicity of carboplatin.
Thrombocytopenia, neutropenia,
leucopenia, a higher incident of
severe leucopenia and
thrombocytopenia. Anemia, Bone
marrow depression.
Gastrointestinal Toxicity:
Vomiting, Nausea, diarrhea,
constipation.
Neurologic Toxicity: Peripheral
neuropathies with mild
paresthesias, visual disturbances
and change in taste occur rarely.
Nephrotoxicity: Development ofabnormal renal function test
results is uncommon with
carboplatin.
Hepatic Toxicity: Abnormal liver
function tests in patients may be
found with normal value.
Electrolyte Changes: The
abnormally decreased serum
electrolyte values may be foundin some patients.
Allergic Reactions: rash, urticaria,
erythema, pruritus and rarely,
bronchospasm and hypotension.
Others: Pain and asthenia occurs
most frequently. Alopecia,
cardiovascular, respiratory ,
genitorurinary.
Carboplatin should be
administered under the
supervision of a qualifies
physician experienced in
the used of cancer
chemotherapeutic agents.
Appropriate management
of therapy and
complications is possible
only when adequate
diagnostic and treatment
facilities are readily
available.
Ensure patients safety.
Watch of for adverse
reaction.Refer patient's tolerance
to chemotherapy
accordigly to the
physician.
Secure accuracy of drug
dose and infusion.
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DRUGMECHANISM OF
ACTIONINDICATION CONTRAINDICATION ADVERSE REACTIONS
NURSING
RESPONSIBILITIES
Docetaxel
(Hentaxel)
80mg
Cytotoxic
Chemotherapy
Docetaxel is an
antineoplastic agent
belonging to paclitaxel
family. It acts by
disrupting the
microtubular networkin cells. Such action is
essential for mitotic
and interphase
cellular functions.
Docetaxel binds to
free tubulin thereby
resulting in the
formation of stablemicrotubules and
subsequently into
microtubule bundles
without normal
function. This leads to
the inhibition of
mitosis in cells.
Docetaxel's binding to
microtubules does not
alter the number of
protofilaments in the
bound microtubules, a
characteristic not
found in most spindle
poisons currently in
clinical use.
Treatment of lcoally
advanced or
metastatic breast
cancer & non-small
cell lung cancer, after
failure of priorchemotherapy.
Patients who have a
history of severe
hypersensitivity
reactions to
docetaxel or to other
drugs formulatedwith polysorbate 80.
Patients with
leukocyte counts of
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DRUGMECHANISM OF
ACTIONINDICATION CONTRAINDICATION ADVERSE REACTIONS
NURSING
RESPONSIBILITIES
Gravisetron
(Sancuso)
Antiemetic
Granisetron is a
selective 5-
hydroxytryptamine3 (5-
HT3) receptor
antagonist with little or
no affinity for other
serotonin receptors
including 5-HT1, 5-
HT1A, 5-HT1B/C, 5-HT2;
for 1-, 2-, or -
adrenoreceptors; for
dopamine-D2; or for
histamine-H1;
benzodiazepine;
picrotoxin or opioidreceptors.
Serotonin receptors of
the 5-HT3 type are
located peripherally on
vagal nerve terminals
and centrally in the
chemoreceptor trigger
zone of the area
postrema. Duringchemotherapy that
induces vomiting,
mucosal
enterochromaffin cells
release serotonin,
which stimulates 5-HT3
receptors. This evokes
vagal afferent
discharge, inducing
vomiting.
Prevention of nausea
and vomiting in
patients receiving
moderately and/or
highly emetogenic
chemotherapy
regimens of up to 5
consecutive days
duration.
Known
hypersensitivity to
granisetron or to any
of the components of
Sancuso.
Constipation, abdominal pain,
diarrhea, headache, arrythmias.
elevation of ALT and AST levels,
nausea and vomiting.
Cardiovascular: Hypertension,
hypotension, angina pectoris,
atrial fibrillation and syncope
have been observed rarely.
Central Nervous System:
Dizziness, insomnia, headache,
anxiety, somnolence and
asthenia.
Hypersensitivity: Rare cases of
hypersensitivity reactions,
sometimes severe (eg,anaphylaxis, shortness of
breath, hypotension, urticaria)
have been reported.
Ensure patchs location.
Assess skin status on
patchs location.
Monitor patients
hydration and
Gastrointestinal status.
Watch out for adverse
reactions and refer
accordingly to physician.
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DRUGMECHANISM OF
ACTIONINDICATION CONTRAINDICATION ADVERSE REACTIONS
NURSING
RESPONSIBILITIES
Pegfilgrastim
(neulastyl)
1 ampule
Hematopoietic
agent
Hematopoietic growth
factor.
Reduction in the
duration of
neutropenia and the
incidence of febrile
neutropenia inpatients treated with
cytotoxic
chemotherapy for
malignancy (with the
exception of chronic
myeloid leukemia
and myelodysplastic
syndromes).
Hypersensitivity to
pegfilgrastim,
filgrastim, E. coli-
derived proteins or
to any excipients ofNeulastyl.
Allergic-type reactions,
including anaphylaxis, skin
rash, urticaria, angioedema,
dyspnoea and hypotension,
occurring on initial orsubsequent treatment have
been reported both with
pegfilgrastim and with the
parent compound of
pegfilgrastim, filgrastim.
Isolated cases of splenic
rupture have been reported
during treatment with
pegfilgrastim.
Reversible, mild to moderate
elevations in uric acid,
alkaline phosphatase and
lactate dehydrogenase, with
no associated clinical effect.
Very common:
Musculoskeletal: Skeletal
pain.
Common: Application Site:
Injection site pain. Body as a
Whole: Chest pain (non-
cardiac), pain. CNS/PNS:
Headache. Musculoskeletal:
Arthralgia, myalgia and pain
in the back, limb,
musculoskeletal and neck.
Before administration,
pegfilgrastim solution
should be inspected
for visible particles.
Only a solution that isclear and colourless
should be injected.
Excessive shaking may
aggregate
pegfilgrastim,
rendering it
biologically inactive.
Monitor CBC levels
especially WBC. Watch
out for adverse
reactions. Refer to
physician accordingly.
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DRUGMECHANISM OF
ACTIONINDICATION CONTRAINDICATION ADVERSE REACTIONS
NURSING
RESPONSIBILITIES
Nimotuzumab
Targeted Cancer
Therapy
Antiepidermal
growth factor (EGF)
receptor.
Nimotuzumab binds
with intermediate
affinity and high
specificity to the
extracellular domain
of epidermal growth
factor receptor
(EGFR, HER1, c-Erb-
1). Nimotuzumab
blocks the binding ofthe EGF and other
ligands
Nimotuzumab has a
potent anti-
angiogenic,
antiproliferative and
pro-apoptotic
effects, and also
decreases motility,
cell invasion and
metastasis in those
tumors that
overexpress the
EGFR.
Treatment of
glioma in adults
and children.
Contrindicated to
hypersensitivity to
the drug and its
component
Common adverse events
with recommended dose
reported following
administration of
nimotuzumab include chills,
fatigue, headache, nausea,
pyrexia, tremors and
vomiting.
Monitor patients
status frequently.
Watch out for
adverse reactions.
Refer to physician
accordingly.
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Surgical TherapySurgery is the preferred treatment
for early and advanced buccal
carcinoma. Patients with advanced
disease should receive
postoperative radiation orchemoradiation. Surgical approach
depends on the size of the tumor
Metastatic neck disease (N+
disease) requires either a modified
radical neck dissection or radicalneck dissection depending on the
extent of disease.
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NURSING INTERVENTIONS
Instruct the patient to avoid exposing themselves to sunlight because ofthe harmful rays.
Instruct patient refrain from smoking and consuming moderate to alcohol.
Encourage good oral hygiene.
Instruct patient to have oral check-ups to help detect the early signs of
cancer. Encourage to eat nutritious foods and must these dietary guidelines
include these seven basic recommendations: Eat a variety of foods.
Control your weight.
Eat a low-fat, low-cholesterol diet.
Eat plenty of vegetables, fruits, and grains. Eat sugar in moderation.
Use salt in moderation.
If you drink alcohol, do so in moderation; no more than two drinks per day ofwine, beer, or spirits.