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oral cancer - evaluation
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DEPARTMENT OF DEPARTMENT OF SURGICAL SURGICAL
ONCOLOGY- GRHONCOLOGY- GRH
PROF.R.RAJARAPROF.R.RAJARAMAN UNITMAN UNIT
Evaluation and Evaluation and staging of oral staging of oral
cancercancerDr Sujay SusikarDr Sujay Susikar
PG in Surgical OncologyPG in Surgical Oncology
Professor Dr R Rajaraman unitProfessor Dr R Rajaraman unit
Government Royapettah Government Royapettah HospitalHospital
Initial head and neck Initial head and neck examinationexamination
Standard and complete head and neck Standard and complete head and neck examinationexamination
All 12 cranial nerves examinedAll 12 cranial nerves examined Otoscopy and anterior rhinoscopyOtoscopy and anterior rhinoscopy Examination of oral cavityExamination of oral cavity Palpation of tongue and tongue basePalpation of tongue and tongue base Mirror and flexible laryngoscope examinationMirror and flexible laryngoscope examination Examination under anaesthesia in patients Examination under anaesthesia in patients
with trismus, SMF, ankyloglossia, with trismus, SMF, ankyloglossia, uncooperative patientsuncooperative patients
WHO Format – oral cavity WHO Format – oral cavity examinationexamination
Exam abstracted from WHO standardized oral Exam abstracted from WHO standardized oral examination method examination method
Consistent with CDC and NIH methodConsistent with CDC and NIH method Requirements:Requirements:
Adequate lightingAdequate lighting Dental mouth mirrorDental mouth mirror Two 2" x 2" gauze squaresTwo 2" x 2" gauze squares GlovesGloves Seated patientSeated patient Removal of intraoral prosthesesRemoval of intraoral prostheses
Should take no longer than 5 minutesShould take no longer than 5 minutes
Extraoral Examination Extraoral Examination FaceFace
Perioral and Intraoral Perioral and Intraoral Soft Tissue Examination Soft Tissue Examination
– Lips – Lips
Perioral and Intraoral Perioral and Intraoral Soft Tissue Examination Soft Tissue Examination
––Labial MucosaLabial Mucosa
Buccal MucosaBuccal Mucosa
Buccal MucosaBuccal Mucosa
GingivaGingiva
Tongue DorsumTongue Dorsum
Tongue Left MarginTongue Left Margin
Tongue Right MarginTongue Right Margin
Tongue VentralTongue Ventral
FloorFloor
Hard PalateHard Palate
OropharynxOropharynx
PalpationPalpation
Histological confirmation of Histological confirmation of diagnosis diagnosis
Wedge Biopsy for infiltrating lesionsWedge Biopsy for infiltrating lesions Punch Biopsy for Proliferative lesionsPunch Biopsy for Proliferative lesions Transoral under LA if possibleTransoral under LA if possible Taken from edgesTaken from edges Adequate depth of tissueAdequate depth of tissue Anaesthesia in Trismus, Ankyloglossia, Anaesthesia in Trismus, Ankyloglossia,
SMF, Infiltrative & Posteriorly placed SMF, Infiltrative & Posteriorly placed lesions lesions
StagingStaging Nodal –Nodal –• ClinicalClinical• UltrasoundUltrasound• CT in CT in
extensive extensive nodal nodal diseasedisease
• PETPET
Metastatic workup Metastatic workup
• X ray ChestX ray Chest• Chest CT / PET in Chest CT / PET in
patients with N2 patients with N2 disease and N2 disease and N2 adenopathy below adenopathy below thyroid notchthyroid notch
• Symptom directedSymptom directed
Tumor-•Examination under anesthesia•X Rays,•Panorex•CT Scan•MRI
Investigations for StagingInvestigations for Staging
Examination under Anesthesia in Examination under Anesthesia in selected casesselected cases
X Ray Mandible, PNS, MaxillaX Ray Mandible, PNS, Maxilla
OrthopantamogramOrthopantamogram Orthopantomogram for involvement of mandible Orthopantomogram for involvement of mandible
& maxilla& maxilla Assessment of the entire dentition and early Assessment of the entire dentition and early
evaluation of erosionsevaluation of erosions Mentum & lingual cortex difficult to assessMentum & lingual cortex difficult to assess
ULTRASOUND NECKULTRASOUND NECK Highly operator dependentHighly operator dependent Sensitive in picking up nodes in clinical N0 Sensitive in picking up nodes in clinical N0
diseasedisease Useful for image guided biopsy Useful for image guided biopsy Ultrasound criteria:Ultrasound criteria: Size min axial diameter 7mm- submental, 8mm for other nodesSize min axial diameter 7mm- submental, 8mm for other nodes Roundness index ratio of transverse to longitudinal diametersRoundness index ratio of transverse to longitudinal diameters Absence of an echogenic hilusAbsence of an echogenic hilus Presence of necrosis – coagulative or cystic within a nodePresence of necrosis – coagulative or cystic within a node Extracapsular spreadExtracapsular spread Colour doppler- disorganised peripheral flow patternColour doppler- disorganised peripheral flow pattern
Coagulative necrosis
Cystic necrosis
Extracapsular disease
Disorganised peripheral flow
ULTRASOUND NECKULTRASOUND NECK
Indications for Ultrasound neck:Indications for Ultrasound neck: Patients with clinical N0 neck with Patients with clinical N0 neck with
primary in areas with high primary in areas with high possibility of lymphatic spreadpossibility of lymphatic spread
Clinically insignificant nodes ?Clinically insignificant nodes ?
CT scanCT scan
Standard practise nowStandard practise now Evaluates site and location of primaryEvaluates site and location of primary Assessment of Metastatic adenopathyAssessment of Metastatic adenopathy Scans done prior to biopsy to avoid Scans done prior to biopsy to avoid
confusion by changes from biopsyconfusion by changes from biopsy
CT scanCT scan
CT scanCT scan
CT scanCT scan
Indications for CT:Indications for CT: For evaluation of primary situated For evaluation of primary situated
adjacent to boneadjacent to bone Evaluation of extent of spread in Evaluation of extent of spread in
large primarieslarge primaries To decide on management of the To decide on management of the
mandiblemandible Evaluation of neckEvaluation of neck
Malignant node criteria for CT :Malignant node criteria for CT : LN > 15 mm. in level IILN > 15 mm. in level II LN > 10 mm. in other levelsLN > 10 mm. in other levels Group of ≥ 3 nodes ( 1-2 mm.)Group of ≥ 3 nodes ( 1-2 mm.) Central necrosisCentral necrosis Loss of tissue planes ( fat plane)Loss of tissue planes ( fat plane)
CT Scan CT Scan ADVANTAGES:ADVANTAGES: Increased speedIncreased speed Bony framework – better evaluatedBony framework – better evaluated Small calcifications more apparentSmall calcifications more apparent
DISADVANTAGES:DISADVANTAGES: Requires ionizing radiationRequires ionizing radiation And iodinated contrast agentsAnd iodinated contrast agents
DentascanDentascan
DentaScanDentaScan performs real time performs real time image reformation image reformation specific to CT dental specific to CT dental imaging: oblique imaging: oblique and panorex and panorex reformation. reformation.
Assessment of Bone Assessment of Bone involvementinvolvement
No motion artifact in No motion artifact in Bulky tumorsBulky tumors
DentascanDentascan
MRI – In Selected casesMRI – In Selected cases Better Soft tissue contrast Multiplanar – better assessment of
Primary Useful additional information in
previously treated patients (recurrence and residues) and in lesions with skull base involvement
No dental amalgam artifact
MRIMRI
Indications for MRI:Indications for MRI: In primaries with possible perineural In primaries with possible perineural
spreadspread For evaluation of possible skull base For evaluation of possible skull base
involvementinvolvement To evaluate exact soft tisue spread To evaluate exact soft tisue spread
of the tumor to plan conservative of the tumor to plan conservative resectionsresections
MRIMRI
MRIMRI
MRIMRIAdvantages:Advantages: More sensitive for subtle spread along nerves More sensitive for subtle spread along nerves
and into the skull baseand into the skull base Better evaluation of cartilage or marrow invasionBetter evaluation of cartilage or marrow invasion
Disadvantages:Disadvantages: Lower patient toleranceLower patient tolerance Dangers with metallic implants, pacemakers and Dangers with metallic implants, pacemakers and
other hardwareother hardware Increased expenseIncreased expense Patient motion always a concernPatient motion always a concern
PET scanPET scanInherent limitations of conventional imaging:Inherent limitations of conventional imaging: Poor sensitivity for detection of disease < Poor sensitivity for detection of disease <
1cm1cm Limited ability to distinguish residual or Limited ability to distinguish residual or
recurrent tumor from scarrecurrent tumor from scar Inability to biologically characterize diseaseInability to biologically characterize disease Inability to provide early prognostic Inability to provide early prognostic
information regarding treatment outcomeinformation regarding treatment outcome
PET scanPET scanAdvantages :Advantages : Useful in detection of additional disease not Useful in detection of additional disease not
seen on routine staging and altering TNM seen on routine staging and altering TNM stagingstaging
Detection rate of occult primary higherDetection rate of occult primary higher Less reliant on size for detection of nodal Less reliant on size for detection of nodal
diseasedisease Can detect distant metastasis and synchronous Can detect distant metastasis and synchronous
second primary malignancies not seen on second primary malignancies not seen on routine work up, therefore avoiding routine work up, therefore avoiding inappropriate aggressive treatmentsinappropriate aggressive treatments
PET scanPET scan
PET scanPET scan
PET scanPET scan
PET scanPET scanUses of PET:Uses of PET: StagingStaging Thereupetic planningThereupetic planning Post therapy restagingPost therapy restaging Thereupetic monitoring and outcomeThereupetic monitoring and outcome Restaging and relapseRestaging and relapse
Dilemmas :Dilemmas : Management of equivocal PET?Management of equivocal PET? Cost effectiveness?Cost effectiveness?
Pre Anaesthetic AssessmentPre Anaesthetic Assessment
General medical evaluation General medical evaluation Routine pre op lab InvestigationsRoutine pre op lab Investigations To rule out Co-morbid conditionsTo rule out Co-morbid conditions
Intra operative Frozen SectionIntra operative Frozen Section For marginsFor margins For nodes if selective node For nodes if selective node
dissection donedissection done
Optimal frozen section reporting: guidelines:
Confirmation of malignancy Closest margins – exact
length Positivity of closest
margins
Pre operative assessment of Speech Pre operative assessment of Speech & swallowing – Baseline for & swallowing – Baseline for
rehabilitationrehabilitation Spectrogram – intensity frequency , Spectrogram – intensity frequency ,
resonance & format of speechresonance & format of speech Modified Barium Swallow – premature Modified Barium Swallow – premature
spillage into hypopharynx & vestibule of spillage into hypopharynx & vestibule of larynxlarynx
Screening for Second PrimaryScreening for Second Primary
4% annual incidence4% annual incidence Pan endoscopy ( triple endoscopy), Pan endoscopy ( triple endoscopy),
sputum & saliva cytology, Xray Chest sputum & saliva cytology, Xray Chest
T - StagingT - Staging
TX – Primary cannot be assessedTX – Primary cannot be assessed T0 – No evidence of primaryT0 – No evidence of primary Tis – Ca. in situTis – Ca. in situ T1 – 2 cm or lessT1 – 2 cm or less T2 – more than 2 cm but not more than 4 T2 – more than 2 cm but not more than 4
cmcm T3 – more than 4 cmT3 – more than 4 cm
T - StagingT - Staging
T4a (lip) - Invading through cortical bone, inferior T4a (lip) - Invading through cortical bone, inferior alveolar nerve, floor of mouth or skin of face(chin alveolar nerve, floor of mouth or skin of face(chin or nose)or nose)
T4a (Oral cavity) – Invading adjacent structures T4a (Oral cavity) – Invading adjacent structures eg,. cortical bone, deep extrinsic muscle of eg,. cortical bone, deep extrinsic muscle of tongue, maxillary sinus or skin of facetongue, maxillary sinus or skin of face
T4b – Invading masticator space, pterygoid plates, T4b – Invading masticator space, pterygoid plates, skull base or encases Internal carotid arteryskull base or encases Internal carotid artery
(Superficial erosion alone of bone/ tooth socket by (Superficial erosion alone of bone/ tooth socket by gingival primary is not T4 )gingival primary is not T4 )
N - StagingN - Staging NX - Nodes cannot be assessedNX - Nodes cannot be assessed N0 – No nodesN0 – No nodes N1 – single ipsilateral node 3 cm or less in greatest N1 – single ipsilateral node 3 cm or less in greatest
dimension dimension N2a – single ipsilateral node more than 3 cm but not more N2a – single ipsilateral node more than 3 cm but not more
than 6 cmthan 6 cm N2b – multiple ipsilateral nodes none more than 6 cmN2b – multiple ipsilateral nodes none more than 6 cm N2c – bilateral or contralateral node none more than 6 cmN2c – bilateral or contralateral node none more than 6 cm N 3 – node more than 6 cm N 3 – node more than 6 cm (Midline nodes are ipsilateral nodes)(Midline nodes are ipsilateral nodes)
M - StagingM - Staging
MX – metastasis cannot be assessedMX – metastasis cannot be assessed M0 – No metastasisM0 – No metastasis M1 – Distant metastasis M1 – Distant metastasis
Stage GroupingStage Grouping Stage 0 – Tis N0 M0Stage 0 – Tis N0 M0 Stage I – T1 N0 M0Stage I – T1 N0 M0 Stage II – T2 N0 M0Stage II – T2 N0 M0 Stage III – T1-3 N1 M0 Stage III – T1-3 N1 M0
T3 N0 M0T3 N0 M0 Stage IV A - T4a N0-1 M0Stage IV A - T4a N0-1 M0
T1-4a N2 M0T1-4a N2 M0 Stage IV B – Any T N3 M0Stage IV B – Any T N3 M0
T4b Any N M0T4b Any N M0 Stage IV C – Any T Any N M1 Stage IV C – Any T Any N M1
Fallacies of TNM stagingFallacies of TNM staging
Depth of Primary not includedDepth of Primary not included
< 2mm - 13% nodes & 3% death< 2mm - 13% nodes & 3% death
2 to 9 mm – 46% nodes & 17% death2 to 9 mm – 46% nodes & 17% death
> 9mm – 65% nodes & 35% death > 9mm – 65% nodes & 35% death Extracapsular involvement in node not Extracapsular involvement in node not
consideredconsidered No provision for molecular markers, IHCNo provision for molecular markers, IHC
Molecular stagingMolecular staging
Molecular assays detect occult Molecular assays detect occult cancer cells previously missed by cancer cells previously missed by physical examination and standard physical examination and standard histopathologic techniques. histopathologic techniques.
Provide more objective analyses with Provide more objective analyses with fewer sampling errorsfewer sampling errors
Intra operative gene Intra operative gene probe – Pilot study probe – Pilot study showed 12 out of 30 showed 12 out of 30 patients with negative patients with negative margin were disease margin were disease free at 2 yearsfree at 2 years
To predict response to To predict response to RT – Breakpoints on RT – Breakpoints on 1p22, 3p21, 8p11, 1p22, 3p21, 8p11, distal 14q were distal 14q were resistant resistant
““Biological staging” - Biological Biological staging” - Biological behaviorbehavior
Useful in assessing cycling cellsUseful in assessing cycling cells
Precancerous lesions Precancerous lesions
Surgical tumor marginsSurgical tumor margins
Predicting aggressive behaviorPredicting aggressive behavior
Invasion frontInvasion front
Metastatic potentialMetastatic potential
““Biological staging” - Biological behaviorBiological staging” - Biological behavior Biomarker Predictors in Oral Biomarker Predictors in Oral
Precancerous & Cancerous LesionsPrecancerous & Cancerous Lesions