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What is Oral cancer?

During the times of Hippocrates, in around 400 BC, the word cancer appeared in literature: Karkinos; from the Greek word for crab.The tumour, with its clutches of swollen blood vessels around it, reminded Hippocrates of crab dug in sand with its legs spread.

Few cancers truly resemble crab with harden, matted surface of tumour similar to tough caracase of crabs body. One of them, most common in India, is cancer arising in oral cavity with legs formed by its submucosal spread in the surroundings.

The oral cancer is third common cancer worldwide and most common in Indian male. Annually over 3,00,000 new cases of oral cancer are diagnosed worldwide.In India it accounts for more than 30% of all cancers. Of these 60-80% present in advanced stages as compared to 40% in western countries. Such a high incidence of cancer in India could be attributed to heavy use of tobacco especially smokeless tobacco, along with alcohol. Advanced presentation is always associated with poor prognosis. Awareness about effects of tobacco and early detection form the pillars to achieve the reduction in this high incidence as well as morbidity and mortality associated with it.

In India, due to typical location of tobacco quid placement, inferior gingivobuccal sulcus is the common site for formation of malignancy, giving the name ‘Indian Oral Cancer’ to this specific location.

Etiology:

“It’s bad bile. It’s bad habits. It’s bad bosses. It’s bad genes.” - Mel Greaves, (Cancer) Out of these causes of cancer formation, bad habits (tobacco and alcohol) and bad genes (hereditary) are applicable for oral cancers. Apart from that chronic trauma (either by betel nut or sharp tooth) also contributes to formation of cancers.

Symptoms and Signs:

Chronic non healing ulcer, growth is the main presenting symptom followed by lump in the neck due to neck nodal metastasis. Any ulcer persisting for more than 15 days should not be neglected. Any suspicious ulcer should be biopsied for proper diagnosis.

Growth/ ulcer can present at any of the subsites in oral cavity

  1. Lip
  2. Buccal mucosa
  3. Tongue
  4. Lower alveolus
  5. Upper alveolus
  6. Hard palate
  7. Floor of mouth
  8. Retromolar triagone

Investigations:

  1. Biopsy:

    It is one the most important and basic investigation that should be done prior to starting treatment. 90-95% of oral cavity malignancy is histologically Squamous cell carcinoma.

    Biopsy can be done under local anesthesia. A small punch is taken from the most representative area of the ulcer/growth avoiding central necrotic area. Lesion needs to be palpated before taking biopsy soas to determine the exact site of biopsy which will yield maximum output.

  2. Fine needle aspiration cytology:

    This investigation can give us histological confirmation of the spread of malignancy to lymph node. To increase yield, it can be done with sonographic guidance.

  3. USG:

    To identify level of lymph node metastasis if present.

  4. CT:

    used to determine the third dimension of the tumour if it is not visible/palpable. i.e to stage the disease properly. And to determine the mandibular involvement by tumour

  5. MRI:

    it gives better soft tissue delineation for proper staging of disease.

Staging:

Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor 2 cm or less in greatest dimension
T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension
T3 Tumor more than 4 cm in greatest dimension
T4 (Lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face, i.e.1 chin or nose
T4a (Oral Cavity) Tumor invades through cortical bone, into deep (extrinsic] muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face
T4b Tumor involves masticator space, ptcrygoid plates, or skull base and/or encases internal carotid artery
Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
Nl Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimen sion
N2 Metastasis in a single ipsilateral lymph node, more than 3 cm hut not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a Metastasis in single ipsilateral Lymph node more than 3 cm but not more than 6 cm in greatest dimension
N2h Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm iii greatest dimension
N3 Metastasis in a lymph node more than 6 cm in greatest dimension
Distant Metastasis (M)
MX Distant metastasis cannot be assessed
MO No distant metastasis
Ml Distant metastasis
Stage Grouping
0 Tis NO MO
I T1 NO MO
II T2 NO MO
III T3 NO MO
T1 Nl MO
T2 MO Nl
T3 NI MO
IVA T4a NO MO
T4a Nl MO
T1 N2 M0
T2 N2 MO
T3 N2 MO
T4a N2 MO
IVB Any T N3 MO
T4b Any N MO
IVC Any T Any N Ml

Management:

Hippocrates had once abstrusely opined that “cancer was best left untreated, since patient lived longer that way”

We have travelled a long way from there. With advances in anaesthesia techniques and sterilisation, we have made surgical excision of many tumours possible. When caught at an early stage complete resection is possible giving the best chance of cure to patient with help of adjuvant therapy.

Treatment options:

1. Lip

T3 T4: Surgery ( wide excision with marginal/segmental mandibulectomy) + Post operative Radiotherapy

2. Buccal mucosa

T1 T2: Surgery ( wide excision with / without marginal mandibulectomy)

Indications of marginal mandibulectomy:

  • Tumour close to mandible
  • Limited periosteal involvement
  • Limited bony erosion
T3 T4: Surgery ( Composite resection with mandible and/or skin) + Post operative radiotherapy

Indications of segmental mandibulectomy:

  • Gross involvement of mandible
  • Edentulous mandible
  • Prior radiotherapy
  • Paramandibular disease

3. Tongue and floor of mouth

T1 T2: wide glossectomy/ hemiglossectomy
T3 T4: appropriate excision + post operative radiotherapy

4. Lower alveolus and RMT

Mandible uninvolved/ minimally involved: marginal mandibulectomy
Mandible involved: segmental mandibulectomy with post operative radiotherapy

5. Upper alveolus

upper alveolectomy

Management of neck:

Conservative surgical principles have affected all areas of surgical oncology. Radical neck dissections have become Modified radical (preserving non lymphatic structures) which have further become selective neck dissections ( preserving lymphatics which are uninvolved and have low risk of metastasis

N0 neck:

T1 T2 lesion: Supra omohyoid neck dissection (Level I-III) [Extended SOHD for tongue (I-IV)]

T3 T4: SOHD Frozen section Modified Radical Neck Dissection

N+ neck: Modified Radical Neck Dissection

Reconstruction:

The objectives of reconstructions in oral cavity is achieving primary healing, maintaining oral competence, facilitate swallowing, prevent aspiration, preserve speech and cosmesis.

Various options for reconstruction include

  1. Mucosal defects
    • Leave raw
    • Split thickness skin graft
    • Mucosal grafts
    • Temporalis flap
    • Radial forearm free flap
    • Lateral arm flap
  2. Full thickness defects
    • Abbe-Estlander flap
    • Tongue flap
    • Nasolabial flap
    • Masseteric flap
    • Facial artery myomucosal flap
    • Forehead flap
    • Submental flap
    • Pectoralis major myocutaneous flap
    • Delto pectoral flap
    • Antero-lateral thigh free flap
  3. Mandibular defects
    • Fibular osteocutaneous free flap
    • Pectoralis major myocutaneous flap
Fig: PMMC flap marking, harvest and inset.
Fig: Free flap
Fig: Submental flap

Radiotherapy:

Role of radiotherapy in oral cavity in oral cavity is for T1/T2 lesions with curative intent and in T3/T4 or node positive cases as adjuvant modality of treatment. However, since disease free and overall survival rates with radiotherapy and surgery being the same, surgery is preferred modality of treatment in such cases.

Indications of postoperative radiotherapy:

  1. T3/T4 lesions
  2. Close margins
  3. Perineural invasion
  4. Angio invasion
  5. Bone/ skin involvement
  6. Two or more positive nodes
  7. Extranodal spread

Indications of chemotherapy

  1. Close/ involved margins
  2. Extranodal spread

Oral Cavity

Stage 5 Year relative servival (95% CI)
I 69.5% - 73.5%
II 55.5% - 60.4%
III 41.8% - 47.3%
IV 40.3% - 33.6%

In the end, increased awareness and early detection of the malignancy are the key points in reducing the morbidity and mortality. So it is our responsibility to make all our patients aware of ill effects of tobacco in any form and to screen them for oral malignancies or premalignant lesions at every possible opportunity.


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