Transcript Document

Surgical Management
of
Malignant Tumors
อ. พญ. ทพญ. นุชดา ศรียารัณย
ภาควิชาศัลยศาสตร์ชอ
่ งปาก
คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่
Etiology and predisposing factors
The exact cause of oral cancer is
unknown
• Variations in incidence rates :
differences in exposure to
carcinogenic initiators
Risk factors
Tobacco
Alcohol
Genetic predisposition
Atmospheric pollution
Immunosuppression
Viruses
Fungal infection
Diet
Dental sepsis
Tobacco
24% of all male deaths in developed world
7% of all female deaths
Smoking is the cause of 45% of all cancer
deaths
95% of all lung cancer deaths
85% of all oral cancer deaths
Tobacco
Carcinogens of tobacco
Benzopyrene
tobacco specific nitrosamines
Act locally on keratinocyte stem cells
Affecting DNA replication
Causing mutation
Alcohol
Pure ethanol is not carcinogenic
Nitrosamines and other impurities
Rising incidence of oral cancer
linked to rising alcohol consumption
Alcohol
Ethanol increases mucous membrane
permeability
Ethanolmetabolised to acetaldehyde locally by
bacterial alcohol dehydrogenases and can
damage cells – poor oral hygiene
Alcoholic liver disease reduces detoxification
of carcinogens
High calorie value suppresses nutrition and
leads to nutritional deficiencies
Risk factors
Genetic predisposition ?
- impaired capacity to metabolise
carcinogens
- DNA damage repair impaired
Atmospheric pollution
- polycyclic aromatic
hydrocarbons/nitrosamines/benzenes
Risk factors
Immunosuppression
- organ transplant patients – lip cancer
- no increased risk with AIDS of oral SCC
Viruses
-HPV 16 and 18
viral oncogene
deactivates p53
inhibit apoptosis
Risk factors
HPV and oral cancer
Prevalence 0-100 % in OSCC
But only 40% of head and neck SCC with
p53 mutations had high risk HPV
Only 40% of HPV positive tumors showed
p53 mutations
HPV infection is pobably an early event
Higher prevalence in younger patients
Risk factors
Other viruses
Herpes simplex
Epstein-Barr virus
Hepatitis virus
no clear evidence of involvement in oral
cancer
Risk factors
Fungal infection
- candida albicans – potential to promote
nitrosation of dietary substrates
Diet
-Protective effect of antioxidants Vit A, C,
E and trace elements Zinc and selenium
Dental sepsis
- poor oral hygiene-socioeconomic status and
nitrosating enzyme in plaque
Age and sex
older age
~ 95% occur in over 40 Yrs
The average age at the time of Dx is about
60 Yrs
more frequent in males
Male : Female ~ 2 : 1
Sites
The Tongue is the most common
site for oral cancer
Floor of mouth
Histologic types
Carcinoma 96%
Sarcoma 4%
The most common type : squamous cell
carcinoma
Major salivary gl. : malignant mixed tumor
Minor salivary gl. : adenoid cystic CA
Lymphoma
Metastatic tumors to oral cavity
Diagnosis
Examination
• Inspection : oral cavity, neck, pharynx
• Palpation : neck , oral masses
Investigations
1. Surgical biopsy
•
•
•
oral cavity : local anesthesia
Small lesions
excisional biopsy
Incisional biopsy is recommended in all
cases
Surgical biopsy
The biopsy : suspicious area of the lesion
and some normal adjacent mucosa
Avoid area of necrosis or gross infection
2. Toluidine blue test
The suspicious area is paint with 1%
aqueous solution of toluidine blue for 10
sec.
Rinsed with 1% solution of acetic acid
The toluidine blue binds to DNA present in
the superficial cells and resists
decoloration by acetic acid
Toluidine blue test
Dye binding is proportional to the
amount of DNA present and the
number and size of superficial nuclei
in the tissues
false negatives
guide
3. Fine needle aspiration biopsy
lumps in the neck (suspicious lymph nodes)
percutaneous puncture of the mass with a
fine needle and aspiration of material for
cytological examination
FNAB
The node is fixed between finger and
thumb
Puncture by a 21 or 23 gauge needle on a
10 ml syringe
A small amount of air is already in the
syringe (2ml) before puncture
FNAB
moving the needle around different parts
of the node
the plunger is then released and the needle
withdrawn through the skin
The tip of the needle must touch the slide
Smear slide
FNAB
Wet fixed material:
an alcoholic ‘spray fixed’
immediately, 10 min
Thinner film : air dry
after the aspiration, aspirate 2ml of
95% ethanol as fixative into the same
syringe
FNAB
fast , almost painless, needs no specialised
equipment and without complication
The technique depends on 2 aspects:
- successful puncture of the node
- transfer of cells and stroma onto slide
FNAB
Frable and Young: 94.5% accuracy with
head and neck lesions
may avoid the need for open biopsy
Risk of spreading malignant cells into the
surrounding tissues
(Tumor implantation into the needle track,
when large gauge needle has been used)
4. Radiography
Limited value
50% of calcified component of bone
must be lost before any radiographic
change
Panthomography
alveolar and
antral involvement
lungs and skeleton
5. Computerised tomography
Great benefit in head and neck
• Primary tumor and lymph node
metastasis
• Value in the investigation of
metastasis in the lungs, liver and
skeleton
6. Radionuclide studies
Technetium pertechnetate bone scans
Not specific
(increased uptake : increased metabolic
activity in the bone)
Detecting distant metastases
7. Magnetic resonance imaging
(MRI)
Highly contrasted image for soft tissue
lesion
Bone is not imaged
only the marrow being directly visualized
8. Ultrasound
Noninvasive, readily available and cost effective
• Abdominal ultrasound : liver metastases
• intra-oral tumors : high degree of accuracy,
demonstrating bone invasion (early stage)
• Regional LN
Precancerous lesion
Leukoplakia
Erythroplakia
Location of leukoplakia/erythroplakia
Occurrence
1. Buccal mucosa
2. Mandibular vestibule
3. Maxillary gingiva
4. Mandibular gingiva
5. Tongue
6. Floor of mouth
7. Lower lip
probability of dysplasia
1. Floor of mouth
2. Tongue
3. Lower lip
4. mandibular gingiva
5. Buccal mucosa
6. Mandibular vestibule
7. Maxillary gingiva
Leukoplakia
Dysplasia
1. Mild Dysplasia
2. Moderate Dysplasia
3. Severe Dysplasia
Leukoplakia
Mangement
Looking for etiology factors
- stop smoking immediately
non/mild dysplasia
- total excision
- F/U 3-6 mo. when non total
excision
Leukoplakia
Moderate dysplasia
- total excision
- F/U 4-8 wk. when non total excision
Severe dysplasia
- total excision
- F/U every 4wk.
Erythroleukoplakia
Moderate dysplasia
Management
- total excision with 1 cm margin ,
extend in submucosa
- F/U every 4wk.
Erythroplakia
Management
- total excision with 1 cm margin ,
extend in submucosa
- F/U every 4wk.
Spread of tumor
Local extension
Lymphatic spread
- stepwise spread
Hematogenous spread
Biology of metastasis
SCC : most to regional LN
sometimes through blood
(lung, brain, bone)
Biology of metastasis
Steps
1. Invasion through basement membrane,
between endothelial cell or blood vessel
(collagenase, heparanase, stromelysin)
2. Entrance into lymphatics or blood vessel
form tumor embolus
3. Survival of cancer cell in lymphatics or
blood vessel
Biology of metastasis
4. Escape from circulation into new tissue
(collagenase, heparanase, stromelysin)
5. Implantation in new tissue area with cloning
require : angiogenic factors, GF to recruit
blood supply, stimulate self-replication,
down regulate host cells, activate host cell
(osteoclast)
Incidence of LN metastases
Depend on :
- size
- site
- histological type of primary
tumor
LN metastases
most commonly in the upper deep cervical
and submandibular nodes on the same side
of the primary tumor
lower deep cervical nodes : rare
Contralateral node metastases : rare
Incidence of LN metastases
Site :
- more posterior lesion in the mouth
the more likely LN metastases
Retromolar trigone : 45%
Tongue : 35%
Floor of mouth = lower alveolus : 30%
buccal mucosa and hard palate, lower
lip : 10-15%
Incidence of LN metastases
Histology
SCC :
The better differentiated, the less metas.
verrucous CA : low
well diff. SCC : 26%
moderated diff. SCC :33%
poorly diff. SCC : 50%
Diagnosis of LN metastases
•
•
•
•
Clinical examination
Imaging
Cytology
Histology
Imaging
CT
- sensitivity similar to clinical exam.
sensitivity > 90%
Node above 1 cm suspicious of malinancy
Diagnosis of LN metastases
Ultrasound
- simple, relative cheap
- used to guide FNAB of impalpable nodes
Diagnosis of LN metastases
Cytology (FNAB)
- useful confirmatory test
- accuracy is high
- false-negative results
open biopsy
Lymphatic drainage
Superficial parotid LN
deep parotid LN
submental LN
submandibular LN
deep cervical LN
Lymphatic drainage
- anterior floor of mouth, anterior alveolar
ridge, lower lip
submental triangle LN
- Posterior floor of mouth, tongue, buccal
mucosa, posterior alveolar ridge
Submandibular LN
- Cancer of tongue
node of Stahr
- retromolar trigone, tonsillar fossa,
pharyngeal tongue
jugulodigastric LN
Lymphatic drainage
- SCC
Oral
Lung (multifocal)
Lung (venous system)
- invasion into small vein
- drain to larger vein
- cancer emboli
SVC
- heart
- pulmonary artery
Classification and staging
TNM classification
TNM classification
Pretreatment Clinical Classification (cTNM)
- clinical, radiological, other investigation
Postsurgical Histopathological Classification
(pTNM)
- by surgical findings and the examination
of the therapeutically resected specimen
T – Primary Tumor
TX
TIS
T0
T1
T2
T3
T4
Primary tumor cannot be assessed
Pre-invasive carcinoma (carcinoma-in-situ)
No evidence of primary tumor
Tumor size ≤ 2 cm
Tumor size > 2 but ≤ 4 cm
Tumor size > 4 cm
Massive tumor or Tumor invades adjacent
structures e.g. through cortical bone,
muscles (intrinsic) of tongue, muscle of
mastication, maxillary sinus, skin
N – Regional Lymph Nodes
NX Regional LNcannot be assessed
N0 Noregional LN metastasis
N1 single ipsilateral LN ≤ 3 cm
N2a ipsilateral LN >3 but ≤ 6 cm
N2b multiple ipsilateral LN ≤ 6 cm
N2c bilateral or contralateral LN ≤ 6 cm
N3
LN > 6 cm
M – Distant Metastases
MX distant metastasis can not assessed
M0 no distant metastasis
M1 metastasis present
Postsurgical histopathological
classification uses the same
categories for pT, pN and pM
The stage grouping in UICC classification
Stage 0
Stage I
Stage II
Stage III
Stage IV
Tis
N0
T1
N0
T2
N0
T3
N0
T1, T2, T3 N1
T4
N0, N1
Any T
N2, N3
Any T
Any N
M0
M0
M0
M0
M0
M0
M0
M1
Histopathological Grading (G)
GX Grade of differentiation cannot be
G1
G2
G3
G4
assessed
Well differentiated
Moderately differentiated
Poorly differentiated
Undifferentiated
The absence or presence of residual
tumor after Tx. (R)
RX Presence of residual tumor cannot be
R0
R1
R2
assessed
No residual tumor
Microscopic residual tumor
Macroscopic residual tumor
Basic aim of treatment
Eradication of tumor with satisfactory
physiological function
: mastication, phonation, facial expression
and an acceptable cosmetic appearance
Treatment of oral cancer
Surgery
Radiotherapy
Chemoradiotherapy
Surgery with adjuvant radiotherapy
Surgery : main of treatment
Primary site is resected,
cervical LN are removed
Radiotherapy
can be primary Tx. or combined
with surgery
Chemotherapy
not suitable as primary Tx.
can be combined with surgery
and radiation
Team work
Surgeon
Radiotherapist
Medical oncologist
Pathologist
Supportive team (nurse, prosthetist,
speech therapist, psychiatrist, etc.)
Prognosis
Factor
• Site
• Size (diameter, thickness , invasion)
• Degree of histologic differentiation
• Lymph node metastasis (Level, number)
• Extranodal spread
• Distant metastasis
CA of oral cavity
management of primary tumor
Choice of treatment
factors in deciding
- site of origin
- stage of disease
- histology of the tumor
- medical condition and lifestyle
Stage of disease
Small lesion :
surgery without deformity (1cm margin)
Large mass with invasion of bone :
Surgery, low cure rates by radiotherapy
Lesions of intermediate stage
(larger T1, most T2, early exophytic T3) :
controversial, similar survival rate
(functional results and morbidity)
Stage of disease
Advanced as to be unresectable :
Radiotherapy or chemotherapy
• Previously irradiated tissue : relatively
radioresistant because of limited blood
supply : not advisable to re-treat
Multiple primary tumors or extensive
premalignant change :
surgery
Histology
SCC :
poorly differentiated ~ higher incidence
of lymphatic spread, worse prognosis
Verrucous CA in early stage (superficial
exophytic lesion : local excision
Adenoid cystic carcinoma of minor salivary
gland : nerve resection, nerve canal resection
Medical condition and lifestyle
Age :
elderly, poor general condition, with
advanced disease
irradiation
Alcoholic patient, smoking : high risk
of postradiation complication
Principles of resection
Palliative resection
Curative resection
Palliative resection
Aim
improve quality of life
• Reduction of the tumor size (when
compression of vital structure)
• Debulking : control of tumor with
subsequent radiotherapy and/or
chemotherapy
• To relieve pain (direct excision or
surgical decompession
Curative resection
Remove tumor in one piece with margin of
microscopically normal tissue
Frozen section
Management of regional lymph nodes
Frozen section
Principle
• Between surgery
• Margin of resection tissue
• residual
Neck dissection
‘Lymphatics and lymph node chain in the
neck are contained in the cervical fascia
and in fatty contents around the cervical
fascia of the neck’
Cervical lymph node in level I-V
Level I
submental LN (submental triangle)
laterally : two anterior bellies of digastric
inferior : hyoid bone
floor : mylohyoid
submandibular LN (digastric triangle)
superior : mandible
anterior : anterior belly of digastric
posterior : posterior belly of digastric
floor : mylohyoid, hyoglossus
Level II
Upper internal jugular nodes
caudal : carotid bifurcation or hyoid
dorsal : dorsal of sternoclidomastoid m.
anterior : stylohyoid muscle
Level III
Mid internal jugular nodes
cranial : hyoid and carotid bifurcation
caudal : omohyoid m.
anterior : sternohyoid m.
posterior : dorsal of sternocleidomastoid m.
Level IV
Lower internal jugular nodes
cranial : omohyoid m.
caudal : clavicular
anterior : sternohyoid m.
posterior : dorsal of sternocleidomastoid m.
Level V
Spinal accessory, supraclavicular LN
and posterior triangle
anterior : dorsal of sternocleidomastoid m.
posterior : trapezius m.
inferior : clavicle
Types of neck dissection
Comprehensive neck dissection
- radical
Selective neck dissection
- functional sparing
Comprehensive neck dissection
Type
Radical ND
Modified RND 1
Modified RND 2
Modified RND 3
Node level
I-V
I-V
I-V
I-V
preserved
none
SAN
SAN, IJV
SAN, IJV, SCM
Standard radical neck dissection
All LN are removed (level I-V)
superiorly : from the level of mandible
inferiorly : to the clavicle
postriorly : from the trapezius m.
anteriorly : to the midline
Sacrificing : sternocleidomastiod m., internal
jugular vein, spinal accessory n.
Indications for radical neck dissection
N3 neck disease where accessory
nerve not preservable
multiple positive LN involving
accessory n. or internal jugular v.
Gross extranodal spread
Residual or recurrent disease after
radiotherapy
Contraindications for radical neck
dissection
Distant metastases
Poor general condition or high risk for
GA
Fixed LN with skin infiltration or
ulceration
Modified radical neck dissection
1. MRND – I
preserves the accessory n.
2. MRND – II
preserves accessory n. and internal
jugular vein
3. MRND – III
preserves accessory n.,
sternocleidomastoid m. and internal
jugular vein
Indications for modified RND
N+ neck where all nodal levels require
dissection
Where certained structures are involved
by nodal metastases but others can be
preserved.
To preserve function especially the
accessory n.
Maintain IJV for microvascular
anastomosis
Selective neck dissection
Some compartment or preserve structure
1. Submandibular triangle dissection
2. Suprahyoid ND (level I-II)
3. Supraomohyoid ND (level I, II, III)
Indications for supraomohyoid ND
Oral cavity tumors
N0 neck
Small N+ disease
Aims of neck dissection
Removed nodal metastases, manage
disease in neck
Node sampling for accurate
pathological staging to direct
further Tx. of the neck
Node disease and survival
Positive LN metastases are the
single most important prognostic
indicator for survival
Survival is decreased by up to 50%
Oral cancer
Tongue and floor of mouth
65% of all oral cancer
SCC : predominantly
The Tongue
20 –30% of oral cancer
Majority : middle third of lateral
margin, extending onto the ventral
aspect and floor of the mouth
25% on posterior 1/3 of the tongue
20% on anterior 1/3 of the tongue
4% on the dorsum (associated with
syphilitic glossitis)
The tongue
Manifestation:
exophytic with ulceration,
superficial ulceration with
infiltration
Endophytic tumor
The Tongue
Typical malignant ulcer:
Often several centimeters in diameter
Hard in consistency with heaped-up and
everted edges
Floor is granular, indurated and bleeds,
area of necrosis
The tongue
difficulty with speech and swollowing
Pain : severe and constant, radiating to
the neck and ears
LN metastases : common (relatively early)
12% may present with no symptoms other
than a lump in the neck
The Tongue
Treatment
• Small lesion : intraoral excision
Excision of less than 1/3: no
reconstruction
• Exceeding 2 cm : hemiglossectomy
The Tongue
Extensive tongue lesion involve floor of
mouth and alveolus :
lip split and mandibulotomy
Tumors reach the alveolus : rim resection
of the mandible, reconstruction with
distant flap
not exceed 2/3 of tongue : radial forearm
free flap with microvascular anastomosis
The Tongue
Large volume defect, total glossectomy,
deeply infiltrating tumor :
resection extends to hyoid bone,
pectoralis major muscle flap
When possible at least one hypoglossal n.
should be preserved
The floor of the mouth
second most common site for oral cancer
Most : anterior of the floor of mouth to
one side of the midline
Indurated mass
Early stage : tongue and lingual aspect of
the mandible become involved
The floor of the mouth
Early
slurring of the speech
Lymphatic metastasis is less common,
usually to submandibular and
jugulodigastric nodes and may be
bilateral
Associated with preexisting
leukoplakia more commonly
Floor of the mouth
Treatment
small tumor : simple excision (1 cm margin)
• involve the under surface of tongue and
lower alveolus :
surgical excision
partial glossectomy
and marginal resection of mandible,
reconstructed with local or distant flap
The Gingiva and alveolar ridge
Predominantly in the premolar and molar
regions
proliferative tissue at the gingival margins
or superficial gingival ulceration
Hx. of tooth extraction with subsequent
failure of the socket to heal or sudden
difficulty in wearing dentures
Edentulous alveolar ridge : indolent
superficial ulceration often adjacent to
leukoplakia
The Gingiva and alveolar ridge
DDx :
apical or periodontal abscess
Pyogenic granuloma
Peripheral giant cell granuloma
Pregnancy granuloma
Polypoid
Sessile fibroepithelial lesion
Denture granuloma
The Gingiva and alveolar ridge
Invasion of the underlying bone 50% of
cases (important consequences for
treatment)
Regional nodal metastasis is common
(30-84%)
Lower alveolus
Modality of choice : surgery
Marginal resection
Extensive invasion :
continuity resection and reconstruct
with free corticocancellous graft
(iliac, rib) or microvascular tissue
transfer
The buccal mucosa
SCC mostly arise at the commissure or
along the occlusal plane to the retromolar
area
majority : situated posteriorly
Exophytic, ulcero-infiltrative and
verrucous type
Sometimes presenting with trismus
(deep neoplastic infiltration into the
buccinator muscle)
The buccal mucosa
LN metastasis :
submental,submandibular,
parotid and lateral pharyngeal nodes
Buccal mucosa
Treatment
• Lesion confined to buccal mucosa :
wide excision include buccinator m. and
split thickness skin graft
• Small defects up to 3 x 5 cm :
excision and closure with buccal fat pad
• More extensive lesions :
reconstruction with free radial fore
arm flap, temporalis muscle flap
The hard palate, maxillary alveolar ridge
and floor of antrum
Presenting symptom :
Complaint of painful or ill-fitting
denture
CA in the floor of maxillary antrum
often present as palatal tumors
present with dental symptoms
early symptoms are non specific
and mimic chronic sinusitis
The hard palate, maxillary alveolar ridge
and floor of antrum
symptom :
painless loose teeth
failure of the sockets to heal after
extraction
swelling in the mucogingival fold
pain, swelling or numbness of the face
Later symptoms : nasal obstruction,
discharge or bleeding oro-antral fistula
The hard palate, maxillary alveolar ridge
and floor of antrum
symptom :
Occasionally localised or referred pain in
the premolar or molar teeth : early
infiltration of the posterior superior
dental n.
Trismus : tumors extend backwards into
the pterygoid region
The hard palate, maxillary alveolar ridge
and floor of antrum
LN metastasis from CA of the palate
and floor of the antrum : late, poor
prognosis
Initially to submandibular nodes and
then to the deep cervical chain
Hard palate and upper alveolus and
maxillary antrum
Tumor of minor salivary gl. are more
common
SCC arise from maxillary antrum
Treatment
Involve bone : surgery
Radiotherapy alone for small early
superficial tumor
Hard palate and upper alveolus and
maxillary antrum
Tumor in hard palate, upper alveolus, floor
of antrum : partial maxillectomy
More extensive tumor confined to maxilla :
total maxillectomy
Exposed through a Weber-Fergusson
incision
Hard palate and upper alveolus and
maxillary antrum
Defect : reconstruction or obturator
prosthesis
Reconstruction : local flap or free flap
Small posterior defect : buccal fat pad or
masseter muscle flap
Carcinoma of the lip
SCC
Lower lip > upper lip
Greater exposure of lower lip to sunlight
Ulcer, keratin crust covers ulcer
Rest of lip vermillion may show actinic
change
Carcinoma of the lip
Up to 1/3 of lower lip can be removed
Up to 1/4 of upper lip can be removed
V or W shaped excision with
primary closure (up to 2 cm diameter)
large central defect of lower lip
Step ladder approach of Johanson
Abbe or Estlander plastic
Retromolar trigone
Anterior surface of ascending ramus
Tumor invade the ascending ramus
Spread to pterygomandibular space
Retromolar trigone
Surgery : lip split and
mandibulotomy
Small defect : reconstructed with
masseter or temporalis muscle flap
Larger defect : free flap