Transcript INTERHOSPITAL CONFERENCE

INTER-HOSPITAL
CONFERENCE
21 DEC.2007
ผูป้ ่ วยชายไทยคู่ อายุ 40 ปี อาชีพ ข้าราชการครู
ภูมิลาเนา จ. ปทุมธานี
CC: เจ็บที่ลิ้นด้านซ้าย 2 สัปดาห์ ก่อนมา ร.พ.
PI : ~ 2 สัปดาห์ ก่อนมา ร.พ. มีแผลที่ลิ้นด้านซ้าย, เจ็บ, ไม่มีเลือดออก,
ทางานหนักพักผ่อนน้อย
PHx. : - ปฏิเสธโรคประจาตัว
- ปฏิเสธแพ้ยา
- ดื่มสุ รา, สูบบุหรี่ เล็กน้อย หยุดมา 2 สัปดาห์
ประวัติเพิ่มเติม
• ได้รับการรักษาโดยแพทย์ หู คอ จมูก จากต่างจังหวัด โดยการจี้ยา
และได้ยาทา
• ปฏิเสธฟันผุ, การใส่ ฟันปลอม
• ปฏิเสธประวัติโรคมะเร็ งในครอบครัว
Physical examination
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Thai male, not pale, no jaundice
v/s T 37˚C PR 80/min BP 120/80 mmHg
Heart : normal
Lung : clear
Abdomen : soft, not tender, no
hepatomegaly
• Neuro sing : WNL
ENT Examination
• AR : normal mucosa, no discharge
• PR : no mass, no discharge
• OC : ulcerative lesion at Lt. lateral tongue
size 0.5 x 0.5 cm.
• IDL : no mass, TVC move bilateral
• Neck : no palpable lymph node
Management?
BIOPSY : Negative for malignancy
DIFFERENTIAL DIAGNOSIS
ENT Examination
• OC : ulcerative lesion at Lt. lateral tongue
size 0.5*0.5 cm., submucosal lesion 2*3cm.,
no limited tongue movement
INVESTIGATION
INVESTIGATION
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B.
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DIAGNOSIS AND
MANAGEMENT
DIAGNOSIS
DIAGNOSIS
• CA Tongue T2N0M0
MANAGEMENT
• Surgery?
• RT?
MANAGEMENT
• Surgery?
• RT?
Wide excision?
DIAGNOSIS AND MANAGEMENT
• Dx. CA Tongue T2N0M0
• Rx. Lt.Hemiglossectomy with
primary closure with Lt. SND I-IV
Surgical Pathology Report
• Tongue : consists of Lt. half portion of
tongue, measuring 5*3*2.5 cm. The outer
surface reveals an ulcerated light tan firm
mass, measuring 2.7*1.8*0.8cm.,
occupying the Lt.half of tongue, 0.5
cm.from medial resected margin and 0.5
cm.from deep resected margin
• Lymph node group I-IV : No evidence of
malignancy
Management
• Combine Post-Op. RT ?
• Combine Chemotherapy ?
Management of the N0 Neck in
CA Oral cavity
Evaluation of the N0 Neck
• The reported false negative rate in
assessing of cervical LN metastasis by
palpation is 20%-50%
• Factor affecting :
• The experience of the examiner
• The patient’s body
• The previous treatment – Sx / RT
Evaluation of the N0 Neck
• Structure in neck mistake
• Transverse process of atlas
• Carotid bifurcation
• Submandibular gland
Evaluation of the N0 Neck
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Digital palpation
CT / MRI
Ultrasound
Ultrasound guided FNAB
Evaluation of the N0 Neck
• Malignancy criteria for CT/MRI
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LN > 15 mm. in level II
LN > 10 mm. in other levels
Group of ≥ 3 nodes ( 1-2 mm.)
Central necrosis
Loss of tissue planes ( fat plane)
N0 Neck affecting
the recurrent/survival rate
Oral cavity CA
Type
N0
1 node
2 nodes
≥ 3 nodes
5 years survival
75%
49%
30%
15%
Therapeutic modalities
for the N0 neck
• Prophylactic Neck dissection
• Prophylactic Neck irradiation
• Observation with therapeutic ND once
regional metastasis become appearance
The N0 neck in oral cavity CA
• Byers et al : the prediction of nodal metas.
In primary oral tongue SCCA
• The depth of muscle invasion
• N stage
• The degree of differentiation of the 1˚ tumor
• T1N0 with muscle invasion < 4 mm., WD
 14% chance of nodal involvement
The N0 neck in oral cavity CA
• SCCA of oral cavity the sites with < 20%
occult metastasis :
• T1/T2 lip
• T1/T2 oral tongue < 4 mm in thickness
• T1/T2 FOM < 1.5 mm in thickness
Surgical therapy in the N0 neck
with oral cavity CA
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SOHND
Minimal morbidity
Reduces the risk of occult disease
Avoid the undesirable side effect of RT
RT is reserved for possible future tx. of
second primary tumor )
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RT in the N0 neck
with oral cavity CA
• An alternative treatment to SOHND
• PORT of the surgically treated primary
tumor site, the neck has not been dissected,
and the risk of occult regional dz. is
substantial
• Primary tumor is treated with RT and the
risk of occult node > 20%
Elective neck dissection VS
Elective neck irradiation
• ENI reduced neck failure rate in pt with control
primary tumor and N0 neck from 18% to 1.9%
• In T1N0 SCCA oral tongue, ENI provided 95%
control rate for neck recurrences compare with
38% without ENI
• Modality is chosen to Tx primary cancer may
also help in formulating a decision as to how to tx
the neck
Elective neck dissection VS
Elective neck irradiation
• Prophylactic neck RT provides equal
control rate for neck metastasis to
prophylactic ND
THANK YOU FOR YOUR
ATTENTION
Combined modality of treatment
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perineural spread
intravascular spread
intralymphatic spread
+ ve margin
2 histo. Positive LN
multiple +ve LN
extracapsular spread
Management of contralateral N0
• 14% incidence of involvement of
contralateral neck node regardless of tumor
stage
• If primary oral cavity cancer is midline
location, bilaterally, along the tip of tongue
or approaches or cross the midline
BASIC LAB .
• CBC : Hct. 36% WBC 11,200 ( N 72.2% L21%
E 2.1% M 3.9%)
• BUN 5 Cr 0.5
• Na 137 K 4.3 Cl 106 CO2 25
• FBS : 107
• LFT : Alk.59 SGPT 12 SGOT 17 TB 0.63 TP 7.8
Alb 4.6
• EKG : Normal
• CXR : No active pulmonaly lesion
BIOPSY.
• Lt. Lateral tongue : Squamous cell
carcinoma, moderate differentiated
@
N0 in early SCCA oral cavity
• Most important prognostic factor in Mx of oral
SCCA is status of cervical LN.
• Present of metastasis to cervical LN can reduce
curative rate by 50%
• 3 Tx options are available.
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Observation with therapeutic ND once regional
metastasis become appearance
Elective neck RT
Elective neck dissection
Morbidities of associated ENI
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Xerostomia
Dsyphagia
Increased oral passage time
Mucositis
Pain
Increased complication if salvage sx.
Long duration of tx.