Care oral Cancer - causes, symptoms, diagnosis, treatment and ongoing

Basics

Description

Malignant tumors affecting the tongue, floor of the mouth, salivary glands, buccal mucosa, gums, hard and soft palate, or vermillion junction of the lipSystem(s) affected: GI

Epidemiology

Incidence

Predominant age: >40 yearsNow seen increasingly in younger age groups with the use of smokeless tobacco and alcoholPredominant sex: Male > Female (2:1)12/100,000/year (35,310 new cases/year)3–5% of all cancers in US each yearOral cancer is the eighth most common cancer worldwide.High incidence in Asia, related to the habit of chewing betel nut, fresh betel leaf, and habitual reverse smoking (lighted end held within the oral cavity)1/3 higher incidence in African Americans than in whites, with a mortality rate almost 2× as high

Geriatric Considerations

Greater incidence > 40 years of agePeak age of 55 years

Prevalence

Oral cavity neoplasms account for 3% of new cancers occurring in men and 2% in women.Lip carcinoma 30%, buccal cancer 5%, floor of the mouth cancers 10–15%, tongue cancers 20–30%

Risk Factors

Most patients with proliferative verrucous leukoplakia (PVL) progress to oral carcinoma (1).Low socioeconomic status (2)Tobacco, alcohol, ultraviolet (UV) light exposures

Genetics

Family history of oral cancer should be noted.

General Prevention

Avoid tobacco (including smokeless) and betel nut.Limit alcohol use.Limit sun exposure/UV light; wear sun block, hats with visors/large rim.Maintain a nutritious diet high in fruits and vegetables (3).Annual complete oral examination, including bimanual palpation of mouth floor by dentist or doctor, especially for those at risk.Early detection may be beneficial in high-risk individuals (e.g., dental offices offer zila tolonium chloride (toluidine blue) [ViziLite Plus] testing with 71% PPV) but has not been proven in low-risk individuals.If detected at an early stage, survival from oral cancer is better than 90% at 5 years, whereas late-stage disease survival is only 30%.Close follow-up of PVL with early and aggressive treatment

Pathophysiology

Of neoplasms, 90% are squamous cell carcinomas; the others include lymphomas and adenocarcinomas from minor salivary gland origin and sarcomas.Variety of cellular differences at molecular level among oral squamous cell carcinomas (4)

Etiology

Use of tobacco (smokeless or smoked, including cigars); 85% of head and neck cancers linked to tobaccoExcessive alcohol consumptionUse of both alcohol and tobacco greatly increases risk as compared with those who use tobacco or alcohol alone (synergistic effect).Exposure to UV light (i.e., sun exposure) in the case of lip carcinomaRadiation exposure from treatment of other facial cancers increases risk of salivary gland cancers.Associations: Epstein-Barr virusHuman papillomavirus (HPV) and alcohol and tobacco may promote invasion of HPV and oral cancers.Betal nut with and without tobacco useCertain occupational chemical exposures, including formaldehyde, perchloroethylene, and pesticides, may be associated with nasopharyngeal and laryngeal cancer.Poor oral hygiene, presence of oral lichenoid, and leukoplakic lesions may act as predisposing factors.Patients with HIV have a higher incidence of head and neck malignances.

Commonly Associated Conditions

Leukoplakias or erythroplakias should be biopsied because they are considered premalignant and are associated with carcinoma at least 10% of the time.Riboflavin deficiency or iron-deficiency anemia and Plummer-Vinson syndrome associated with oral cancers

Diagnosis

History

Nonhealing ulcer or mass of mouth or lipArea that bleeds easily or unexplained painDysphagia/odynophagiaChronic sore throat or hoarsenessEar painProblems articulatingRegurgitation of liquids secondary to nasopharyngeal incompetence from the tumorHistory of risk factors (e.g., tobacco exposure, chronic alcohol use, radiation treatment, excessive UV light exposure)

Physical Exam

Friable granular exophytic and/or infiltrative mass or ulcer that frequently is tender and confused with infectionWhite or red lesions notedHard, indurated margins extending beyond the borders of the ulcer noted on palpationHard neck mass suggesting metastatic disease in the nodal chain along the internal jugular veinCranial sensory and motor nerves may be compromised.

Diagnostic Tests & Interpretation

Physical exam, including an extensive bimanual intra- and extraoral head and neck examTransoral biopsy of any ulceration or erythroplasia/leukoplasia lesion present for 4 weeks provides the definitive diagnosis.Brush or punch biopsy test for smaller oral lesions can determine need for surgical biopsy.

Imaging

Plain films of head and neckCT scan (for bony involvement) or MRI (for soft tissue involvement) if clinical suggestion of intracranial metastasisCXR to assess metastasis to the lungs, the most common site of spread outside the neckImaging bone scans if there is pain in the bones suggesting bone metastasisAbdominal CT scan if liver metastasis suspectedPET scan may be necessary in some cases; modified sugars preferentially absorbed by cancer cells

Pathological Findings

PremalignantMalignant changes characteristic of cell typesMost common is squamous cell (90%), followed by salivary gland, lymphomas, and sarcomasThose originating in the lip and buccal mucosa are usually well differentiated; those originating in the oral pharynx and floor of mouth are less well differentiated and have higher risk for metastasis.

Differential Diagnosis

Exudative tonsillitis (usually bilateral involvement)Stomatitis or glossitis secondary to infectious etiology, most commonly candidiasisBenign tumors of the oral cavity (slow growing and usually not erosive or ulcerative)Kaposi sarcomaMycosis fungoidesPremalignant lesions such as leukoplakia or erythroplasiaLichen planus

Treatment

Medication

Opiates for pain relief

Additional Treatment

General Measures

Treatment varies depending on location (e.g., tongue, buccal wall, pharynx, palate, lip).Resection treatment of choice, if possibleSmall, superficial lesions can be treated with combined external-beam radiation therapy (EBRT) and intraoral cone or surface mold.Primary radiotherapy (and/or chemotherapy for palliation) is suggested for unresectable tumors and patients not amenable to surgery.Obtain dental consult prior to any treatment to prevent serious complications later. Can evaluate questionable teeth, fabricate mouth guards to wear during radiation treatments, and fabricate fluoride trays.

Issues for Referral

Biopsy any suspicious lesions.

Additional Therapies

Secondary prevention of smoking, alcohol, betal nut abstinenceAnnual follow-up oral examinations

Surgery/Other Procedures

Wide resection ± radiation therapy and/or chemotherapy is the treatment of choice.There is some evidence that concomitant radio-/chemotherapy with surgery is more effective than radiation therapy with surgery in the treatment of head and neck cancers in general (5).For a neoplasm such as a melanoma, surgery is believed to be the most effective treatment. The role of radiation, however, is controversial. Many experts believe melanoma neoplasms to be radioresistant.Tracheotomy may be necessary if the patient has problems handling secretions or difficulty breathing.

In-Patient Considerations

Admission Criteria

Inpatient for surgeryOutpatient for radiation therapy and chemotherapySurgery, airway management, infection

Ongoing Care

Follow-Up Recommendations

As needed by patient’s nutritional and physical status

Patient Monitoring

Routine periodic head, mouth, and neck exams by medical and dental professionals to detect possible 2nd primary or recurrence in the upper respiratory and digestive tracts, especially within the first 36 months and if radiology was used

Diet

Depends on the extent of disease and whether the patient is able to chew or swallowUsually early lesions can be managed with a regular diet. As disease progresses, a soft diet is necessary.Nutrition is of prime importance for normal wound healing, especially if patient requires surgery. Patients may need nasogastric and/or gastrostomy feedings if they are orally disabled.

Patient Education

Primary prevention for all about avoidance of risk factors and secondary prevention for those diagnosed

Prognosis

Early lesions with adequate treatment leads to a >80% cure.5-year relative survival rate for localized stage: 82%5-year relative survival rate for all stages combined: 59%

Complications

Functional and/or cosmetic disabilities proportional to the degree of surgery and stage of tumorStomatitis with or without candidiasis, tissue hypoxia, tongue mucositis, hypocellularity, and fibrosis secondary to radiation therapy or chemotherapyPersistent dysphagia secondary to surgery or radiation therapyPersistent problems with articulation or deglutition depending on the amount of tongue resection and age of patientRadiation may cause new neoplasms.

References

1. Cabay RJ, Morton TH, Epstein JB. Proliferative verrucous leukoplakia and its progression to oral carcinoma: a review of the literature. J Oral Pathol Med. 2007;36:255–61.

2. Conway DI, Petticrew M, Marlborough H, et al. Socioeconomic inequalities and oral cancer risk: A systematic review and meta-analysis of case-control studies. Int J Cancer. 2008.

3. Pavia M, Pileggi C, Nobile CG, et al. Association between fruit and vegetable consumption and oral cancer: a meta-analysis of observational studies. Am J Clin Nutr. 2006;83:1126–34.

4. Severino P, Alvares AM, Michaluart Jr P, et al. Global gene expression profiling of oral cavity cancers suggests molecular heterogeneity within anatomic subsites. BMC Res Notes. 2008;1:113.

5. Oliver RJ, Clarkson JE, Conway DI, et al. Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment. Cochrane Database Syst Rev. 2007;CD006205.

Additional Reading

Becher H, Ramroth H, Ahrens W, et al. Occupation, exposure to polycyclic aromatic hydrocarbons and laryngeal cancer risk. Int J Cancer. 2005;116:451–7.

Hisham, Khalifa. Primary Malignant Melanoma of the Tongue. Canadian Journal of Surgery. December 2009.

Kademani D. Oral cancer. Mayo Clinic Proceedings, 2007; 87(7): 878–87.

Shah JP, Gil Z. Current concepts in management of oral cancer – Surgery. Oral Oncol. 2008.

See Also (Topic, Algorithm, Electronic Media Element)

Algorithm: Bleeding Gums

Codes

ICD9

140.9 Malignant neoplasm of lip, unspecified, vermilion border141.9 Malignant neoplasm of tongue, unspecified142.9 Malignant neoplasm of salivary gland, unspecified143.9 Malignant neoplasm of gum, unspecified144.9 Malignant neoplasm of floor of mouth, part unspecified145.9 Malignant neoplasm of mouth, unspecified146.9 Malignant neoplasm of oropharynx, unspecified

Snomed

372001002 primary malignant neoplasm of oral cavity (disorder)371996000 primary malignant neoplasm of lip (disorder)94101009 primary malignant neoplasm of tongue (disorder)109828002 primary malignant neoplasm of salivary gland duct (disorder)371990006 primary malignant neoplasm of gum (disorder)93802007 primary malignant neoplasm of floor of mouth (disorder)

Clinical Pearls

Primary and secondary prevention by doctors and dentists about risk factor avoidance and complete oral exams at annual visits to doctor and dentist officeLeukoplakias or erythroplakias should be biopsied because they are considered premalignant and are associated with carcinoma at least 10% of the time.Patients should see a dentist prior to undergoing treatment of head and neck tumors to allow planning to reduce potential dental-related complications.Concomitant radio/chemotherapy together with surgery is likely more effective than radiation therapy alone with surgery in the treatment of head and neck cancers, in general.