oral cancer - evaluation

1. DEPARTMENT OF
SURGICAL
ONCOLOGY- GRH
PROF.R.RAJARAMAN
UNIT

2. Evaluation and staging
of oral cancer
Dr Sujay Susikar
PG in Surgical Oncology
Professor Dr R Rajaraman unit
Government Royapettah Hospital

3. Initial head and neck examination
 Standard and complete head and neck
examination
 All 12 cranial nerves examined
 Otoscopy and anterior rhinoscopy
 Examination of oral cavity
 Palpation of tongue and tongue base
 Mirror and flexible laryngoscope examination
 Examination under anaesthesia in patients with
trismus, SMF, ankyloglossia, uncooperative
patients

4. WHO Format – oral cavity
examination
 Exam abstracted from WHO standardized oral
examination method
 Consistent with CDC and NIH method
 Requirements:
 Adequate lighting
 Dental mouth mirror
 Two 2" x 2" gauze squares
 Gloves
 Seated patient
 Removal of intraoral prostheses
 Should take no longer than 5 minutes

5. Extraoral Examination Face

6. Perioral and Intraoral Soft Tissue
Examination – Lips

7. Perioral and Intraoral Soft Tissue
Examination –
Labial Mucosa

8. Buccal Mucosa

9. Buccal Mucosa

10. Gingiva

11. Tongue Dorsum

12. Tongue Left Margin

13. Tongue Right Margin

14. Tongue Ventral

15. Floor

16. Hard Palate

17. Oropharynx

18. Palpation

19. Histological confirmation of
diagnosis
 Wedge Biopsy for infiltrating lesions
 Punch Biopsy for Proliferative lesions
 Transoral under LA if possible
 Taken from edges
 Adequate depth of tissue
 Anaesthesia in Trismus, Ankyloglossia,
SMF, Infiltrative & Posteriorly placed
lesions

20. Staging
 Metastatic
Tumor-  Nodal –
•Examination • Clinical workup
under • X ray Chest
anesthesia
• Ultrasound
• Chest CT / PET
•X Rays, • CT in
•Panorex extensive in patients with
•CT Scan nodal N2 disease and
•MRI N2 adenopathy
disease
below thyroid
• PET
notch
• Symptom
directed

21. Investigations for Staging
 Examination under Anesthesia in
selected cases
 X Ray Mandible, PNS, Maxilla

22. Orthopantamogram
 Orthopantomogram for involvement of mandible
& maxilla
 Assessment of the entire dentition and early
evaluation of erosions
 Mentum & lingual cortex difficult to assess

23. ULTRASOUND NECK
 Highly operator dependent
 Sensitive in picking up nodes in clinical N0
disease
 Useful for image guided biopsy
 Ultrasound criteria:
 Size min axial diameter 7mm- submental, 8mm for other nodes
 Roundness index ratio of transverse to longitudinal diameters
 Absence of an echogenic hilus
 Presence of necrosis – coagulative or cystic within a node
 Extracapsular spread
 Colour doppler- disorganised peripheral flow pattern

24. Coagulative Cystic
necrosis necrosis
Extracapsular Disorganised
disease peripheral flow

25. ULTRASOUND NECK
Indications for Ultrasound neck:
 Patients with clinical N0 neck with primary in
areas with high possibility of lymphatic spread
 Clinically insignificant nodes ?

26. CT scan
 Standard practise now
 Evaluates site and location of primary
 Assessment of Metastatic adenopathy
 Scans done prior to biopsy to avoid
confusion by changes from biopsy

27. CT scan

28. CT scan

29. CT scan
Indications for CT:
 For evaluation of primary situated adjacent to
bone
 Evaluation of extent of spread in large primaries
 To decide on management of the mandible
 Evaluation of neck

30.  Malignant node criteria for CT :
 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)

31. CT Scan
ADVANTAGES:
 Increased speed
 Bony framework – better evaluated
 Small calcifications more apparent
DISADVANTAGES:
 Requires ionizing radiation
 And iodinated contrast agents

32. Dentascan
 DentaScan performs
real time image
reformation specific to
CT dental imaging:
oblique and panorex
reformation.
 Assessment of Bone
involvement
 No motion artifact in
Bulky tumors

33. Dentascan

34. MRI – 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

35. MRI
Indications for MRI:
 In primaries with possible perineural spread
 For evaluation of possible skull base
involvement
 To evaluate exact soft tisue spread of the tumor
to plan conservative resections

36. MRI

37. MRI

38. MRI
Advantages:
 More sensitive for subtle spread along nerves and into
the skull base
 Better evaluation of cartilage or marrow invasion
Disadvantages:
 Lower patient tolerance
 Dangers with metallic implants, pacemakers and other
hardware
 Increased expense
 Patient motion always a concern

39. PET scan
Inherent limitations of conventional imaging:
 Poor sensitivity for detection of disease < 1cm
 Limited ability to distinguish residual or
recurrent tumor from scar
 Inability to biologically characterize disease
 Inability to provide early prognostic information
regarding treatment outcome

40. PET scan
Advantages :
 Useful in detection of additional disease not
seen on routine staging and altering TNM
staging
 Detection rate of occult primary higher
 Less reliant on size for detection of nodal
disease
 Can detect distant metastasis and synchronous
second primary malignancies not seen on
routine work up, therefore avoiding
inappropriate aggressive treatments

41. PET scan

42. PET scan

43. PET scan

44. PET scan
Uses of PET:
 Staging
 Thereupetic planning
 Post therapy restaging
 Thereupetic monitoring and outcome
 Restaging and relapse
Dilemmas :
 Management of equivocal PET?
 Cost effectiveness?

45. Pre Anaesthetic Assessment
 General medical evaluation
 Routine pre op lab Investigations
 To rule out Co-morbid conditions

46. Intra operative Frozen Section
 For margins
 For nodes if selective
node dissection done
Optimal frozen section
reporting: guidelines:
 Confirmation of
malignancy
 Closest margins –
exact length
 Positivity of closest
margins

47. Pre operative assessment of Speech
& swallowing – Baseline for
rehabilitation
 Spectrogram – intensity frequency ,
resonance & format of speech
 Modified Barium Swallow – premature
spillage into hypopharynx & vestibule of
larynx

48. Screening for Second Primary
 4% annual incidence
 Pan endoscopy ( triple endoscopy),
sputum & saliva cytology, Xray Chest

49. T - Staging
 TX – Primary cannot be assessed
 T0 – No evidence of primary
 Tis – Ca. in situ
 T1 – 2 cm or less
 T2 – more than 2 cm but not more than 4
cm
 T3 – more than 4 cm

50. T - Staging
 T4a (lip) - Invading through cortical bone,
inferior alveolar nerve, floor of mouth or skin
of face(chin or nose)
 T4a (Oral cavity) – Invading adjacent
structures eg,. cortical bone, deep extrinsic
muscle of tongue, maxillary sinus or skin of
face
 T4b – Invading masticator space, pterygoid
plates, skull base or encases Internal carotid
artery
(Superficial erosion alone of bone/ tooth
socket by gingival primary is not T4 )

51. N - Staging
 NX - Nodes cannot be assessed
 N0 – No nodes
 N1 – single ipsilateral node 3 cm or less in
greatest dimension
 N2a – single ipsilateral node more than 3 cm
but not more than 6 cm
 N2b – multiple ipsilateral nodes none more
than 6 cm
 N2c – bilateral or contralateral node none
more than 6 cm
 N 3 – node more than 6 cm
(Midline nodes are ipsilateral nodes)

52. M - Staging
 MX – metastasis cannot be assessed
 M0 – No metastasis
 M1 – Distant metastasis

53. Stage Grouping
 Stage 0 – Tis N0 M0
 Stage I – T1 N0 M0
 Stage II – T2 N0 M0
 Stage III – T1-3 N1 M0
T3 N0 M0
 Stage IV A - T4a N0-1 M0
T1-4a N2 M0
 Stage IV B – Any T N3 M0
T4b Any N M0


54. Fallacies of TNM staging
 Depth of Primary not included
< 2mm - 13% nodes & 3% death
2 to 9 mm – 46% nodes & 17% death
> 9mm – 65% nodes & 35% death
 Extracapsular involvement in node not
considered
 No provision for molecular markers, IHC

55. Molecular staging
 Molecular assays detect occult cancer cells
previously missed by physical examination and
standard histopathologic techniques.
 Provide more objective analyses with fewer
sampling errors

56.  Intra operative gene
probe – Pilot study
showed 12 out of 30
patients with negative
margin were disease
free at 2 years
 To predict response
to RT – Breakpoints
on 1p22, 3p21, 8p11,
distal 14q were
resistant

57. “Biological staging” - Biological
behavior
 Useful in assessing cycling cells
 Precancerous lesions
 Surgical tumor margins
 Predicting aggressive behavior
 Invasion front
 Metastatic potential

58. “Biological staging” - Biological behavior
Biomarker Predictors in Oral
Precancerous & Cancerous Lesions