Oral+Cavity


 * Epidemiology: || ** Epidemiology- ** is the study of defining the distribution and determinants causing disease and injury in human populations.
 * Comprise roughly ** 30% of all head and neck cancers **
 * Epidemiology of oral cancers strongly reflects exposure to certain environmental agents, (** mainly tobacco and alcohol **)
 * Depending on age and sex the incidence varies of oral cavity and pharynx is ** 8.3 per 100,000. **
 * ** Male’s incidence is higher ** in northernFrance, southernIndia, a few regions of central and Eastern Europe andLatin America. (this is linked to increased alcohol and chew mixture “pan” in India)
 * In the United States cancer of the oral cavity afflicts **__older patients__ more than younger and is three times more frequent in men than women **.
 * Incidence rates are ** higher for African American men **, with mortality rates doubling that of Caucasians 7.5/100,000 vs. 3.9/100,000.
 * ** Survival rates are 61% in whites versus 39% in African Americans **.
 * New studies reveal that 4%-6% of oral cancers ** now occur at ages younger than 40 ** years old. (2) ||
 * Etiology: || **Etiology** is the study of the causes of disease; signs and symptoms.
 * Patients who have **poor oral and dental hygeniene** are associated with oral cancer.(1)
 * ** Strong relationship; between smoking ** and cancer of the oral cavity, identified as an independent risk factor in **80-90%** of patients who present with cancer of the oral cavity.
 * **Alcohol** use is another high-risk activity associated with oral cancer. There is known to be a very strong ** synergistic effect ** on oral cancer risk when a person is both a heavy smoker and drinker. The risk is greatly increased compared to a heavy smoker, or a heavy drinker alone.
 * Interesting enough younger patients are at increased risk to oral cancer because a hypothesis that says they are ** predisposed to genetic instability **.
 * ** Ultraviolet radiation ** associated with lip cancer
 * ** Herpes simplex virus (HSV) ** and ** human papilloma virus (HPV) ** also linked to etiology of oral cancer
 * ** Plummer-Vinson syndrome is a strong correlation for women** (which is iron deficiency anemia) although rare and accounts for small number of oral cavity (1) ||
 * Signs & Symptoms: || * Most cancers show up on the anterior surface on either side of the mouth.
 * The most common of these is a non-healing wound on the tongue, in the floor of mouth or along the inner cheek.
 * These can be painful, but in some cases do not cause significant discomfort. There may be bleeding from the area which occurs in an “on and off” manner.
 * Dentists and or general practitioner is usually responsible for clinical detection
 * Inspection and palpation are the first steps
 * Malignant ulcers are usually raised, centrally ulcerated, with hard edges and an infiltrated base.
 * ** Biopsy ** is mandatory for staging
 * As the lesions increase in size, more symptoms occur.
 * Complaints may include new or increased pain, pain was swallowing, ear pain, a change in speech, uncoordinated swallowing, or a lump in the neck.
 * The most important factor to note is that **sores in the mouth** and they should heal within three weeks. (1)(4) ||
 * Diagnostic Procedure || The first step in diagnosing oral cavity malignancies is a complete history with assessment of risk factors followed by a thorough physical exam. Visualization of the suspicious area via a nasolaryngoscope is followed by manual palpation if possible. Visual inspection and manual palpation of the entire external head and neck area is performed to determine possible metastatic spread to the regional lymph nodes. Imaging studies including Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are performed of the head and neck region. CT, MRI and standard x-rays may also be performed of the chest area to assess for possible metastatic spread to the lung. [1] Imaging studies of advanced lesions (stages III and IV) should also include a Panorex of the mandible to rule-out extension through the mental foramen. Positron Emission Tomography (PET) scans can also provide useful information in these advanced stages.[2] A biopsy is performed of the suspicious lesion and/or lymph node under local or general anesthetic. General anesthesia allows for a more thorough exam of the area to determine size and exact location of the lesion as well as adjacent structures. This is particularly important since between 5 and 15% of individuals with one head and neck cancer also have a second tumor present in another area of the head or neck.[1] The tissue is then sent to a pathologist for determination of malignancy, cell type and differentiation. Various lab tests can also be ordered. A preventive dental examination is ordered for a malignant diagnosis that requires radiation therapy.[3] ||
 * Histology: || Most oral cavity cancers (95%) are squamous cell carcinomas (SCC) that arise from the lining of the oral cavity.[4]They are often preceded by various precancerous lesions such as leukoplakias, white patchy areas. The cancers can be non-invasive or invasive, varying from well, moderately, poorly or un-differetiated, with a predominance of well and moderately well differentiated.[1] These subdivisions describe how closely the malignant cells resemble normal lining cells. Other less common tumors include minor salivary gland cancers found in the hard palate that include adenoid cystic carcinoma, mucoepidermoid carcinoma and adenocarcinoma. Even less common types are sarcomas, lymphomas, and melanomas.[2] ||
 * Lymph Node Drainage: || [[image:Katie-LymphNodes-Neck.jpg align="center" caption="Major lymph nodes of the head and neck. 5"]]
 * Upper lip = Submandibular (Node Level I), some drainage into periauricular and parotid (Node Level II)[1,2]
 * ==== Lower lip = Submandibular, subdigastric (posteriorly) (Node Level I) ====
 * ==== Lip lymph node involvement = rare, 5-10% of patients with no clinical signs of metastatic neck disease later develop metastases ====
 * ==== Lower gingiva = Submandibular, subdigastric (Node Level I) ====
 * ==== Upper gingiva node involvement = 15-20% upon diagnosis, later developed cervical lymph node (Node Level V) involvement is also approximately 15-20% in patients with no initial clinical signs of metastatic neck disease ====
 * ==== Floor of mouth = Submandibular, subdigastric (Node Level I) ====
 * ==== Oral tongue = Primary: Submandibular, subdigastric (Node Level I); disease that bypasses these primary sites is often found in the midjugular (Node Level II) ====
 * ==== Floor of mouth and oral tongue lymph node involvement = 30-65% of patients present with positive neck nodes; 40% of patients with no clinical signs of node involvement are pathologically positive for nodal disease; 20-35% of patients initially presenting with no negative nodes are expected to eventually develop positive neck nodes with no treatment; less than 5% of patients develop metastatic disease in the submental nodes ====
 * ==== Buccal Mucosa = Submandibular, subdigastric (Node Level I) ====
 * ==== Tongue (tip/extending across midline) = Ipsilateral cervical nodes (Node Level V)[3] ====

|| The incidence of distant metastases is highest in lesions of nasopharynx, tonsillar fossa, and hypopharynx.(3) Distant metastases from primary squamous cell carcinoma of the oral cavity cancers are rare. That being said, with advanced-stage lymph node metastases there is a significant risk of distant mets.(2) The highest incidence is in lung and in brain. (3) Metastases can be correlated with the initial staging of the cervical nodes-the incidence of distant spread goes along with the extent of initial neck involvement. Large lesions almost always have a high incidence of metastases, but so can a tiny biologically virulent tumor. If the disease is unresectable, the chance for distant spread is higher than in those patients that are disease-free above the clavicle.(3) || Histological Grading refers to an assessment that differentiates a tumor according to how closely the tumor cells resemble normal tissues at the tumor site. Grades (G) are expressed in numeric terms G1-G4. G1 representing tumor cells with the most differentiation and G4 with the least differentiation.[1] GX Grade cannot be assessed G1 Well differentiated G2 Moderately differentiated G3 Poorly differentiated || According to the American Joint Commission on Cancer (AJCC) the TNM system is an expression of the anatomical extent of disease, which encompasses three components.[1] They are as follows: Table 1 demonstrates the AJCC staging system for oral cavity carcinomas ||  ||   || Overall survival rates for all cancers of the oral cavity are as follows: stage I or II, 70% five-year survival; stage III, 50% five-year survival; and stage IV, 35% five-year survival.[1] Long term vigilance of all patients is necessary as they have an increased chance of developing a second primary tumor of the upper aerodigestive tract.[5] || *Studies have shown that relative risk of death was significantly reduced with radiation therapy and concurrent chemotherapy vs. radiation therapy alone. [1] Radiation Techniques:  
 * Metastatic Spread: || Approximately 30-65% of patients with oral tongue and floor of mouth cancer have positive nodes on presentation. Of all patients with negative nodes clinically (able to be palpated), about 40% have pathologically (unable to be palpated) positive nodes. Regarding all patients with negative nodes at presentation, without any treatment at all the incidence of nodal metastases is about 20-35%. Submental lymph nodes are involved <5% of patients. (1)
 * Grading: || ** GRADING **
 * Staging: || ** STAGING **
 * T ** Extent of the primary tumor
 * N ** The presence or absence and extent of regional lymph node metastasis
 * M ** The presence or absence of distant metastasis
 * ** Table 1[2] ** || ** Cancer Staging for Oral Cavity Cancer ** ||
 * **// Primary Tumor (T) //** ||   ||
 * ** TX ** ||  Primary tumor cannot be assessed  ||
 * ** T0 ** ||  No evidence of primary tumor  ||
 * ** Tis ** ||  Carcinoma in situ  ||
 * ** T1 ** ||  Tumor less than or equal to 2cm in the greatest dimension  ||
 * ** T2 ** ||  Tumor is more than 2cm in greatest dimension but not more than 4cm in greatest dimension  ||
 * ** T3 ** ||  Tumor more than 4cm in greatest dimension  ||
 * ** T4 (Oral Cavity) ** ||  Tumor invades adjacent structures such as cortical bone, deep muscle of tongue, maxillary sinus, or skin.  ||
 * ** T4 (Lip) ** ||  Tumor invades adjacent structures such as cortical bone, inferior alveolar nerve, floor of mouth, or skin of face.  ||
 * ** Regional Lymph Nodes (N) ** ||   ||
 * ** NX ** ||  Regional lymph nodes cannot be assessed  ||
 * ** NO ** ||  NO regional lymph node metastasis  ||
 * ** N1 ** ||  Metastasis in a single ipsilateral lymph node less than or equal to 3cm in greatest dimension  ||
 * ** N2 ** ||  Metastasis in a single ipsilateral lymph node more than 3cm but not greater than 6cm in greatest dimension,  ||
 * || or in bilateral lymph nodes or contralateral none more than6cm in greatest dimension  ||
 * ** N2a ** ||  Metastasis in a single ipsilateral lymph node more than 3cm but not greater than 6cm in greatest dimension  ||
 * ** N2b ** ||  Metastasis in multiple ipsilateral lymph nodes, none larger that 6cm in greatest dimension  ||
 * ** N2c ** ||  Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension  ||
 * ** N3 ** ||  Metastasis in a lymph node larger than 6cm in greatest dimension  ||
 * ** Distant Metastasis (M) ** ||   ||
 * ** MX ** ||  Presence of distant metastasis cannot be evaluated  ||
 * ** M0 ** ||  No distant metastasis  ||
 * ** M1 ** ||  Distant metastasis  ||   ||
 * Radiation Side Effects: || The side effects of radiation therapy are separated into two categories; acute effects and late effects. Acute effects of the oral canal include mucositis, loss of taste, and xerostomia. Using a daily dose of 200cGy x 5 fractions will result in mucosal (soft palate, tonsillar pillars, pharyngeal walls, buccal mucosa, lateral borders of the tongue, and areas of larynx) erythema and by two weeks into treatment the red mucosal erythema begins to develop small white and yellow patches—leading to a sore throat. Loss of taste begins at one week into treatment and progresses quickly between 2000-4000cGy. Xerostomia occurs at 1000cGy. Acute side effects suffered by the skin include erythema, peeling, and tanning of the skin. Skin erythema develops into moist desquamation and begins to heal after field has been reduced and/or treatment is concluded. Epilation of the beard occurs at three weeks. Regarding the skin, at the same dose the face reacts less to radiation than the upper neck and the upper neck reacts less to radiation than the low neck and supraclavicular area.(4) ||
 * Prognosis: || The stage and specific site of lip and oral cavity cancers determines the rate of curability. Early cancers of the lip have cure rates of 90% to 100%. Local control rates in the order of 90% can be achieved in small cancers of the anterior tongue, the floor of the mouth and buccal mucosa. Small tumors of the hard palate, upper gingiva and the retromolar trigone are highly curable with survival rates of 100%.[5]
 * Radiation Side Effects: || The side effects of radiation therapy are separated into two categories; acute effects and late effects. Acute effects of the oral canal include mucositis, loss of taste, and xerostomia. Using a daily dose of 200cGy x 5 fractions will result in mucosal (soft palate, tonsillar pillars, pharyngeal walls, buccal mucosa, lateral borders of the tongue, and areas of larynx) erythema and by two weeks into treatment the red mucosal erythema begins to develop small white and yellow patches—leading to a sore throat. Loss of taste begins at one week into treatment and progresses quickly between 2000-4000cGy. Xerostomia occurs at 1000cGy. Acute side effects suffered by the skin include erythema, peeling, and tanning of the skin. Skin erythema develops into moist desquamation and begins to heal after field has been reduced and/or treatment is concluded. Epilation of the beard occurs at three weeks. Regarding the skin, at the same dose the face reacts less to radiation than the upper neck and the upper neck reacts less to radiation than the low neck and supraclavicular area.(4) ||
 * Prognosis: || The stage and specific site of lip and oral cavity cancers determines the rate of curability. Early cancers of the lip have cure rates of 90% to 100%. Local control rates in the order of 90% can be achieved in small cancers of the anterior tongue, the floor of the mouth and buccal mucosa. Small tumors of the hard palate, upper gingiva and the retromolar trigone are highly curable with survival rates of 100%.[5]
 * Treatments: || In General:
 * T1 and Superficial T2 Lesions
 * Surgery and radiation therapy produce similar results [1]
 * Radiation side effects may be significant, making surgery the treatment of choice
 * Interstitial implants are sometimes used
 * Post-op RT is used when the surgical margins are in question
 * Large T2 and T3 Lesions
 * Surgical excision works best
 * For close or positive margins, post-op RT is used
 * Advanced Lesions - T4
 * Post-op Rt is preferred
 * Pallative RT - 30 Gy in 10 fractions or 50 Gy in 20 fractions
 * Oral Tongue
 * Immobilization with an aquaplast and a cork for the tongue
 * Parallel opposed fields with borders:
 * Superior: 2 cm margin above dorsum of tongue
 * Posterior: 2cm posterior of sternoclastoid muscle
 * Inferior: Thyroid notch
 * With nodal involement, AP field (Block larynx) and lateral fields to include nodes (Start off-cord at 45 Gy)
 * Inraoral cones are also used - maintaining a 1 cm margin for coverage
 * Interstitial implants can also be used - Ir-192
 * Doses:
 * Microscopic disease: 55-60 Gy
 * T1 and T2: 65-70 Gy
 * T3 and T4: 60 Gy post-op (If only RT, dose is higher)
 * Lip
 * Treatment fields all use a 1.5 cm margin around the tumor volume
 * Can be treated with kev photons or mev photons
 * Smaller lesions are treated to 50 Gy while larger lesions are taken to 60 Gy
 * Interstital is an option for smaller lesions
 * Buccal Mucosa
 * Treatment fields all use a 1.5 cm margin around the tumor volume
 * Tumor volumes and lymph nodes involved are treated to 55-60 Gy and the tumor volumes are boosted to 75-80 Gy
 * Gingiva
 * Parallel opposed fields or wedged pair
 * T1 and T2 lesions taken to 60-65 Gy
 * T3 lesions taken to 70 Gy
 * Interstitial implants are not used for the gingiva because of the proximity to the mandible - prevent osteoradionecrosis
 * Retromolar Trigone
 * Ipsilateral field used with mixed beams - photon and electrons - with borders:
 * Anterior: 2 cm anterior of tumor
 * Superior: Include pterygoid plates
 * Posterior: Posterior aspect of the spinous process
 * Inferior: Thyroid notch
 * T1 and T2 lesions taken to 60-65 Gy
 * T3 lesions taken to 70 Gy
 * Hard Palate
 * Parallel opposed lateral fields to with margins large enough to include involved neck nodes
 * Anterior field to also include neck nodes
 * Initial volume to recieve 50-54 Gy and the tumor bed to be boosted to 70-75 Gy
 * Cone can be used for boost ||
 * TD5/5: || Below is a list of TD 5/5 doses to volumes of organs at risk around the oral cavity. At these doses, 1 in 20 patients will exhibit the listed outcomes within 5 years of dose administration.
 * Parotid = 3200 cGy to 2/3 or 3/3 volume; outcome = xerostomia [4]
 * Larynx = 7900 cGy to 1/3, 7000 cGy to 2/3 or 3/3; outcome = cartilage necrosis
 * Larynx = 4500 to 2/3 or 3/3; outcome = laryngeal edema
 * Thyroid = 4500 cGy to 3/3; outcome = hypothyroidism
 * Middle ear = 3000 cGy to 1/3, 2/3, or 3/3; outcome = acute serous otitis
 * Middle ear = 5500 cGy to 1/3, 2/3, or 3/3; outcome = chronic serous otitis
 * Oral mucosa = 6000 cGy to 50 cubic centimeters (cm); outcome = ulcer/fibrosis
 * Spinal cord = 5000 cGy to 5 or 10 cm, 4700 cGy to 20 cm; outcome = myelitis/necrosis ||



1 AJCC. Purposes & Principles of Staging. //Cancer Staging Manual.// 6th ed. Chicago, IL: American Joint Commission on Cancer; 2002:5-7. 2 Chao, C., Perez, C., & Brady, L. Oral Cavity. //Radiation Oncology Management Decisions.// 2nd ed. Phidelphia, PA: Lippincott, Williams & Wilkins; 2002:226.
 * 1) Oral Cavity Cancer. American Head and Neck Society Web site. __[|http://www.ahns.info/ patienteducation/docs/oralcavity.php]__ . Accessed May 23, 2011.
 * 2) Hansen EK, Schechter NR. Cancer of the lip and oral cavity. In: Hansen EK, Roach M III, eds. // Handbook of Evidence-based Radiation Oncology. // New York, NY: Springer Science + Business Media, LLC; 2007:95-107.
 * 3) <span style="background-color: #ffffff; color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 16px; line-height: 115%; text-decoration: none; vertical-align: auto;">Chao KSC, Perez CA, Brady LW. Oral Cavity. In: Chao KSC, Perez CA, Brady LW, eds. // Radiation Oncology Management Decisions. //Philadelphia, PA: Lippincott Williams & Wilkins; 2002:223-233.
 * 4) <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: #ffffff; color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 16px;"> Beenken S W, Urist M M, Casiano R R. Cancer of the oral cavity. // Cancer Health Network //. __[|http://www.health.am/cr/cancer-of-the-oral-cavity]__ . Accessed May 23, 2011.
 * 5) <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: #ffffff; color: #0000ff; font-family: 'Times New Roman',Times,serif; font-size: 16px;"> General Information About Lip and Oral Cavity Cancer Treatment (PDQ®). National Cancer Institute Web site. __[]__ Professional. Accessed May 23, 2011.

1. Chao, Perez, Brady; Oral Cavity; //Radiation Managment Decisions 2nd edition//; Philadelphia PA. Lippincott, Williams, & Wilkins; 2002: 225 2. Perez, Brady, Halperin, Schmidt-Ulrich, //Principles & Practice of Radiation Oncology 4th edition//; Philadelphia PA; Lippincott, Williams & Wilkins; 2004: 1005-1019 3. Fletcher; //Textbook of Radiotherapy;// Philadelphia PA. Lea & Febiger; 1980: 249-288

4. Million, Cassisi; //Management of Head and Neck Cancer-A Multi-Disciplinary Approach// //2nd Ed.;// Philadelphia PA; Lippincott Co.; 1994: 247-257

3. Chong V. Cervical lymphadenopathy: what radiologists need to know. //Cancer Imaging//. 2004;4(2):116-120.
4. Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys//.1991;21(1):109-122. 5. National Cancer Institute Website.http;//training.seer.cancer.gov/head-neck/anatomy/lymph-node.html.// Accessed May 26, 2011.

// 1. Washington, C., & Leaver, D. Principles and Practice of Radiation Therapy 3rd Edition. Mosby-year Book, Inc. 2010: 705-710 // // 2. Perez, Brady, Halperin, Schmidt-Ulrich, // Principles & Practice of Radiation Oncology 5th edition//; Philadelphia PA; Lippincott, Williams & Wilkins; 2008: 891-957 3. Arthur L. Boyer, Ph.D., Stanford School of Medicine Dosimetry Training Tool,Radiation Physics Division, Radiation Oncology Department, 2007, web access: May 24, 2011. <span style="background-color: transparent; color: #00ff00; font-family: 'Arial','sans-serif'; line-height: 115%; text-decoration: none; vertical-align: auto;">4. Oral Cavity Cancer. American Head and Neck Society Web site. [|__[[http://www.ahns.info/] patienteducation/docs/oralcavity.php__]] <span style="background-color: transparent; font-family: 'Arial','sans-serif'; line-height: 115%; text-decoration: none; vertical-align: auto;"> Accessed May 26, 2011.

<span style="background-color: #ffffff; color: #00faff; font-family: 'Arial','sans-serif'; font-size: 90%; line-height: 115%; text-decoration: none; vertical-align: auto;">1. Gunderson L, Tepper J. Clinical Radiation Oncology. Churchill Livingstone. Philadelphia PA. 2000: 428-451