Dott.re Giuseppe Spinelli

Carcinoma Oral Cavity

CARCINOMA ORAL CAVITY

Oncologic Surgery

INTRODUCTION CARCINOMA ORAL CAVITY

Most frequent in male subjects.

Most common in elderly subjects (from V decade).

Etiopathogenic factors:

  • Luxuries habits (smoking, alcoholism);
  • Pre-existing precancerous lesions with possible neoplastic degeneration (leukoplakia, erythroplasia, lichen, submucosal fibrosis);
  • Microtrauma from battered teeth and dentures unsuitable and not rebased correctly.
BIOLOGY
  • Mostly starts as micro-papular surface lesions but tends rapidly to ulcerate and infiltrate the underlying structures (muscles, periosteum, bone).
  • The most common clinical appearance is that of a ulceration in rough edges, collected and hard, with irregular fleshy bottom, easy to bleed.
  • Cancer of the oral cavity spreads through the lymphatic lateral cervical lymph nodes.
  • The frequency of lymph node metastases is dependent on some histological features (thickness, degree of malignancy, perineural invasion as well as the size of the tumor).
  • The spread through lymphatics generally takes place in a progressive manner, starting from the lymph nodes closest to the primary tumor to continue then in those further away.
  • The frequency of distant metastases is relatively low and in any case much more frequent as the size of the tumor is large.
SYMPTOMATOLOGY
  •  Persistent pain at lips or mouth
  • Occurrence of an abnormal mass on the lips, inside the mouth or throat
  • Appearance of a white or red plaque on the gums, tongue or lining of the mouth
  • abnormal bleeding or numbness in the mouth
  • Sore throat that does not heal or sensation of a lump in the throat
  • Difficulty or pain when chewing or swallowing
  • Swelling of the jaw that prevents the dentures to fit perfectly or at least makes it annoying to use
  • Changes in tone of voice and / ear pain
  • Swelling at the laterocervical level
DIAGNOSIS
  • Clinical examination performed by the maxillofacial surgeon: exploration and palpation of the lesion (tumor size) and nearby structures (evaluation of local infiltration) (Approximate diagnosis in 90% of cases).
  • The diagnosis has to be formulated with diagnostic biopsy and must be of incisional type and must not alter the configuration of the injury (diagnosis).
  • Orthopanoramic (OPT) to assess the infiltration of the mandible at the macroscopic level;
  • TC of the oral cavity and neck with and without MDC (organo-iodine) to evaluate the size of the lesion, the extension and the involvement of structures adjacent to the lesion, the reaction to the contrast medium and the extension of the primary disease to lymph nodes laterocervical: suitable for neoplasms affecting the bone structures.
  • RMN of the oral cavity and neck with and without MDC (gadolinium) to evaluate the size of the lesion, the extension and the involvement of adjacent structures to the lesion (most specific for bone structures), the reaction to the contrast medium and the extension of the primary disease to the laterocervical lymph nodes: suitable for soft tissue tumors of the oral cavity and for those allergic to iodine MDC organ.
  • PET and total body scintigraphy to evaluate the extent of the neoplastic disease at a distance.
  • Staging of cancer according to the TNM mode: T = tumor, N = lymph nodes, M = metastases.
THERAPY
  • Multidisciplinary care: maxillofacial surgeon, radiation oncologist, medical oncologist.
  • Reconstructive surgery and radical at the same time.
    The surgery on T involves the removal of the tumor with margins of healthy tissue (relations with adjacent bony structures involving the need to sacrifice in part or in whole, bone formation adjacent to the tumor, such as the jaw, the upper alveolar border, the hard palate ) and where indicated treatment for therapeutic or prophylactic exclusively on N.
    Reconstructive surgery is now able to restore the body parts removed with a good relationship between form and function. Today, it is very often a programmable reconstruction with implants or autologous transplants. It’s possible in fact a broad range of options between different processes of reconstruction according to the location and function that you have to rebuild. It is therefore to be proscribed the definition of “devastating” refers to interventions more on the oral cavity. This term often leads to the rejection of the intervention by the patient (or relatives) and is used just as often by doctors who have never seen what actually can be achieved with modern reconstructive surgery.
  • Most cancers of the oral cavity are very sensitive to radiation treatment. The modern technique radiotherapeutic today allows to realize irradiation volumes of content, so as to achieve a good economy of healthy tissue surrounding the tumor. The standard of care requires the adoption of a conventional fractionation of radiation dose, or a fraction of a day, five days a week for about 7-8 weeks totally, and preferably continuously. Most of the treatments can be conducted under complet ambulatory schemes. Radiation therapy is often used as a complementary treatment to surgery (postoperative radiotherapy). The irradiation has proved able to reduce the incidence of filming loco-regional disease.
  • Globally the local healing of carcinomas of the oral cavity can be obtained today with a rather high frequency (60 – 65%). Obviously, the percentages vary depending upon the location and extent of disease, from 95% for small carcinomas of the lip to 30% of large tumors of the tongue and retromolar pad. The loco-regional healing varies depending on the presence or absence of lymph node metastases and of their extension.