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What is the 2nd most common cause of death in the US?
Which cancer is the most common cause of death?
Men and women: lung cancer
How prevalent is oral cancer?
- Oral cancer is the 8th most common cancer in men.
- Not as common in women
What is the ratio of oral cancer between men and women?
How many cases of oral cancer exist worldwide?
8.1 million cases
Which region has the highest incidence of oral cancers?
- Melanesia, near Australia
- More common in developed regions (smoking)
How many cancer cases are oral cancer?
Signs and symptoms of oral cancer
- Non-healing ulcer
- White/red patch on gums, tongue, oral lining
- difficulty chewing/swallowing
- Numbness in the mouth
Where are ulcers most suspicious?
Dorsal tongue and floor of the mouth
Oral tissue inspection list (know well)
- Extraoral salivary gland exam (lymphatic, fmx, probing)
What is the first area you check when screening for oral cancer?
Difference in painful vs. painless lymph palpation
- Painless: possibly metastatic cancer!
- Painful: inflammatory process
What is the most common type of oral cancer?
Squamous cell carcinomas
What most effectively improves morbidity and mortality of oral cancer?
Early detection and screening
Environmental risk factors of oral cancer
- Tobacco- most common risk factor
Non-environmental risk factors of oral cancer
- Genetic predisposition (oncogenes, tumor suppressor genes)
- Human papilloma viruses
5 year survival rates for blacks and whites
- Black: 40%, peak mortality age 55-64 years
- White: 60%, peak mortality age >75 years
How many oral cancer patients smoke?
9/10 oral cancer patients smoke
What element in tobacco has been isolated to induce buccal carcinoma?
White lesions associated with smoking
- Nicotinic stomatits
- tobacco pouch
- submucous fibrosis
- pipe smokers
- Associated with pipe/cigar smoking
- Correlation with severity and smoking intensity
- Greatly increased by reverse smoking
- Increased keratinization(opaque with red dots- salivary ducts)
- Entire palate is white
Chewing tobacco pouch
- Placed in mucobuccal fold
- Changes occur in cheek mucosa
- Thick, leathery buccal mucosa
- Chronic ulceration
- Moderate trismus (fibrosis of TMJ)
- Indian male betel quid use
Which diet can prevent HNSCC and precancer?
- Diets rich in fresh fruits and vegetables
- Vitamin A
What are biomarkers used for?
- To measure the progress of disease
- To measure treatment effects
What are the two most common tumor suppressor genes?
p53 and p16
What are the three apoptotic genes?
Which virus plays a role in oropharyngeal carcinomas?
Human papilloma virus (HPV)
What are the two proliferative markers?
- PCNA (proliferating Cell Nuclear Antigen)
- Nuclear protein (Ki-67)
What are oncogenes?
- Control cell growth, proliferation, and differentiation
- Can mutate to produce abnormal products or overexpress genes
p53 Tumor suppressor gene
- Important role in normal growth and differentiation
- Mutation inactivation can result in a tumorFound on chromosome 17
- Mutated in 45% of SCC
Human papilloma virus
- 100+ types
- HPV 6 and 11- condylomas and papillomasHPV 16 and 18- tumorogenic in epithelial cells
- E6 and E7- viral oncoproteins in HPV 16 and 18. inactivate p53
Where is HPV mostly present?
- In young female tongue SCC (non smokers and non drinkers)
- HPV 16 in 25% of HNSCC (oropharynx and tonsillar)
- HPV is positive in 4-12% of oral cavity SCC
What are the two HPV vaccines available?
- Gardasil- against HPV 6, 11, 16, 18 (quadrivalent)
- -prevents genital warts in both genders
- Cervarix- against HPV 16, 18 (bivalent)
- -does not protect against genital warts
- -high risk vaccine
What are the dosage recommendations for Gardasil and Cervarix?
Both are given in 3 doses at 6 month intervals
At what age should females receive the HPV vaccine?
- 11-12 years or 13-26 if not previously vaccinated
- As young as age 9 if high risk
Which has a better prognosis, HPV + or - SCC?
HPV + has a better prognosis
What is the order of oral cancer progression?
- 1. Benign squamous hyperplasia
- 2. Dysplasia
- 3. Carcinoma in-situ
- 4. Carcinoma
- Intraepithelial neoplasia
- Invasion of CT has not occurred yet
- Squamous cell carcinoma
- Invasion of the connective tissue
Leukoplakia vs. Erythroplakia
- Leukoplakia- 15% dysplasia and 20% CA development
- Erythroplakia- 90% dysplasia and >75% CA development
- White patches that don't rub off
- Wide range of clinical and microscopic presentations
- usually related to localized irritation
- Most are benign
Leukoplakia of ventral tongue surfaces and floor of mouth
- Hardest areas to access
- Likely cancer (few physical trauma sources)
- Likely will need surgery
What are the 3 types of oral cancer staging (TNM system)
- Size of tumor
- Degree of local invasion
- Extent of spread-metastasis
Stages of Oral cancer spread
- 0- Carcinoma in situ
- 1- confined to site of origin
- 2- cancer is locally invasive
- ---progression around 41 months---
- 3- spread to regional structures
- 4- spread to distant sites
- after stage 4, unresectable in 4 months
Second primary tumors
- Known consequence of oral SCC
- 25-40% develop SPT over time
- Does not improve with smoking cessation
Three levels of Oral cancer reduction
- 1. Primary prevention (tobacco)
- 2. Secondary prevention (screening, early detection)
- 3. Improved treatment
Oral brush biopsy
- Detection of precancerous and cancerous mouth lesions
- Complete transepithelial tissue sample
- Not a definitive diagnostic tool
- Basic thiazine metachromatic dye with nucleic acid affinity
- Used for suspicious malignant lesions
- Stains actively growing tissues
- Only retained in dysplastic sites
What part of an ulcerated lesion do you biopsy
The borders, not the middle!
- Visualizes leukoplakic areas
- Uses diffuse chemiluminescent lightDetects atypical or dysplastic mucosal abnormalities
- Visually enhanced lesion scope
- Watch for changes in color
- Emits a pale green fluorescence normally
- Dysplastic and early tumor cells appear green to black
- -loss of fluorescence
What is the only tool that can confirm oral cancer diagnosis?
Which HPV strains can cause oral cancer?
16 and 18
Which is more likely cancerous, moveable or fixed lymph nodes?
Fixed lymph nodes are more likely cancerous
Do SPTs usually occur in the primary site?
No. Remember they are secondary
What percent of leukoplakia lesions progress to cancer?