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Quitting smoking after diffinitive treatment for OC malignancy reduces risk of recurrence or development of a second malignancy from ___ to ___%?
40% to 6%
This stimulant from India and Southeast Asia is associated with oral cavity malignancy.
Betel nut. Chewed. Destructive to oral mucosa and dentition. Highly carcinogenic.
SCC commonly present where on the lip?
Vermillion border of the lower lip.
These two HPV subtypes are considered carcinogenic
16 and 18. HPV ocoproteins E6 and E7 have ability to bind and degrade tumor suppressor gene products of p53 and pRB, respectively. HPV is a stronger risk factor for OC Ca (OR 3.7) than tobacco (2.63) or alcohol (2.57). Some have noted an increased risk with HPV 6 as well.
Type of tongue cancer usually seen in young patients?
Pts younger than 35 were more likely to present with oral tongue than older pt (76% vs 33%) and less likely to present with FOM (10% vs 36%). Younger pts have better survival prognosis.
This artery supplies the majority of the vascular supply to the oral tongue and tongue base.
lingual artery. Found deep to the hyoglossus, requires devision of the muscle for maximal exposure.
Two structures found superficial to the hyoglossus and deep to the mylohyoid.
hypoglossal nerve and lingual vein.
Describe the blood supply of the hard palate
Greater palatine and superior alveolar arteries.
The descending palatine artery branches off of the maxillary artery in the pterygopalatine fossa and descends through the greater palatine canal along with the greater palatine nerve (from the pterygopalatine ganglion). Once emerging from the greater palatine foramen, it changes names to the greater palatine artery and begins to supply the hard palate. As it terminates it travels through the incisive canal to anastomose with the sphenopalatine artery to supply the nasal septum.
The only intrinsic muscle of the tongue not supplied by the hypoglossal nerve.
palatoglossus. By the pharyngeal branch of vagus.
Tip of the tongue drains preferentially to ___ nodes. Lateral tongue drains to ____ nodes.
- Tip: Submental
- Lateral tongue: level I/II, though III/IV can occur
What parts of the tongue have bilateral lymphatic drainage?
Base of tongue. Anterior tongue lacks lymphatic anastomoses. Strangely, this is the reverse of FOM lesions, where anterior lymphatics drain bilaterally and posterior portion drains lymphatically.
What is the risk of leukoplakia progressing to SCC?
6% to SCC. Leukoplakia is a clinical term without a histologic definition. 1/3 will regress, 1/3 won't change, 1/3 experienced no change.
Which is more likely to progress to SCC? Erythroplakia or leukoplakia?
Leukoplakia coverts to SCC in 6% of cases. In biopsies of erythroplakia, 91% were found to have evidence of invasive SCC, carcinoma in situ, or severe dysplasia.
This oral lesion demonstrates a lacy pattern of white striae. Atrophic lesions are red and smooth, whereas erosive lesions have depressed margins.
- Lichen planus.
- Histologically shows T-cell infiltration.
- 1% progress to SCC
Butterfly-shaped ulceration of the hard and soft palate in a patient with poorly fitting dentures. Likely diagnosis?
Though you have to consider a palatal SCC, this is a common presentation of necrotizing sialometaplasia. Although clinically ominous, this is benign. Caused by necrosis of minor salivary acini, often secondary to localized pressure injury (poorly fitting dentures).
Most common minor salivary gland malignancy?
Adenoid cystic. Then mucoep, polymorphous low grade adenocarcinoma, and adenocarcinoma.
Nonpigmented lesion of the lower lip that presents as an ulceration and has a high incidence of perineural invasion?
Desmoplastic neurotrophic melanoma
Panendoscopy in work-up of suspected head and neck cancer is recommended because the reported risk of second lesion is ___%
Between 5-10% in newly diagnosed patients. Many perform only DL, defer bronch, esophagoscopy until symptoms arise.
How does depth of invasion correlate to prognosis in oral SCC?
- <2 mm: 13% regional mets, 95% 5-year survival
- 2-9mm: 46% regional mets, 85% 5-year survival
- >9mm: 65% regional mets, 65% 5-year survival
Factors associated with poor prognosis in oral SCC.
- 5 or more positive lymph nodes
- extracapsular spread
- poor differentiation
- advanced stage (III/IV)
A synchronous tumor is one diagnosed within ___ from diagnosis of primary tumor.
For patients with oral cavity and oropharyngeal malignancy, site of a second malignancy is most frequently where?
Perioperative antibiotics are most effective when administered in this manner.
Before surgery and up to 24 hours postop.
Majority of neoplastic lesions of the lip present on which lip?
- lower 95%
- upper 4%
- commissure 1%
SCC predominates on the ___ lip.
BCC arises disproportionately on the ___ lip.
An increased risk of regional metastasis is associated with which location of lip carcinoma?
Higher risk with upper lip and commissure lesions. Low risk (~10%) with lower lip. However, lower lip lesions may metastasize bilaterally. Neck dissections aren't typically indicated for N0 necks.
How would you manage a small lip carcinoma?
RT and surgery have equal efficacy, but surgery is recommended because you get a path diagnosis and margins.
Reconstruction options if you excise 1/3 of the lip? 2/3? More than 2/3?
- 1/3: primary closure
- 2/3: lip switch (Abbe-Estlander) or Johansson stepladder flap
- >2/3: Gilles fan flap, bilateral adv flaps, Karpandzic, or free radial forearm
What is the Karapandzic flap?
- A sensate, neuromuscular flap that includes the remaining orbicularis oris muscle, supplied by the labial artery.
What is the most sensitive technique for evaluating mandibular bone invasion?
A. Bone scan
(this multiple choice question has been scrambled)
What degree of invasion into the mandible or its adjacent tissue warrants a marginal mandibulectomy?
If periostium is invated, marginal mandibulectomy is indicated.
Invasion of what aspect of the mandible warrants a segmental mandibulectomy?
Tumor extension into a tooth socket into the medullary bone.
When is a neck dissection indicated in alveolar ridge SCC?
- N0: I-III for all advanced stage tumors, early stage at the symphysis, or moderate to poorly differentiated tumors.
- N+: modified radical neck
75% of oral tongue tumors occur on this aspect
The posterolateral tongue
Healing by secondary intention is acceptable if less than ___ of the tongue is removed.
If a portion of the FOM is removed, at least a STSG should be used for this reason
to prevent tethering
Kurokawa demonstrated a tumor depth of ___ was associated with occult lymph node mets in oral tongue ca.
For lateral tongue carcinoma, what levels of the neck must be addressed?
Lateral tongue is associated with skip mets, so level I-IV should all be addressed if tumor depth is 4 mm or greater. If tumor approaches midline, B/L necks are warranted.
Treatment for advanced stage tongue ca?
Surgery and post-op RT.
>90% of oral cavity occult mets are in these neck levels.
I-III, so supraomohyoid ND is oncologically sound in N0 neck.
Most common location of oral cancer?
- Lips, rule of 90s
- 90% on the lower lip
- 90% five year survival if <2 cm (overall 70-90%)
- 90% SCC
Though hard palate SCC is less aggressive than SCC of other oral cavity subsites, there are these two pathways of tumor extension.
- incisive foramen: extension into anterior nose
- palatine foramen: extension to pterygopalatine fossa
T staging for oral cavity cancer
- T1: <2cm
- T2: 2-4cm
- T3: >4cm
- T4a: invades cortical bone, inferior alveolar nerve, floor of mouth, skin, extrinsic muscles of tongue, maxillary sinus
- T4b: invasion of masticator space, pterygoid plates, skull base, or encases ICA
Management of T1-T2 oral cavity cancer
- Surgery vs RT
- N0 neck: elective ipsilateral or bilateral (if midline or oral tongue) level I-III neck dissection vs RT
- early stage hard palate or lower lip don't require elective neck dissection
- N1-N3: MRND
Management of T3/T4 oral cavity cancer?
- Single modality: surgery vs RT
- N0 neck: elective ipsilateral or bilateral (if midline or oral tongue) level I-III neck dissection vs RT. If specimen is positive, observe vs completion neck vs RT
- N1-N3: MRND
- post-op RT indicated for postitive margins, multiple positive nodes, extracapsular extension, perineural or intravascular invasion, invasion of bone, cartilage or soft tissue