Transcribed by Janki Gajera!

01/21/2014

CCP 1: Oral Lesions

Slide 1 - Clinical Case Presentation Dr. Ross Kerr - ... Slide 2 - 43 year old caucasian male Dr. Ross Kerr - ... Slide 3 - Medical History Dr. Ross Kerr - ... [podcast started late, and the rst three slides are pretty self-explanatory :) ] Slide 4 - Social History and Nutritional History Dr. Ross Kerr - What it is, is that it gives you the cumulative burden of cigarette smoking. Obviously, the higher pack history, the more likely he is to develop the consequences of smoking. He drinks 2-3 glasses of wine a night - is that normal? What is normal/abnormal? Generally speaking, for women, 7 drinks/week; men, 14 drinks/week. If you go beyond that, youre not necessarily at risk for certain things, but it puts you at a higher risk profile for developing alcohol-related issues - whether it is alcoholism or other alcohol-associated problems. He smokes marijuana 4 times a week, and he is an executive chef. So you see, beginning to put together the picture. Nutritional history: he has an excellent diet - hes an executive chef. Slide 5 - Family History and Dental History Dr. Ross Kerr - Family history: his father died at age 70 from a heart attack. Hes got high cholesterol, so maybe thats a bit of an issue. Dental history: routine dental care, no previous periodontal problems. A few restorations He brushes regularly, occasional flossing. He uses an alcohol-containing mouth-rinse. Slide 6 - Review of Systems (RS) Dr. Ross Kerr - Any other questions youd like to ask in the medical history, his HIV disease? Maybe well come back to that. We always perform a review of systems - it is part of the medical history, we review the different organ systems - because patients who come into the dental office sometimes have medical issues that can cause organ system damage, and it can be multi-organ system damage. Or they can come to the office not knowing they have medical problems and can present symptoms that would suggest there is some underlying systemic disease. Classic example - patient comes

Transcribed by Janki Gajera!

01/21/2014

to office with signs and symptoms of uncontrolled diabetes. They may present with polyuria, polyphasia, all these cardinal symptoms of diabetes. They may have a dry mouth. You may be the first person to intercept possible signs and symptoms of diabetes - you would either get a chair-side blood glucose or send them to the physician to have them worked up for a possible case of diabetes. So we always go through organ systems and ask them questions related to the different organ systems - like the pulmonary system, we ask How is your breathing, do you have any difficulties? for the cardiac system because it could be related to cardiac symptoms the shortness of breath. So we went thru all of that. Cardiovascular - his blood pressure was pretty normal. Respiratory rate within normal limits (WNL). Nervous system seemed to be fine. Endocrine, renal, gastrointestinal, skin and mucosa, osteoarticular - all WNL. Slide 7 - Examination Dr. Ross Kerr - So weve done our data collection in terms of the historical information we can illicit by speaking with the patient. Now, the second part of our assessment is the examination. Were thinking in our mind: hes got something going on in the upper left quadrant. Dentists and specialists think that maybe there is a periodontal problem. Theyve done standard procedures for periodontal problems, including 3 rounds of scaling and root planning and a round of antibiotics. What is scaling and root planning? When a patient presents with periodontal attachment loss - the supporting structures of the teeth, teeth are embedded in alveolar bone - due to periodontal disease, the loss of that supporting structure occurs. There are going to microorganisms - periodontal pathogenic organisms - that will be in the supporting structures. We want to remove them to the best of our abilities. We go in under local anesthesia, and remove the inflamed tissue and periodontal pathogens by using hand instrumentation where we scale and root plan of root surfaces of the associated teeth. Sometimes we give antibiotics to control the periodontal pathogens. Youll learn about this as times goes on. When we perform an examination, we begin with an extra-oral examination. Something interesting was that there was no lymphadenopathy - having an abnormal lymph node in the area. As you may recall, lymph nodes drain from the oral structures and may carry bacteria, other microorganisms or antigens that can illicit an immunological response where the lymph node becomes enlarged - slightly swollen, slightly tender under an infection. Or, potentially lymph nodes can respond to things like cancers where they can become enlarged as well. Here, he didnt seem to have an acute infection going. In the intramural exam, we noticed that he had an exophytic sessile and friable mass upper left buccal gingivae between teeth 14 and 15. What does exophytic mean? Phytic means growing, exo means away, so it is growing away from the surface, expanding from the surface. Friable means that it bleeds very easily, so we need to start thinking what that means. What does an exophytic lesion mean? What does a friable mass mean? Obviously, you know what gingivae are and where number 14 and 15 are located.

Transcribed by Janki Gajera!

01/21/2014

We also probe using a periodontal probe - we can measure that there is a pocket that is 10mm between 14 and 15. What is a normal probing depth? Anywhere between 1-3 mm. One can argue 4 mm, but generally 1-3 mm. If we are going further than that, what does that tell you? We have lost support in the structure of the periodontal structure attaching to the bone. There may be movement in the tooth - tooth mobility. Radiographically, we noted extensive bone loss. Ill show you the radiographs in a moment. We also discovered, in a totally different area of the mouth, distal to tooth 18, ulceration. What is oral ulceration? What is the relationship between epithelium and an ulcer? Loss of epithelium is an ulcer. Its very important that you understand what an ulcer is. Slide 8 - rst picture on right Dr. Ross Kerr - Lets see whats going on in the patients mouth. Were looking at the upper teeth. Here are 14, 15, and normal gingivae. Suddenly, you hit this area which expands away. You can see little flecks of blood vessels. These are all abnormal blood vessels. Slide 9 Dr. Ross Kerr - Now, this is with a mirror shot. Here you can see there has been a significant loss, almost a hole here, where youve lost bone support. It bleeds very easily. This is just bumping into it with that mirror to get a good photo. You can see what I mean by exophytic - it is growing away from the surface. The other word I used was sessile - its broad based, as opposed to pedunculator which is where you get a stalk. This doesnt look normal. Slide 10 - see second picture on right Dr. Ross Kerr - Then we have the radiograph. Whats going on here (1) vs right here (2)? (2) is the bone. There is a lot of bone loss between 14 and 15. 15 is a little mobile as a result.

Transcribed by Janki Gajera!

01/21/2014

Slide 11 - third picture on right Dr. Ross Kerr - This is tooth 19. 18 was removed. Distal to 19, in the site where 18 was, there is an area of ulceration. You can see the epithelium ends at (1). Youd drop into this superficial ulceration if you were standing on the edge. No one had picked that up, at all. The patient was presenting for the upper left area. This is someone from my private practice. Slide 12 Dr. Ross Kerr - So now what? We have our information, here is another radiograph showing a little bit of loss in bone density distal to 19. The bone level is a lot better than the upper left. What should we do now? Whats the next step in the patient assessment process? What should we do next as a clinician? [Student volunteers an answer: Refer the patient out] This patient went a dentist multiple times and went to a specialist, and now theyre with me. Who am I going to refer them to? Hes been to the periodontist, who did the antibiotics and scaling and root planning, and nothing happened. The patient actually left the periodontist because no one was helping him. So, referral is Id like you to think like a specialist, what is the next step here in the process? [Student answers: Biopsy] Before you perform a biopsy, you need to have a reason for doing the biopsy. You need to do a differential diagnosis - have in your mind a list of possible diagnoses. In order to test out that list, you organize those diagnoses in your mind so that the most likely is at the top of the list, the least likely is at the bottom. Then you decide what is the best way to test that hypothesis. It may be that a biopsy is need, and in this case that is correct. So why do you want to send them for a biopsy - whats on your mind? Cancer. The dentist and periodontist werent thinking cancer, even though you as a D1 were. Why didnt they do a biopsy? They did scaling and root planning and each time that didnt work, no improvement. No one decided to do a biopsy. Why? The differential diagnosis has to be something other than periodontal disease. Is it possible that three people - their technical abilities are not sufficient to handle a periodontal infection? No, thats unlikely. But the periodontist thought the dentist wasnt doing the right thing. What type of cancer? Oral cancer. What types of oral cancer are there? Squamous cell carcinoma, lymphoma, osteogenic sarcoma (unlikely to present this way). Slide 13 - Diagnosis and Risk Assessment Dr. Ross Kerr - Next step is a diagnosis and risk assessment. Lets look thru the history, one thing at a time and try to put this together. I want you to synthesize this information and come to the diagnosis by really thinking things thru. Do you think cigarette smoking played or is

Transcribed by Janki Gajera!

01/21/2014

playing a role in this? Maybe, if there is a malignancy. What about marijuana smoking? What about HIV infection - could that play a role? What about hypercholesterolemia? What about medications the patient is taking? What about the: alcohol history, diet, periodontal history, and use of alcohol containing mouth-rinses? These are all elements of the history that you are putting into the equation - thinking in terms of risk factors for the diseases. We know the patient is HIV infected or probably at a higher risk for developing malignancies and other chronic diseases. They may also find it more difficult to heal as a result of HIV infections, even though his CD4 count is WNL, that could be the case. Slide 14 - Differential Diagnosis Dr. Ross Kerr - Weve also got two different areas. For the upper left, there are certain reactive lesions of the gingivae in response to their relative lesions in reaction to some periodontal issue: pyogenic granuloma, peripheral ossifying fibroma, peripheral giant cell granuloma. But certainly malignancy was something that was on my mind. On the lower left, we have an ulcer. Whats the differential diagnosis of ulcers? We have no idea about how long that ulcers been there. We have no history of discomfort - the patient wasnt even aware of it. It was just found when we did a careful exam. Could it have been a viral infection like herpes simplex, deep fungal, bacterial - again, all can occur in immunocompromised patients. Or could this also be a malignancy? Slide 15 - Diagnosis Dr. Ross Kerr - Lets get to the biopsies. I did two biopsies - one for each site. We take that tissue, put it into formalin and sent it to the diagnosis pathology lab. Slide 16 - Biopsy 1: ULQ Dr. Ross Kerr - This is the specimen from the upper left. This is a lower power view. Slide 17 - Biopsy 1 Dr. Ross Kerr - There are sheets and islands of epithelial-like cells. Slide 18 - Biopsy 1 Dr. Ross Kerr - They are abnormal with abnormal nuclei. Slide 19 - Biopsy 2 Dr. Ross Kerr - This is the second biopsy taken from the lower left. Slide 20 - Biopsy 2: LLQ

Transcribed by Janki Gajera!

01/21/2014

Dr. Ross Kerr - Again we have these abnormal epithelial-like cells infiltrating deep into the tissues with very abnormal-looking nuclei. Slide 21 - Biopsy 2 Dr. Ross Kerr - This is the best to really show you the abnormal-looking nuclei. Look at these cells (1). They are very dark, have dark nuclei, strange changes. Undergoing active mitosis. Bad looking cancer. It is squamous cell carcinoma. Both of these areas turned out to be squamous cell carcinoma. This is a rare example of a patient who has two primary malignancies. Those two are not connected to each other. This very rare, but it happened on 4 occasions in my career with HIV infected patients. Generally speaking, we have a patient with one malignancy but he had two at the same time. Slide 22 - Squamous cell carcinoma Dr. Ross Kerr - Youve had all of the info about squamous cell carcinoma. You can read about this. Ive given you this lecture already, so Im not going to go into too much detail about that. Id like to discuss what well do in this situation. Slide 23 Dr. Ross Kerr - Recall risk factors. As we go through this, what were the potential risk factors for this disease? History of smoking 10 packs but they quit 5 years ago - does it still play a role? Maybe, we cant rule it out. Obviously current smoking is a higher risk. The fact that hes quit for 5 years means that he is slowly returning to the risk profile of a non-smoker. It takes about 10 years for that to happen. Any other risk factors? Alcohol. He is drinking 2-3 glasses wine/ night. Maybe that is playing a role. What else? HIV disease. What were finding in patients with HIV is that theyre developing malignancies at a much earlier age, in their 40s and 50s because of the chronic immunosuppression. They are at a high risk in the context of conventional risk factors like smoking and alcohol. Any other risk factors? Smoking marijuana. Is that a risk factor? Its limited evidence. No conclusive data to establish marijuana as a causative risk for oral cancer. Anything else? What about alcohol mouthwash? No real evidence between alcohol-containing mouth-rinses and oral cancer. The meta-analysis shows no increasing odds ratio in these populations. Having said, that, every patient is different so you never know. Is it playing a role? Evidence suggests no to alcohol-containing mouth-rinses. Not much else here: age, ethnicity, socioeconomic status, dont seem to play a role in this situation. Since 2009, HIV should be under emerging risk factors. Weve got enough data to support they are at a higher risk. Slide 24 - Treatment

Transcribed by Janki Gajera!

01/21/2014

Dr. Ross Kerr - How will we manage this patient? Whats the next step after diagnosing? Before surgery, what would an oncology team do? Theyve got to diagnose this first. Lets talk about the upper left squamous cell carcinoma first. You all know someone who has had cancer. What is the next step following diagnosis? You want to see how its spread. Are all cancers treated the same way? Have you heard of staging? Staging means: there are 4 stages of cancer for most, if not all, cancer systems. Stage 4 has a worse prognosis than Stage 1. Stage 4 means your cancer is very advanced. First you stage the cancer. Slide 25 Dr. Ross Kerr - Staging system for oral cancer, known as the TNM staging system. T= tumor size. N = nodal metastases, has it metastasized through the lymphatics into the regional lymph nodes? M = metastasis below clavicle to distant organ systems. Everything from Stage 1 to Stage 4, which is divided into A, B, C. Im not going to test you on the staging system, I just want you to understand the concept that someone who has been diagnosed needs to be staged. In his case, he was staged with Stage 4a because the primary cancer had invaded into the maxillary sinus, right above those teeth. Once the bone breaks down and penetrates into the sinus - he went in for a CT scan that showed where the cancer was in terms of the sinus - no obvious lymphadenopathy, even with the CT scan. So thats good news. The lower one didnt show any real invasion - it was a small cancer - it was Stage 1 cancer. Based on the staging, whats next? Slide 26 Dr. Ross Kerr - What type of operation or treatment would this patient need? These are known as the NCCN guidelines - the National Comprehensive Cancer Network. It is basically an algorithm that oncologists follow when patients present with a certain stage of cancer. In this situation, we have a T4a and N - he had it in his neck and no lymphadenopathy, but because of the size of the tumor and invasion into the sinus, it was considered to be Stage 4, T4a. Slide 27 Dr. Ross Kerr - They go through all of these different tests. The T4a would be 3 first. If its N0, wed resect the primary and possibly do an ipsilateral/bilateral neck resection. It all depends on the result of the resection. When they take out the tumor, the pathologist looks at the margins and decides whether or not the margins are at all uninvolved. Whether or not there are adverse features - e.g. invasion of the nerves - that is an adverse poor prognosis factor. If that occurs, theyll get radiation and chemotherapy. Surgery is the principle modality for oral cancers. Depending on the tumor, we may, in addition to the surgery, add radiation and chemotherapy for advanced disease. Radiation therapy is sometimes considered to be the first treatment line when you cant do an operation because the tumor is associated with some important anatomical place that are not possible to undergo surgery. Surgery is the first line. Radiation

Transcribed by Janki Gajera!

01/21/2014

and chemotherapy are given in a setting where they add that to the surgery. Dont memorize this. Conceptually understand the staging process and based on the staging process, we decide on menu of treatment options. Start with surgery and add on radiation and/or chemotherapy if its advanced. Slide 28 Dr. Ross Kerr - The lesson to learn: this is what happens when you have the alveolar ridge removed on the maxilla. It obviously will open into the sinus or nasal cavity depending on the person. This person will have a defect where an obturator, which will fit into the mouth and is a prothesis with a large plastic bulb that fits into that hole to allow for speaking. This is what the patient had done. Slide 29 - Prognosis Dr. Ross Kerr - Radiation is where a patient will go over a period of 6 weeks every day except for weekends into the radiation oncology office where they are fitted with a head mask made of fiber glass that will position the head and neck in the same position every time they go in and they receive IMRT (intensely moduled radio-therapy), where they get packets of radiation delivered from 360 degrees around their head and neck from the rotating machine to give the highest dose to the tumor and minimize doses to normal anatomic structures of the head and neck to minimize complications. His story was that he was treated successfully with radiation and chemotherapy. With two cancers, he elected to have the most aggressive treatment. Mysteriously, he developed lymphadenopathy in his abdomen and did chemotherapy; it spread, and he died about two months. Its a very sad story. As I look back on it, I think about why wasnt it detected earlier? If we had intercepted this disease earlier, we might have changed the outcome. But it might not have mattered if it was a really aggressive disease. This is the message: early detection. I get quite emotional about this patient because he was an amazing person and I feel terribly about the outcome. Slide 30 - Oral Cancer Walk: April 27th