Clinical Update

Vol. 26, No. 11

Naval Postgraduate Dental School National Naval Dental Center 8901 Wisconsin Ave Bethesda, Maryland 0889!"#0

November 2004

Oral cancer: part III Lieutenant Steven Marc Stokes, DC, USN an! Comman!er "ames Castle, DC, USN Squamous carcinoma S#uamous carcinoma o$ t%e %ea! an! neck re&resents a s&ectrum o$ mor&%olo'ic an! clinical subt(&es t%at commonl( lea!s to !i$$iculties in &atient mana'ement as )ell as $ormulatin' a !i$$erential !ia'nosis. *nce a mali'nanc( %as been !ia'nose!, tumor 'ra!e an! sta'e serve as 'ui!elines $or $uture treatment mo!alities an! &re!ictors o$ overall biolo'ic be%avior o$ t%e tumor. Tumor grade +s &reviousl( mentione!, s#uamous cell carcinoma ma( arise $rom !(s&lastic e&it%elium or entirel( in!e&en!ent o$ it. S#uamous cell carcinoma &rimaril( s&rea!s via !irect invasion an! l(m&%atic routes.1,2,, -nvasive carcinoma is %istolo'icall( 'ra!e! an! s&eci$ie! as )ell.!i$$erentiate!, mo!eratel( )ell.!i$$erentiate!, or &oorl( !i$$erentiate!. +lt%ou'% t%e 'ra!e o$ t%e tumor !oes not $actor into t%e sta'in' &rotocol, it !oes serve as an im&ortant a!/unctive ai! to t%e overall biolo'ic be%avior o$ t%e tumor. -n 'eneral, tumors )%ic% more closel( resemble t%eir native tissue are consi!ere! to be )ell.!i$$erentiate! 0lo).'ra!e1. 2%is is in contrast to tumors e3%ibitin' si'ni$icant c(tomor&%olo'ic at(&ia an! !emonstrate little or no resemblance to native s#uamous e&it%elium. 2%ese lesions are consi!ere! to be &oorl( !i$$erentiate! 0%i'% 'ra!e1 an! %ave an increase! &ro&ensit( $or re'ional metastasis an! a &oorer &ro'nosis. +!!itional $eatures t%at &orten! a more a''ressive nature inclu!e &erineural s&rea!, l(m&%atic invasion, an! tumor e3tension be(on! t%e l(m&% no!e ca&sule. 2,, 4emato'enous s&rea! is an uncommon mo!e o$ travel $or carcinomas. 1,2,,,4 Regional and distant metastasis 5or s#uamous cell carcinomas o$ t%e %ea! an! neck, t%e inci!ence o$ l(m&% no!e metastasis is relate! to t%e si6e an! t%ickness o$ t%e &rimar( tumor. 7enerall(, metastasis $rom oral s#uamous cell carcinoma most $re#uentl( !evelo&s in t%e i&silateral cervical l(m&% no!es. 2umors o$ t%e lo)er li& an! $loor o$ mout% ma( initiall( involve t%e submental l(m&% no!es.2,,,4 Contralateral or bilateral cervical metastases can also occur, es&eciall( in tumors o$ t%e base o$ t%e ton'ue, in a!vance! tumors, an! in tumors t%at occur near t%e mi!line. 4 L(m&%atics o$ t%e $loor o$ t%e mout% contribute to t%is e3tension as t%e( %ave numerous connections t%at cross t%e mi!line allo)in' an oral cavit( tumor to metastasi6e to t%ese bilateral, contralateral as )ell as i&silateral l(m&% no!es. -nvolve! no!es are usuall( enlar'e!, $irm, an! nonten!er to

&al&ation. -$ a tumor &er$orates t%e no!al ca&sule an! inva!es into t%e surroun!in' connective tissue 0e3traca&sular invasion1, t%e no!e )ill $eel $i3e! an! immobile. +s man( as ,08 o$ oral cancers %ave cervical metastases, eit%er &al&able or occult, at t%e time o$ initial evaluation. 9 -n &articular, t%e ton'ue %as a ric% bloo! su&&l( an! l(m&%atic !raina'e, )%ic% accounts $or t%e $act t%at a&&ro3imatel( 608 o$ &atients )it% &rimar( ton'ue lesions %ave neck !isease at t%e time o$ !ia'nosis.6 Distant metastases are most common in t%e lun's, liver, an! bones, but an( &art o$ t%e bo!( ma( be a$$ecte!.1,2,,,4 :%en oral s#uamous cell carcinoma is sus&ecte!, a t%orou'% %ea! an! neck evaluation is man!ate!. 2%e neck s%oul! be sta'e! &rior to bio&s( o$ t%e &rimar( tumor. 5ailure to !o so ma( result in a re'ional reactive l(m&%a!eno&at%( subse#uent to bio&s( t%us %in!erin' t%e a&&ro&riate sta'in' o$ !isease. Un$ortunatel(, some &atients ma( %ave microsco&ic l(m&% no!e !isease )%ic% ma( not be !etecte! clinicall(, an! as suc%, elective neck !issections are sometimes &er$orme! to eliminate t%is eventualit(. Staging Sta'in' o$ oral cancer is t%e most im&ortant in!icator o$ &ro'nosis an! serves to establis% a&&ro&riate treatment mo!alities. Sta'in' &rotocol !e&en!s on #uanti$(in' t%ree basic clinical $eatures; si6e o$ &rimar( tumor, status o$ re'ional l(m&% no!es, an! t%e &resence or absence o$ metastasis. 2%e tumor si6e an! t%e e3tent o$ metastatic s&rea! o$ oral s#uamous cell carcinoma are t%e best in!icators o$ &atient &ro'nosis. 2%e +merican "oint Committee on Cancer 0+"CC1 utili6es t%e tumor, l(m&% no!e, an! metastases 02NM1 classi$ication s(stem $or t%eir sta'in' &rotocol.< *nce t%e t%ree &arameters are !etermine!, t%e a&&ro&riate sta'e can be ren!ere!. -n t%is case, t%e %i'%er t%e sta'e 01 .41, t%e &oorer t%e &ro'nosis. Survival o$ &atients )it% oral an! oro&%ar(n'eal cancer is stron'l( relate! to t%e sta'e o$ !isease at !ia'nosis. 1,2,,,4 Survival rates at 9 (ears are as $ollo)s; Sta'e -.=98> Sta'e --.<98> Sta'e ---.668> an! Sta'e -V.,08. ?( t%e time o$ !eat%, 108.,08 o$ &atients )ill %ave %a! clinicall( !etecte! !istant metastases. Treatment +lt%ou'% sur'er( is most o$ten t%e mo!e o$ treatin' s#uamous cell carcinoma o$ t%e %ea! an! neck, ra!iot%era&( an! c%emot%era&(, eit%er alone or in combination, &la( im&ortant roles. Mana'ement o$ s#uamous cell carcinoma o$ t%e oral cavit( is a $unction o$ t%e anatomic site o$ t%e &rimar( cancer, status o$ t%e neck, antici&ate! $unctional an! cosmetic results, antici&ate! &atient com&liance, an! t%e overall me!ical status o$ t%e &atient. -n re'ar!s to )%ic% &atients ma( nee! treatment o$ t%e cervical area, tumor t%ickness ma( be a more use$ul 'ui!e t%an tumor sta'e. -t %as been $oun! t%at &atients )it% lesions o$ t%e $loor o$ t%e mout% less t%an 1.9mm in t%ickness s%oul! be $ollo)e! )it% observation onl(, as onl( 28 o$ suc% &atients !evelo&e! a cervical metastasis. 2%e inci!ence increases to ,,8 )%en t%e lesion reac%es 1.6 to

,.9mm in t%ickness an! 608 $or lesions t%icker t%an ,.6mm. 2%is )as true re'ar!less o$ t%e lesion@s overall si6e.= :%en &atients are acce&table can!i!ates $or sur'er(, t%e ablation o$ oral s#uamous cell carcinoma involves bot% local an! re'ional tec%ni#ues. Local sur'er( must a!e#uatel( encom&ass all o$ t%e 'ross as )ell as t%e &resume! microsco&ic e3tent o$ !isease 0o$ten )it% t%e use o$ intra.o&erative $ro6en sections1.2,, -$ re'ional l(m&% no!es are &ositive, cervical no!e !issection is usuall( !one in continuit(. Neck !issections are 'enerall( classi$ie! as com&re%ensive an! selective. Com&re%ensive neck !issections inclu!e t%e ra!ical an! mo!i$ie! ra!ical neck !issections. 2,, 2%ese !issections are &er$orme! $or &atients )%o %ave &ositive l(m&% no!e involvement at t%e initial )ork u& sta'e an! entails com&lete removal o$ all l(m&%atic tissue $rom t%e neck 0levels -.-V1.9,6 2%e classic ra!ical neck !issection inclu!es com&re%ensive no!e !issection )it% removal o$ t%e sternoclei!omastoi! muscle, internal /u'ular vein, an! s&inal accessor( nerve. Mo!i$ie! ra!ical 0$unctional1 neck !issection )as !evelo&e! to !iminis% t%e morbi!it( b( removin' all cervical no!es but &reservin' im&ortant anatomical structures. Selective neck !issections involve t%e removal o$ l(m&% no!e 'rou&s at %i'%est risk o$ containin' metastasis $rom a &rimar( tumor.2,, 2%ese are &roce!ures usuall( &er$orme! in &atients )it%out &re.o&erative clinicall( !etectable no!es but %ave e3tensive tumor at t%e time o$ sur'er( )%ic% encroac%es u&on areas o$ l(m&%atic !raina'e an! )%ere occult !isease is antici&ate!. + selective neck !issection s%oul! not be em&lo(e! as t%e sole treatment o$ clinicall( &al&able !isease. +!/unctive ra!iot%era&( is &rimaril( use! as &osto&erative treatment $or cases in )%ic% resection mar'ins are not $ree o$ tumor, sur'ical inaccessibilit(, or t%ere %as been &erineural 'ro)t% an! bone invasion., A3ternal beam ra!iation t%era&( %as been )i!el( use! in &atients )it% cancers o$ t%e ton'ue an! $loor o$ mout%. Batients )it% a sin'le &ositive neck no!e smaller t%an ,cm ma( be cure! in C08 o$ cases )it% &rimar( ra!iot%era&( alone. , 5or all l(m&% no!es lar'er t%an ,cm, a combination o$ neck !issection )it% ra!iot%era&( is &re$erable to 'ain %i'%er re'ional control rates. + variet( o$ c%emot%era&eutic a'ents are use! as a!/unctive t%era&(, %o)ever, none %ave si'ni$icantl( im&rove! survival rates. C%emot%era&( ma( also be 'iven as &alliative treatment to &atients )it% locall( recurrent !isease, )%ic% cannot be cure! )it% sur'er( or ra!iot%era&(, or to &atients )it% !istant metastases. 1,2,, Conclusion 2%e abilit( to control oral an! oro&%ar('eal cancer is &re!icate! u&on t)o &rinci&les; &revention an! earl(

!etection. 2%ere$ore, )it% s#uamous cell carcinoma bein' t%e most common %ea! an! neck mali'nanc(, it is incumbent u&on t%e !ental &ro$essional to &er$orm re'ular oral cancer e3aminations an! to be $amiliar )it% t%e earl( si'ns o$ oral carcinoma. References 1. Neville ?:. *ral an! ma3illo$acial &at%olo'(, 2n! e!ition. &. 3v, =4,. B%ila!el&%ia; :? Saun!ers> 2002. 2. ?arnes L. Sur'ical &at%olo'( o$ t%e %ea! an! neck. &. 2 v. 03i, 1=66 1. Ne) Dork; Dekker> 1C=9. ,. 7ne&& D . Dia'nostic sur'ical &at%olo'( o$ t%e %ea! an! neck, &. 3i, ===. B%ila!el&%ia; Saun!ers> 2001. 4. Neville ?:, Da( 2+. *ral cancer an! &recancerous lesions. C+ Cancer " Clin. 2002 "ul.+u'>92041;1C9.219. 9. S%a% "B, Can!ela 5C, Bo!!ar +E. 2%e &atterns o$ cervical l(m&% no!e metastases $rom s#uamous carcinoma o$ t%e oral cavit(. Cancer. 1CC0 "ul 1>66011;10C.1,. 6. 4o CM, Lam E4, :ei :-, Lau SE, Lam LE. *ccult l(m&% no!e metastasis in small oral ton'ue cancers. 4ea! Neck. 1CC2 Se&.*ct>14091;,9C.6,. <. 7reene 5L. +merican "oint Committee on Cancer, an! +merican Cancer Societ(. +merican "oint Committee on Cancer sta'in' manual, 6t% e!ition, &. 3iv, 421 ill. Ne) Dork; S&rin'er.Verla'> 2002. =. Mo%it.2abatabai M+, Sobel 4", us% ?5, Mas%ber' +. elation o$ t%ickness o$ $loor o$ mout% sta'e - an! -- cancers to re'ional metastasis. +m " Sur'. 1C=6 *ct>192041; ,91.,. Dr. Steven Marc Stokes is a resi!ent in t%e *ral an! Ma3illo$acial Bat%olo'( De&artment, an! Dr. Castle is C%airman o$ t%e *ral an! Ma3illo$acial Bat%olo'( De&artment. 2%e o&inions an! assertions containe! in t%is article are t%e &rivate ones o$ t%e aut%ors an! are not to be construe! as o$$icial or re$lectin' t%e vie)s o$ t%e De&artment o$ t%e Nav(.