Day 2 :
- Clinical and Diagnostics of Oral Cancer
Oral Cancer Treatment : Surgical and Non-Sugical Methods
Associate professor at Chiang Mai University.
Dr. Chitapanarux has completed her MD and postdoctoral studies in Radiation Oncology from Chiang Mai University. She is the associate professor and the Deputy Head of Department of Radiology, Faculty of Medicine, Chiang Mai University. She is also the Head of Chiang Mai Cancer Registry. She has published more than 50 papers in reputed journals.
This study reports the results of treatment for squamous cell carcinoma of oral cavity (SCCOC) with different treatment modalities and goal. We evaluated the treatment outcomes of 775 SCCOC patients treated in our hospital. The cohort consisted of newly diagnosed in 2001-2010 and were treated with surgery ± adjuvant therapy (n = 323) or radiotherapy (RT) ± chemotherapy for curative intent (n= 315) or RT for palliative intent (n = 137). Median follow-up duration was 13.0 months (IQR: 6.4-48.3 months). The overall 10-year survival rate was 22.06%. The hazard ratio of death from cancer in RT group was 2.0 times (95% CI 1.7-2.4, p-value <0.001) as compared to surgical group. Statistically significant difference was noted in 10-year overall survival when SCCOC was managed surgically as compared to curative RT and palliative RT with 34.1% vs 16.2% vs 7.3%, respectively. Most of the patients who receive curative RT were locally advanced stage (III-IVC) or inoperable (56.2%) whereas 46.7% in surgical treatment, suggested that surgery must be the mainstay of treatment in this group of patient. Moreover, even the patients who received palliative RT, this modality still offered long term survival in some SCCOC.
Sajith Babu completed MBBS from Calicut medical college, India and did MS (otorhinolaryngology) from Armed Forces Medical Colleges, Pune. He completed a fellowship in head and neck surgery from Regional Cancer Centre, Trivandrum. He is now working as associate professor at Malabar cancer Centre, Kerala. He is involved in training fellows, doing clinical researches along with treating of head and neck cancer patients. He has published about 12 papaers and has made many presentations in conferences.
Introduction: The reconstruction of surgical defects after Oncological resections after oral cancer often poses a difficult challenge.The submental artery island flap (SAIF) is an option in reconstruction of selected oral cavity defects. There has been doubts on the oncological safety of SAIF as dissections of level 1 is considered difficult. This study is a retrospective analysis of prospectively collected data to find out the oncological safety of SAIF. Methodology: The details of patients undergoing reconstruction with SAIF after resections for oral cancer during the period June 2009- June 2013 were prospectively recorded. This database was analysed retrospectively to see the outcome of patients. Results: 400 resections were done for oral cavity cancers during the period of four years. Fifty patients with SAIF reconstruction were evaluated for their outcome. Majority were T2 lesions (68 %). Mean duration of surgery was 3.25 hours. Average postoperative stay was 8 days. Level 1A was cleared in 41 patients. One patient had complete loss of the flap ,7 had partial loss. 30 had adjuvant radiotherapy,two received concurrent chemotherapy. The median follow up was 28 months. Four had recurrence in the primary site.There was no recurrence beneath the flap. Six patients had ipsilateral nodal recurrence and contra lateral nodal recurrence in five patients. Conclusion: Submental artery island flap is a safe option in reconstruction of selected oral cavity defects.
Nathalie Tabchouri has completed her medical degree from Université Pierre et Marie Curie, France. She completed a master’s degree in Cancer Immunology after her residency in surgery at Paris University Hospitals. She is currently a second year fellow in Maxillofacial Surgery at Pitié-Salpêtrière Hospital. Her interests are in oncological surgery, and advancing medical knowlegde about immunotherapy.
The surgical management of oral squamous cell carcinoma invading the mandible remains controversial. The choice of the mandibular resection is based on the clinical and radiological extent of bone invasion. There are conflicting reports regarding the accuracy of tomography (CT) and magnetic resonance imaging (MRI).
Objectives : To retrospectively evaluate the accuracy of clinical exam, panoramic radiography, CT and MRI in predicting mandibular involvement by oral squamous cell carcinoma. The secondary aim was to establish the incidence of unnecessary segmental resections and insufficient mandibular resections.
Material and Methods : Ninety-two patients who presented with potential mandibular invasion by oral squamous cell carcinoma underwent CT and MR before surgery. The imaging results were correlated with histopathologic findings.
Results : A total of 40 patients underwent marginal resections and 52 underwent segmental resections. Histological bone invasion was present in 10 patients in the marginal resection group. Eight patients did not present with bone invasion in the segmental group. The sensitivity, the specificity and the accuracy for mandibular invasion were 77,5%, 93,9% and 84,9% for CT and 66,7%, 91,4% and 77,9% for MR imaging, respectively. 8.7% of all patients were undertreated. The incidence of unnecessary segmental resections was 10.9%. These over treated patients were found to be younger (p=0.016) and had less potentially malignant lesions (p=0.012).
Conclusions : In assessing the presence of mandibular invasion by OSSC, the combined use of CT and MR imaging is necessary but still insufficient for the treatment planning.
Saarland University Medical Center
Dr. Linxweiler has studied medicine at the Saarland University and is a resident at the Department of Otorhinolaryngology at the Saarland University Medial Center (Homburg, Germany). His research focuses on the applicability of liquid based cytology for the non-invasive analysis of biomarkers in head and neck cancer as well as the identification of new therapeutic targets and their validation in animal models. He has published his work in reputed international journals and has achieved several research awards.
BACKGROUND: High-risk human papillomavirus (HPV) infection could be identified as a relevant risk for the development of head and neck squamous cell carcinomas (HNSCC) and the incidence of HPV positive cancers is still on the rise. As HPV status has also gained a role as prognostic and predictive biomarker for this entity, there is a growing demand for valid HPV testing in HNSCC patients. However, currently used tests can still not distinguish between a latent HPV infection with the potential of self-limitation and a HPV infection leading to cancerous transformation. METHODS: Liquid-based cytological suspensions from 45 HNSCC and 20 control patients were used for the detection of high-risk HPV-DNA by PCR and a simultaneous immunocytochemical detection of p16 and Ki67 applying the CINtecPLUS kit (Roche mtm laboratories, Heidelberg, Germany) that is routinely used in gynecology. RESULTS: In 13/60 (22%) cases, high-risk HPV-DNA could be detected in the cytological suspension. From these HPV-DNA-positive cases, tumor cells showed a simultaneous expression of Ki67 and p16 in 9 samples (64%) representing a staining pattern that is strongly associated with a carcinogenic high-risk HPV infection. CONCLUSIONS: A simultaneous immunocytochemical detection of p16 and Ki67 can reliably be performed on liquid-based cytological smears of HNSCC using the CINtecPLUS kit and the same cytological material can be used for the detection of HPV-DNA by PCR. Results enable a discrimination between latent and carcinogenic HPV infections and thus can provide information on the prognosis of HNSCC patients and facilitate therapeutic decisions.
Dr. Lanfranchi obtained his DDS at the University of Cordoba, and completed his PhD at the University of Buenos Aires. He has been Head Professor of the Oral Medicine Department of the School of Dentistry, University of Buenos Aires since 1991. He was Board Member at Large (2001-2005) of the International Association for Dental Research (IADR), and he received the IADR Distinguished Service Award in 2010. He is Co-director of the Oral Cancer Prevention Campaign of the regional development program of the IADR and is the Director of the Oral Medicine Department of the German Hospital of Buenos Aires.
In view of the poor results observed in oral cancer patients diagnosed at a late stage of the disease in the city of Buenos Aires, we implemented a change in the oral cancer prevention strategy, which was first applied in the aforementioned city and then in almost all universities and provinces across Argentina. The new strategy involved three different levels: Examination of the border of the tongue as a first step in oral examination, as has been a mandatory requirement for students of the course for the last ten years, since this is the most frequent location of oral cancer in patients diagnosed at our Department. Training of 520 general practitioners from public hospitals in 15 provinces in Argentina for detection of early stage cancer. Creation of an online diagnostic network through which professionals send a photograph of the lesion taken with a conventional digital camera to the regional departments and the reference center at the School of Dentistry (UBA) for clinical diagnosis. Coinciding with World Head and Neck Cancer Day, a one-week campaign, “Poke your TONGUE out at cancer”, to increase awareness in the population was implemented in 15 provinces in Argentina for three consecutive years. The campaign involved the participation of all public and some private universities, public health ministries and health care centers, and a number of intermediate professional organizations. As a result of the last campaign carried out in 2015, a total 31 cases of OSCC and 601 of potentially malignant disorders were diagnosed.
Senior Resident at King George Medical University
Dr Jeetendar Paryani completed his graduation (MBBS) at the age of 23 years from Government medical Nagpur under Maharastra University of Health Sciences. He completed his masters in General surgery(MS) at BJ Medical College and Civil Hospital Ahmedabad under Gujarat university at the age of 27 years. He further pursued surgical oncology course and was selected for same thru national level exam. He is currently undergoing training as senior resident in Department of Surgical oncology at King George Medical University Lucknow. He has presented various papers at national level conferences.
PMMC with single stage DeltoPectoral (DP) Composite Flap in huge defects after head and neck surgery:- A innovative solution .
Introduction:- Carcinomas of Oral cavity are the most common malignancy in our country. Its not very uncommon for cancer to present at advanced stage. Resection of such lesion may result in large complex defects. Reconstruction of such defects could be done by loco Regional Flaps or combination of flaps or alone by free flaps. We describe the technique of composite PMMC –DeltoPectoral(DP) Flap reconstruction for reconstruction of such defects . This is a single stage procedure. Also the technique of DP has been modified so as to avoid detachment of flap later on so as minimize in hospital patient stay Methods: The patients with locally advanced oral cavity cancer from the period of September 2015 to December 2015 were operated & reconstructed using this technique in our institute. Standard Techniques used for resection & neck dissection. DP flaps were raised first with the usual technique after which PMMC flaps were raised.PMMC Flaps were used for coverage on the mucosal side of the defect and DP flap was used to cover the skin loss and both flaps sutured to each other at the junction. Donor site was covered with spilt thickness graft taken form thigh. Postoperative outcome and final cosmesis was evaluated Results: 10 patients were reconstructed using this technique. 9 were males and one was female. 4 patients were with central arch mandible lesion with involvement of chin skin, 5 were RMT and alveolus skin lesions with involvement of cheek skin. One patient was parotid malignancy with skin involvement .Only one patients suffered major Flap necrosis.. But patient recovered and reconstructed using the same flap. Two patients developed minor orocutaneous fistula which recovered on conservative management. The cosmesis of the patients was good Discussion: Large complex defects involving both oral cavity and skin posses a unique reconstructive challenge . Although a single free flap or combinations of free flap may represent a better solution, in country like ours such facilities may not be always available .This technique represents an innovative solution in reconstruction oral cavity defects with large skin loss . This flaps provide inner PMMC in oral lesion & DP provides outer skin coverage. We believe such technique resection has not been described in previously in literature. There has been a case where oral cavity defect was covered with PMMC and skin involvement in neck was covered by DP flap. But to use both the flaps which are sutured at the junction represents a new answer to difficult question of reconstruction of large defects. Also that solution does not require complex micro vessel anastomosis or significant donor site morbidity. Other options for reconstruction for such defects are bipaddle PMMC or forehead flap .Bipaddle PMMC is cumbersome in patient with fatty chests or females. Whereas forehead flap are esthetically not suitable for large defects they may also require second stage for division of flap Deltopectoral flaps also require second stage surgery for delay / divison of flap. We have modified the technique of flap in such a way that edge of flap is sutured to neck dissection wound. This avoids the need for second stage for divison of defect. Resulting in shortening of traditionally long hospital stay required for standard deltopectoral flaps. With continuing use of such composite flaps we plan to refine better technique & modifications to improve outcomes and cosmesis in patients requiring large reconstructions.
Fellow Student at Wayne State University School of Medicine
Misako Nagasaka, MD is a Hematology/Oncology Fellow at the Barbara Ann Karmanos Cancer Institute in Detroit, Michigan. Ammar Sukari, MD, is a medical oncologist, leader of the Head and Neck Multidisciplinary Team and a member of the Thoracic Multidisciplinary Team at Barbara Ann Karmanos Cancer Institute in Detroit, Michigan. He is also an assistant professor of oncology at Wayne State University School of Medicine and has authored and coauthored more than 10 papers in reputed journals.
The treatment of residual disease post definitive chemoradiation in HNSCC often involves extensive salvage surgery. PET scans post treatment may help differentiate between viable tumor and treatment effects and there has been increased debate on this topic.
Methods and Results: Case presentation a review of the literature.
Case: A 58 year old man with stage IVa (T4a N0 M0) SCC of the right base of tongue, p16 positive, was treated with definitive chemoradiation utilizing cisplatin 100mg/m2 every 3 weeks and a total of 70Gy of radiation. His initial MRI findings 12 weeks post chemoradiation showed a bulky enhancement at the base of tongue, 1.2 x 1.9 x 1.2 cm in size, worrisome for possible residual disease. A repeat MRI done at 20 weeks did not show improvement. He therefore had a PET scan at 25 weeks. The PET scan did not show any FDG uptake. He was therefore continued on surveillance with clinic visits, serial imagings with neck MRIs as well as nasopharyngolaryngoscopies. He continues to do well without evidence of disease 17 months post completion of chemoradiation and has successfully been spared of salvage surgery.
Discussion: PET scans in patients with HNSCC who have received chemoradiotherapy have shown high negative predictive values of 96%. There are also emerging data from observations reporting that HPV positive tumors may take more time to involute post therapy.
Conclusion: PET scans may have a role in identifying those who could be safely followed post definitive therapy even with residual findings on MRIs.
University of Calabar, Nigeria
Dickson Okoh S graduated from the University of Benin in 2002 with a BDS degree. He completed his postgraduate residency training in Oral pathology in 2014 and he’s a fellow of the West African College of Surgeons (FWACS). Presently, he is a Consultant Oral Pathologist in the University of Calabar Teaching Hospital, Cross River State, Nigeria and a lecturer in the School of Dentistry, College of Medical Sciences, University of Calabar, Nigeria
In our environment, oral cancer is one of the most common lethal diseases that will be encountered in dental practice. It is frequently diagnosed in late stages because most patients present to the hospital late into the course of the disease. This may be attributed to their low socioeconomic status, illiteracy, and some traditional beliefs in alternative native therapies. World-wide, oral cancer is regarded as the sixth most common cancer. Several authors in different geographic locations in our setting have reported on oral cancers generally; however few studies have reported specifically on carcinomas, sarcomas and haematolymphoid cancers of the orofacial region. This study aims to review the prevalence, awareness and clinicopathologic patterns of oral cancers in our own environment. Methods Information was sourced from journals, electronic data base such as Medline, Pubmed, Elsevier ScienceDirect , and Cochrane Library and personal research work. The search words were oral cancers, Orofacial carcinoma, and orofacial sarcoma.
Several prevalence rates have been reported by several authors in different geographic locations in our environment. Orofacial carcinomas were reported mostly in the older age groups while the Orofacial sarcomas were mostly found in the slightly younger age groups. Squamous cell carcinoma is the predominant histological type seen. There is a low level of awareness of these lesions especially among the low socio-economic group which makes them present late in our health care facilities for treatment hence a poor prognosis. There is a need for increased awareness, advocacy, preventive care and oral cancer screening.