NEOPLASMS OF THE ORAL CAVITY

Divisi Onkologi

ANATOMY
Lips to the junctional of hard and soft pallate Mucosa buccal Upper and lower alveolar bridges Retromollar trigone 2/3 oral tongue Floor mouth Hard palate

EPIDEMIOLOGI
Risk factor alcohol, tobacco 95% Ca sel skuamosa Pria : Wanita = 1:2 95% > 40 tahun; umur rata-rata 60 tahun the human papillomavirus (HPV) may play a role in the etiology of oral cavity

LESI PRAKANKER
Leukoplakia premalignant lession, tetapi eritroplasia beresiko tinggi sebagai penanda keganasan Leukoplakia secara mikroskopik hiperkeratosis dan displasia Penyebab leukoplakia berhubungan dengan penggunaan tobacco atau trauma berulang, tetapi hubungannya belum jelas karena leukoplakia menghilang setelah menghentikan agen iritasi Beberapa leukoplakia dapat berkembang menjadi lesi malignant

Lesi mukosa putih ataupun merah membutuhkan biopsi Lesi leukoplakia benigna dan tidak menghilang setelah menghentikan tobako, pengobatan masih tidak jelas. Surgical excision, laser excision, and similar techniques have all been used with some degree of success. Nonsurgical approaches, such as topical vitamin A therapy, also have been tried, with complete response rates in the 10% to 27% range and partial response rates in 54% to 90% of patients. The side effects were minimal, but leukoplakia recurred in 50% of patients after discontinuation of the medication

RADIATION THERAPY

Radiation therapy and surgery have equal success in controlling T1 lesions of the oral cavity. Treatment options must be determined by numerous factors, including the location, the patient's physical condition and social and economic situation, and the experience of those delivering the care. Radiation therapy tends to provide a better functional result with superior speech and swallowing, but significant disadvantages of radiation therapy are diminution of taste, xerostomia, and the protracted nature of the treatment course. Unlike surgery, a curative dosage of radiation therapy requires at least 6 weeks of treatment, and this can affect the treatment choice. When considering oral cavity cancers, the highest rate of complications related to external beam radiation occurs in patients with floor-of-mouth cancer; historically, in one fourth or more of these patients, osteoradionecrosis of the mandible developed. Newer techniques brachytherapy and intensity-modulated radiation therapy (IMRT) more focused targeting and reduced complications

CHEMOTHERAPY
Although the combination of radiation therapy and surgery provides a better chance for cure for stage III and IV disease than does either modality alone, substantial evidence suggests that the addition of concomitant chemotherapy to postoperative radiation therapy improves locoregional control and survival in these patients

BUCCAL CARCINOMA
uncommon cancer Buccal carcinomas occur most commonly in 70-year-old men and are found in a region of cheek leukoplakia. The exophytic lesions may have a relatively benign appearance and may not penetrate into the soft tissues of the cheek until they are relatively large. The ulcerative lesions, however, penetrate early and make cure more difficult because of their involvement of adjacent muscle, bone, and skin Because no natural barriers to tumor penetration exist in the cheek, cure rates are not as good as one might expect in a region so easily inspected.

As with most oral cavity neoplasms, T1 lesions can be treated either with surgery or radiation therapy, although resection and coverage of the area with a split-thickness skin graft may be more convenient and expedient. Because T1 lesions are rare, large series comparing treatment modalities cannot be found. Three-year survival rates for T1 and T2 lesions are approximately 80% and 60%, respectively, and depending on the extent of the lesions, marginal or rim mandibulectomy or partial maxillectomy or both may be necessary for adequate margins Surgery plus radiation therapy is the treatment of choice for stage III and IV disease. The extent of resection of these larger lesions is variable, but may include resection of the maxilla or mandible, parotidectomy, neck dissection, or a combination of these. Reconstruction is with free (radial forearm) or regional myocutaneous (temporalis, pectoralis major) flaps or with an osteomyocutaneous free flap if bone is needed.

HARD PALATUM CARCINOMA

Primary malignancies of the hard palate are uncommon with a relatively equal incidence of squamous cell carcinoma and salivary gland malignancies. Because nodal metastases are retropharyngeal, it is unnecessary to be concerned with prophylactic neck therapy. Only those patients with T4 lesions begin to approach an incidence of nodal metastases (25%) for which prophylactic neck irradiation would be considered. Although distant metastases are rare with squamous cell carcinoma of the hard palate, an incidence of 12% has been found in patients with salivary gland tumors

Radiation therapy has been reported to be as effective as surgery in treating T1 and T2 lesions, for those of both salivary gland and squamous etiology. It is probably true, however, that T1 lesions are most easily treated by excision. For the larger T3 and T4 lesions (the 5-year survival rate decreases from 85% for a T1 lesion to 30% for a T4 lesion), the treatment of choice is a combination of surgery and radiation therapy Partial or total maxillectomy is often required, and the traditional reconstruction has been with a prosthetic obturator, requiring preoperative evaluation by a prosthodontist

ORAL TONGUE
In deciding on treatment modalities for oral tongue cancer, the same factors are applicable as for most other head and neck sites. T1-2 lesions can be treated by surgery or radiation therapy, and T3-4 lesions do best with combination therapy. Radiation treatment alone achieves control rates of 86% for T1 and 75% for T2 lesions. Because of the high complication rate associated with curative doses suggested a policy of initial surgery, with postoperative radiation therapy being reserved for patients with a suspected high rate of local or neck failure.

ALVEOLUS CARCINOMA

Alveolus carcinoma is a relatively rare oral cavity cancer; 80% are of the lower jaw, with most occurring in the posterior third of the dental arch. Treatment is primarily surgical, but the addition of radiation therapy is important when bony invasion, nodal metastases, or perineural invasion is present. Stage I and II disease can be treated with surgery alone, with expected 2-year disease-free survival rates of 80% and 70%, respectively. For stage III and IV disease, radiation therapy is required for the N0 neck, and a MRND with radiation therapy is indicated for positive nodal disease. When combined therapy is used, the expected 2-year survival rates are 60% and 50%, respectively, for patients with stage III and IV disease

FLOOR OF MOUTH

One of the problems of using radiation therapy as curative treatment for oral cavity tumors is the proximity of the mandibular arch. Cancers of the floor of the mouth are undertreated and tend to reflect a poor stage-for-stage prognosis. In a recent retrospective study involving 227 patients, stage I and II floor-of-mouth cancers had a 5-year disease-specific survival rate of 72% and 63% Elective neck dissection is typically recommended for T2 and larger or more-aggressive T1 lesions. Stage III and IV lesions had disease-specific survival rates of 44% and 47% , these require combination therapy, which frequently involves composite resection and complex reconstruction. Treatment failures occurred at the primary site more than twice as often as did recurrence in the neck

1.

The incisive foramina house the

A.
B. C. D.

E.

Greater palatine vessels and nerves Sphenopalatine nerve Palatine nerves and nasopalatine arteries Anterior and posterior superior alveolar nerves Lesser palatine nerve

2. A benign oral cavity lession sometimes mistaken pathologically for squamous cell carcinoma is a. Squamous papilloma b. Granular cell myoblastoma c. leukoplakia d. fibrous histiocytoma e. erythroplakia

3. Of oral cavity cancers treated primarily with radiotherapy for cure, the site treated with the highest complication rate is the a. Floor of mouth b. Tongue c. buccal mucosa d. Anterior tonsillar pillar e. Retromolar trigone

4. Due to lack of natural barriers in the cheek, buccal carcinomas, with the following thickness have a batter prognosis a. Less than 10 mm b. Less than 6 mm c. between 10 and 12 mm d. Greater than 6 mm e. Less than or equal to 15 mm

5. Primary malignancies of which oral cavity site are equally distributed between salivary gland and squamous cell carcinoma a. Floor of mouth b. Anterior tonsillar pillar c. hard palate d. Tongue e. Buccal mucosa

6. Alveolus carcinomas are most commonly located in the a. Anterior maxillary segment b. Posterior third of the mandible c. anterior mandibular arch d. Body of mandible e. Posterior alveolus

7. Concern for potential nodal metastase associated with alveolus carcinoma increases when which of the following is present? a. Bony invasion and/or perineural invasion b. Lesions greater than 1,5 cm c. tumor stuck to periosteum d. Involvement of tooth sockets e. Assosiated dental infection

8. The deep lymphatic plexus of the floor of mouth drains to the a. Ipsilateral and contralateral nodes b. Contralateral nodes only c. ipsilateral nodes only d. Submental and contralateral nodes e. Submental nodes only

9. The most common surgical reconstructive technique for the resurfacing of oral cavity defects after oncologic resection is a. Full-thickness skin graft b. Split-thickness skin graft c. radial forearm free flap d. Tongue flap e. Myocutaneous flap

10. Rim mandibulectomy may be assosiated with all but which of the following? a. Maintenance of mandibular continuity b. Possible bone necrosis c. possible pathologic fracture d. A satisfactory base for denture placement e. Malignance of a normal cosmetic appearance