Management of the Mandible in cancer of the Oral Cavity

Professor Alexander D. Rapidis MD DDS PhD FACS

Chairman Dept. of Maxillofacial / Head and Neck Surgery

Greek Anticancer Institute, Saint Savvas Hospital

Athens Greece

Cancer of the mandible refers to mucosal squamous cell carcinoma of the alveolar process of the mandible that invades the underlying mandibular bone.According to several statistics, it represents the second in frequency site after

carcinoma of the tongue.

has the highest local recurrence rate

No Bone Invasion

T 1

Invasion within Alveolar Bone

T 1 T 2

Invasion beyond alveolar bone Invasion including the LMC

but above the LMC

T 3

Invasion including the LMC

T 4

LMC: Level of Mandibular Canal

Classification

Histological Patterns of Tumor Invasion

• Invasive pattern (infiltrative pattern)• Invasive pattern – (infiltrative pattern)– Islands of tumor infiltrate cancellous spaces– Little osteoclatic activity– Little osteoclatic activity– No intervening connective tissue

• Erosive pattern – (compressive patterns)• Erosive pattern – (compressive patterns)– Tumor advances as a broad front– Active osteoclasts separating tumor from boneActive osteoclasts separating tumor from bone– Connective tissue layer separating tumor/bone

Carter RL et al Patterns and mechanisms of bone invasion by squamous carcinomas of the head and neck Am J Surg 146:451, 1983

Patterns of invasion in the invasive front

Erosive

Solid border /solid cords

Patterns of invasion in the invasive front

InvasiveInfiltrating small groupsInfiltrating small groups

and single cells

Patterns of Mandibular InvasionRoutes of Entry into Mandibley

• Direct penetration through occulsal surfaceDirect penetration through occulsal surface

•Through periodontal membrane (interdental)

F th tt h d i i•From the attached gingiva

Patterns of Mandibular InvasionRoutes of Entry into Mandibley

• Through mental or mandibular foramena

• From metastatic neck tumor through lower gborder of mandible

• Cortical bone defects in edentulous alveolarCortical bone defects in edentulous alveolar ridge

How to detect mandibular invasionHow to detect mandibular invasion

• Clinical examination

• Radiographs (plain OPG)

• CT – DentaScan

• MRIMRI

• Bone scans

• Ultrasound

• PET CT

• Ultimate proof: histology

DentaScan as an accurate method of predicting mandibular invasion with squamous cell carcinoma of the oral cavity, Brockenbrough J, Petruzzelli GJ,

Lomasney L, Arch Otolaryngol Head Neck Surg 2003;129:113-117

Marginal resection

Anterior Marginal Mandibulectomyg y

Marginal resection

Take home message

Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma

• Clinical examination

• OPGOPG

• Denta Scan

• Bone Scan (Tc 99 – SPECT)( )

Take home message

Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma

• Clinical examination

• OPGOPG

• Denta Scan

• Bone Scan (Tc 99 – SPECT)( )

When negative:

M i l dib lMarginal mandibulectomy

Take home message

Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma

• Clinical examination

• OPGOPG

• Denta Scan

• Bone Scan (Tc 99 – SPECT)( )

When positive:

S l dib l i d iSegmental mandibular resection and reconstruction

Take home message

Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma

• Clinical examination

• OPGOPG

• Denta Scan

• Bone Scan (Tc 99 – SPECT)( )

When equivocal:

I i i l i iIntraoperative periosteal stripping

Take home message

Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma

• Clinical examination

• OPGOPG

• Denta Scan

• Bone Scan (Tc 99 – SPECT)( )

When equivocal:

I i i l i iIntraoperative periosteal stripping

When positive:When positive:Segmental mandibular resection and reconstruction

Take home message

Suspected mandibular invasion from oral squamous cell carcinomacell carcinoma

• Clinical examination

• OPGOPG

• Denta Scan

• Bone Scan (Tc 99 – SPECT)( )

When equivocal:

I i i l i iIntraoperative periosteal stripping

When positive:When positive:Segmental mandibular resection and reconstruction

When negative:Marginal mandibulectomy

Second World Congress of the gInternational Academy of Oral Oncology

(IAOO)( )

July 8 – 11, 2009

Sheraton Centre Toronto

Invitation to Toronto!