DEPARTMENT OF DEPARTMENT OF SURGICAL SURGICAL

ONCOLOGY- GRHONCOLOGY- GRH

PROF.R.RAJARAPROF.R.RAJARAMAN UNITMAN UNIT

Evaluation and Evaluation and staging of oral staging of oral

cancercancerDr Sujay SusikarDr Sujay Susikar

PG in Surgical OncologyPG in Surgical Oncology

Professor Dr R Rajaraman unitProfessor Dr R Rajaraman unit

Government Royapettah Government Royapettah HospitalHospital

Initial head and neck Initial head and neck examinationexamination

Standard and complete head and neck Standard and complete head and neck examinationexamination

All 12 cranial nerves examinedAll 12 cranial nerves examined Otoscopy and anterior rhinoscopyOtoscopy and anterior rhinoscopy Examination of oral cavityExamination of oral cavity Palpation of tongue and tongue basePalpation of tongue and tongue base Mirror and flexible laryngoscope examinationMirror and flexible laryngoscope examination Examination under anaesthesia in patients Examination under anaesthesia in patients

with trismus, SMF, ankyloglossia, with trismus, SMF, ankyloglossia, uncooperative patientsuncooperative patients

WHO Format – oral cavity WHO Format – oral cavity examinationexamination

Exam abstracted from WHO standardized oral Exam abstracted from WHO standardized oral examination method examination method

Consistent with CDC and NIH methodConsistent with CDC and NIH method Requirements:Requirements:

Adequate lightingAdequate lighting Dental mouth mirrorDental mouth mirror Two 2" x 2" gauze squaresTwo 2" x 2" gauze squares GlovesGloves Seated patientSeated patient Removal of intraoral prosthesesRemoval of intraoral prostheses

Should take no longer than 5 minutesShould take no longer than 5 minutes

Extraoral Examination Extraoral Examination FaceFace

Perioral and Intraoral Perioral and Intraoral Soft Tissue Examination Soft Tissue Examination

– Lips – Lips

Perioral and Intraoral Perioral and Intraoral Soft Tissue Examination Soft Tissue Examination

––Labial MucosaLabial Mucosa

Buccal MucosaBuccal Mucosa

Buccal MucosaBuccal Mucosa

GingivaGingiva

Tongue DorsumTongue Dorsum

Tongue Left MarginTongue Left Margin

Tongue Right MarginTongue Right Margin

Tongue VentralTongue Ventral

FloorFloor

Hard PalateHard Palate

OropharynxOropharynx

PalpationPalpation

Histological confirmation of Histological confirmation of diagnosis diagnosis

Wedge Biopsy for infiltrating lesionsWedge Biopsy for infiltrating lesions Punch Biopsy for Proliferative lesionsPunch Biopsy for Proliferative lesions Transoral under LA if possibleTransoral under LA if possible Taken from edgesTaken from edges Adequate depth of tissueAdequate depth of tissue Anaesthesia in Trismus, Ankyloglossia, Anaesthesia in Trismus, Ankyloglossia,

SMF, Infiltrative & Posteriorly placed SMF, Infiltrative & Posteriorly placed lesions lesions

StagingStaging Nodal –Nodal –• ClinicalClinical• UltrasoundUltrasound• CT in CT in

extensive extensive nodal nodal diseasedisease

• PETPET

Metastatic workup Metastatic workup

• X ray ChestX ray Chest• Chest CT / PET in Chest CT / PET in

patients with N2 patients with N2 disease and N2 disease and N2 adenopathy below adenopathy below thyroid notchthyroid notch

• Symptom directedSymptom directed

Tumor-•Examination under anesthesia•X Rays,•Panorex•CT Scan•MRI

Investigations for StagingInvestigations for Staging

Examination under Anesthesia in Examination under Anesthesia in selected casesselected cases

X Ray Mandible, PNS, MaxillaX Ray Mandible, PNS, Maxilla

OrthopantamogramOrthopantamogram Orthopantomogram for involvement of mandible Orthopantomogram for involvement of mandible

& maxilla& maxilla Assessment of the entire dentition and early Assessment of the entire dentition and early

evaluation of erosionsevaluation of erosions Mentum & lingual cortex difficult to assessMentum & lingual cortex difficult to assess

ULTRASOUND NECKULTRASOUND NECK Highly operator dependentHighly operator dependent Sensitive in picking up nodes in clinical N0 Sensitive in picking up nodes in clinical N0

diseasedisease Useful for image guided biopsy Useful for image guided biopsy Ultrasound criteria:Ultrasound criteria: Size min axial diameter 7mm- submental, 8mm for other nodesSize min axial diameter 7mm- submental, 8mm for other nodes Roundness index ratio of transverse to longitudinal diametersRoundness index ratio of transverse to longitudinal diameters Absence of an echogenic hilusAbsence of an echogenic hilus Presence of necrosis – coagulative or cystic within a nodePresence of necrosis – coagulative or cystic within a node Extracapsular spreadExtracapsular spread Colour doppler- disorganised peripheral flow patternColour doppler- disorganised peripheral flow pattern

Coagulative necrosis

Cystic necrosis

Extracapsular disease

Disorganised peripheral flow

ULTRASOUND NECKULTRASOUND NECK

Indications for Ultrasound neck:Indications for Ultrasound neck: Patients with clinical N0 neck with Patients with clinical N0 neck with

primary in areas with high primary in areas with high possibility of lymphatic spreadpossibility of lymphatic spread

Clinically insignificant nodes ?Clinically insignificant nodes ?

CT scanCT scan

Standard practise nowStandard practise now Evaluates site and location of primaryEvaluates site and location of primary Assessment of Metastatic adenopathyAssessment of Metastatic adenopathy Scans done prior to biopsy to avoid Scans done prior to biopsy to avoid

confusion by changes from biopsyconfusion by changes from biopsy

CT scanCT scan

CT scanCT scan

CT scanCT scan

Indications for CT:Indications for CT: For evaluation of primary situated For evaluation of primary situated

adjacent to boneadjacent to bone Evaluation of extent of spread in Evaluation of extent of spread in

large primarieslarge primaries To decide on management of the To decide on management of the

mandiblemandible Evaluation of neckEvaluation of neck

Malignant node criteria for CT :Malignant node criteria for CT : LN > 15 mm. in level IILN > 15 mm. in level II LN > 10 mm. in other levelsLN > 10 mm. in other levels Group of ≥ 3 nodes ( 1-2 mm.)Group of ≥ 3 nodes ( 1-2 mm.) Central necrosisCentral necrosis Loss of tissue planes ( fat plane)Loss of tissue planes ( fat plane)

CT Scan CT Scan ADVANTAGES:ADVANTAGES: Increased speedIncreased speed Bony framework – better evaluatedBony framework – better evaluated Small calcifications more apparentSmall calcifications more apparent

DISADVANTAGES:DISADVANTAGES: Requires ionizing radiationRequires ionizing radiation And iodinated contrast agentsAnd iodinated contrast agents

DentascanDentascan

DentaScanDentaScan performs real time performs real time image reformation image reformation specific to CT dental specific to CT dental imaging: oblique imaging: oblique and panorex and panorex reformation. reformation.

Assessment of Bone Assessment of Bone involvementinvolvement

No motion artifact in No motion artifact in Bulky tumorsBulky tumors

DentascanDentascan

MRI – In Selected casesMRI – In Selected cases Better Soft tissue contrast Multiplanar – better assessment of

Primary Useful additional information in

previously treated patients (recurrence and residues) and in lesions with skull base involvement

No dental amalgam artifact

MRIMRI

Indications for MRI:Indications for MRI: In primaries with possible perineural In primaries with possible perineural

spreadspread For evaluation of possible skull base For evaluation of possible skull base

involvementinvolvement To evaluate exact soft tisue spread To evaluate exact soft tisue spread

of the tumor to plan conservative of the tumor to plan conservative resectionsresections

MRIMRI

MRIMRI

MRIMRIAdvantages:Advantages: More sensitive for subtle spread along nerves More sensitive for subtle spread along nerves

and into the skull baseand into the skull base Better evaluation of cartilage or marrow invasionBetter evaluation of cartilage or marrow invasion

Disadvantages:Disadvantages: Lower patient toleranceLower patient tolerance Dangers with metallic implants, pacemakers and Dangers with metallic implants, pacemakers and

other hardwareother hardware Increased expenseIncreased expense Patient motion always a concernPatient motion always a concern

PET scanPET scanInherent limitations of conventional imaging:Inherent limitations of conventional imaging: Poor sensitivity for detection of disease < Poor sensitivity for detection of disease <

1cm1cm Limited ability to distinguish residual or Limited ability to distinguish residual or

recurrent tumor from scarrecurrent tumor from scar Inability to biologically characterize diseaseInability to biologically characterize disease Inability to provide early prognostic Inability to provide early prognostic

information regarding treatment outcomeinformation regarding treatment outcome

PET scanPET scanAdvantages :Advantages : Useful in detection of additional disease not Useful in detection of additional disease not

seen on routine staging and altering TNM seen on routine staging and altering TNM stagingstaging

Detection rate of occult primary higherDetection rate of occult primary higher Less reliant on size for detection of nodal Less reliant on size for detection of nodal

diseasedisease Can detect distant metastasis and synchronous Can detect distant metastasis and synchronous

second primary malignancies not seen on second primary malignancies not seen on routine work up, therefore avoiding routine work up, therefore avoiding inappropriate aggressive treatmentsinappropriate aggressive treatments

PET scanPET scan

PET scanPET scan

PET scanPET scan

PET scanPET scanUses of PET:Uses of PET: StagingStaging Thereupetic planningThereupetic planning Post therapy restagingPost therapy restaging Thereupetic monitoring and outcomeThereupetic monitoring and outcome Restaging and relapseRestaging and relapse

Dilemmas :Dilemmas : Management of equivocal PET?Management of equivocal PET? Cost effectiveness?Cost effectiveness?

Pre Anaesthetic AssessmentPre Anaesthetic Assessment

General medical evaluation General medical evaluation Routine pre op lab InvestigationsRoutine pre op lab Investigations To rule out Co-morbid conditionsTo rule out Co-morbid conditions

Intra operative Frozen SectionIntra operative Frozen Section For marginsFor margins For nodes if selective node For nodes if selective node

dissection donedissection done

Optimal frozen section reporting: guidelines:

Confirmation of malignancy Closest margins – exact

length Positivity of closest

margins

Pre operative assessment of Speech Pre operative assessment of Speech & swallowing – Baseline for & swallowing – Baseline for

rehabilitationrehabilitation Spectrogram – intensity frequency , Spectrogram – intensity frequency ,

resonance & format of speechresonance & format of speech Modified Barium Swallow – premature Modified Barium Swallow – premature

spillage into hypopharynx & vestibule of spillage into hypopharynx & vestibule of larynxlarynx

Screening for Second PrimaryScreening for Second Primary

4% annual incidence4% annual incidence Pan endoscopy ( triple endoscopy), Pan endoscopy ( triple endoscopy),

sputum & saliva cytology, Xray Chest sputum & saliva cytology, Xray Chest

T - StagingT - Staging

TX – Primary cannot be assessedTX – Primary cannot be assessed T0 – No evidence of primaryT0 – No evidence of primary Tis – Ca. in situTis – Ca. in situ T1 – 2 cm or lessT1 – 2 cm or less T2 – more than 2 cm but not more than 4 T2 – more than 2 cm but not more than 4

cmcm T3 – more than 4 cmT3 – more than 4 cm

T - StagingT - Staging

T4a (lip) - Invading through cortical bone, inferior T4a (lip) - Invading through cortical bone, inferior alveolar nerve, floor of mouth or skin of face(chin alveolar nerve, floor of mouth or skin of face(chin or nose)or nose)

T4a (Oral cavity) – Invading adjacent structures T4a (Oral cavity) – Invading adjacent structures eg,. cortical bone, deep extrinsic muscle of eg,. cortical bone, deep extrinsic muscle of tongue, maxillary sinus or skin of facetongue, maxillary sinus or skin of face

T4b – Invading masticator space, pterygoid plates, T4b – Invading masticator space, pterygoid plates, skull base or encases Internal carotid arteryskull base or encases Internal carotid artery

(Superficial erosion alone of bone/ tooth socket by (Superficial erosion alone of bone/ tooth socket by gingival primary is not T4 )gingival primary is not T4 )

N - StagingN - Staging NX - Nodes cannot be assessedNX - Nodes cannot be assessed N0 – No nodesN0 – No nodes N1 – single ipsilateral node 3 cm or less in greatest N1 – single ipsilateral node 3 cm or less in greatest

dimension dimension N2a – single ipsilateral node more than 3 cm but not more N2a – single ipsilateral node more than 3 cm but not more

than 6 cmthan 6 cm N2b – multiple ipsilateral nodes none more than 6 cmN2b – multiple ipsilateral nodes none more than 6 cm N2c – bilateral or contralateral node none more than 6 cmN2c – bilateral or contralateral node none more than 6 cm N 3 – node more than 6 cm N 3 – node more than 6 cm (Midline nodes are ipsilateral nodes)(Midline nodes are ipsilateral nodes)

M - StagingM - Staging

MX – metastasis cannot be assessedMX – metastasis cannot be assessed M0 – No metastasisM0 – No metastasis M1 – Distant metastasis M1 – Distant metastasis

Stage GroupingStage Grouping Stage 0 – Tis N0 M0Stage 0 – Tis N0 M0 Stage I – T1 N0 M0Stage I – T1 N0 M0 Stage II – T2 N0 M0Stage II – T2 N0 M0 Stage III – T1-3 N1 M0 Stage III – T1-3 N1 M0

T3 N0 M0T3 N0 M0 Stage IV A - T4a N0-1 M0Stage IV A - T4a N0-1 M0

T1-4a N2 M0T1-4a N2 M0 Stage IV B – Any T N3 M0Stage IV B – Any T N3 M0

T4b Any N M0T4b Any N M0 Stage IV C – Any T Any N M1 Stage IV C – Any T Any N M1

Fallacies of TNM stagingFallacies of TNM staging

Depth of Primary not includedDepth of Primary not included

< 2mm - 13% nodes & 3% death< 2mm - 13% nodes & 3% death

2 to 9 mm – 46% nodes & 17% death2 to 9 mm – 46% nodes & 17% death

> 9mm – 65% nodes & 35% death > 9mm – 65% nodes & 35% death Extracapsular involvement in node not Extracapsular involvement in node not

consideredconsidered No provision for molecular markers, IHCNo provision for molecular markers, IHC

Molecular stagingMolecular staging

Molecular assays detect occult Molecular assays detect occult cancer cells previously missed by cancer cells previously missed by physical examination and standard physical examination and standard histopathologic techniques. histopathologic techniques.

Provide more objective analyses with Provide more objective analyses with fewer sampling errorsfewer sampling errors

Intra operative gene Intra operative gene probe – Pilot study probe – Pilot study showed 12 out of 30 showed 12 out of 30 patients with negative patients with negative margin were disease margin were disease free at 2 yearsfree at 2 years

To predict response to To predict response to RT – Breakpoints on RT – Breakpoints on 1p22, 3p21, 8p11, 1p22, 3p21, 8p11, distal 14q were distal 14q were resistant resistant

““Biological staging” - Biological Biological staging” - Biological behaviorbehavior

Useful in assessing cycling cellsUseful in assessing cycling cells

Precancerous lesions Precancerous lesions

Surgical tumor marginsSurgical tumor margins

Predicting aggressive behaviorPredicting aggressive behavior

Invasion frontInvasion front

Metastatic potentialMetastatic potential

““Biological staging” - Biological behaviorBiological staging” - Biological behavior Biomarker Predictors in Oral Biomarker Predictors in Oral

Precancerous & Cancerous LesionsPrecancerous & Cancerous Lesions