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What is the 2nd most common cause of death in the US?
Cancer
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Which cancer is the most common cause of death?
Men and women: lung cancer
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How prevalent is oral cancer?
- Oral cancer is the 8th most common cancer in men.
- Not as common in women
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What is the ratio of oral cancer between men and women?
2:1 M/F
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How many cases of oral cancer exist worldwide?
8.1 million cases
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Which region has the highest incidence of oral cancers?
- Melanesia, near Australia
- More common in developed regions (smoking)
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How many cancer cases are oral cancer?
3%
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Signs and symptoms of oral cancer
- Non-healing ulcer
- White/red patch on gums, tongue, oral lining
- difficulty chewing/swallowing
- Numbness in the mouth
- Soreness
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Where are ulcers most suspicious?
Dorsal tongue and floor of the mouth
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Oral tissue inspection list (know well)
- Discoloration
- Ulceration
- Dryness
- Swelling
- Extraoral salivary gland exam (lymphatic, fmx, probing)
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What is the first area you check when screening for oral cancer?
Lymph nodes
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Difference in painful vs. painless lymph palpation
- Painless: possibly metastatic cancer!
- Painful: inflammatory process
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What is the most common type of oral cancer?
Squamous cell carcinomas
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What most effectively improves morbidity and mortality of oral cancer?
Early detection and screening
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Environmental risk factors of oral cancer
- Tobacco- most common risk factor
- Alcohol
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Non-environmental risk factors of oral cancer
- Genetic predisposition (oncogenes, tumor suppressor genes)
- Human papilloma viruses
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5 year survival rates for blacks and whites
- Black: 40%, peak mortality age 55-64 years
- White: 60%, peak mortality age >75 years
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How many oral cancer patients smoke?
9/10 oral cancer patients smoke
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What element in tobacco has been isolated to induce buccal carcinoma?
Hydrocarbons (benzopyrene)
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White lesions associated with smoking
- Nicotinic stomatits
- tobacco pouch
- submucous fibrosis
- pipe smokers
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Nicotinic stomatitis
- Associated with pipe/cigar smoking
- Correlation with severity and smoking intensity
- Greatly increased by reverse smoking
- Increased keratinization(opaque with red dots- salivary ducts)
- Entire palate is white
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Chewing tobacco pouch
- Placed in mucobuccal fold
- Changes occur in cheek mucosa
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Submucous fibrosis
- Thick, leathery buccal mucosa
- Chronic ulceration
- Moderate trismus (fibrosis of TMJ)
- Indian male betel quid use
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Which diet can prevent HNSCC and precancer?
- Diets rich in fresh fruits and vegetables
- Vitamin A
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What are biomarkers used for?
- To measure the progress of disease
- To measure treatment effects
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What are the two most common tumor suppressor genes?
p53 and p16
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What are the three apoptotic genes?
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Which virus plays a role in oropharyngeal carcinomas?
Human papilloma virus (HPV)
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What are the two proliferative markers?
- PCNA (proliferating Cell Nuclear Antigen)
- Nuclear protein (Ki-67)
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What are oncogenes?
- Control cell growth, proliferation, and differentiation
- Can mutate to produce abnormal products or overexpress genes
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p53 Tumor suppressor gene
- Important role in normal growth and differentiation
- Mutation inactivation can result in a tumorFound on chromosome 17
- Mutated in 45% of SCC
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Human papilloma virus
- 100+ types
- HPV 6 and 11- condylomas and papillomasHPV 16 and 18- tumorogenic in epithelial cells
- E6 and E7-
viral oncoproteins in HPV 16 and 18. inactivate p53
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Where is HPV mostly present?
- In young female tongue SCC (non smokers and non drinkers)
- HPV 16 in 25% of HNSCC (oropharynx and tonsillar)
- HPV is positive in 4-12% of oral cavity SCC
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What are the two HPV vaccines available?
- Gardasil- against HPV 6, 11, 16, 18 (quadrivalent)
- -prevents genital warts in both genders
- Cervarix- against HPV 16, 18 (bivalent)
- -does not protect against genital warts
- -high risk vaccine
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What are the dosage recommendations for Gardasil and Cervarix?
Both are given in 3 doses at 6 month intervals
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At what age should females receive the HPV vaccine?
- 11-12 years or 13-26 if not previously vaccinated
- As young as age 9 if high risk
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Which has a better prognosis, HPV + or - SCC?
HPV + has a better prognosis
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What is the order of oral cancer progression?
- 1. Benign squamous hyperplasia
- 2. Dysplasia
- 3. Carcinoma in-situ
- 4. Carcinoma
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- Intraepithelial neoplasia
- Invasion of CT has not occurred yet
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- Squamous cell carcinoma
- Invasion of the connective tissue
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Leukoplakia vs. Erythroplakia
- Leukoplakia- 15% dysplasia and 20% CA development
- Erythroplakia- 90% dysplasia and >75% CA development
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Leukoplakia
- White patches that don't rub off
- Wide range of clinical and microscopic presentations
- usually related to localized irritation
- Most are benign
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Leukoplakia of ventral tongue surfaces and floor of mouth
- Hardest areas to access
- Likely cancer (few physical trauma sources)
- Likely will need surgery
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What are the 3 types of oral cancer staging (TNM system)
- Size of tumor
- Degree of local invasion
- Extent of spread-metastasis
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Stages of Oral cancer spread
- 0- Carcinoma in situ
- 1- confined to site of origin
- 2- cancer is locally invasive
- ---progression around 41 months---
- 3- spread to regional structures
- 4- spread to distant sites
- after stage 4, unresectable in 4 months
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Second primary tumors
- Known consequence of oral SCC
- 25-40% develop SPT over time
- Does not improve with smoking cessation
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Three levels of Oral cancer reduction
- 1. Primary prevention (tobacco)
- 2. Secondary prevention (screening, early detection)
- 3. Improved treatment
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Oral brush biopsy
- Detection of precancerous and cancerous mouth lesions
- Complete transepithelial tissue sample
- Not a definitive diagnostic tool
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Toluidene blue
- Basic thiazine metachromatic dye with nucleic acid affinity
- Used for suspicious malignant lesions
- Stains actively growing tissues
- Only retained in dysplastic sites
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What part of an ulcerated lesion do you biopsy
The borders, not the middle!
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oral speculoscopy
- Visualizes leukoplakic areas
- Uses diffuse chemiluminescent lightDetects atypical or dysplastic mucosal abnormalities
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Velscope
- Visually enhanced lesion scope
- Watch for changes in color
- Emits a pale green fluorescence normally
- Dysplastic and early tumor cells appear green to black
- -loss of fluorescence
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What is the only tool that can confirm oral cancer diagnosis?
BIOPSY
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Which HPV strains can cause oral cancer?
16 and 18
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Which is more likely cancerous, moveable or fixed lymph nodes?
Fixed lymph nodes are more likely cancerous
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Do SPTs usually occur in the primary site?
No. Remember they are secondary
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What percent of leukoplakia lesions progress to cancer?
10-20%
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