INTERHOSPITAL CONFERENCE

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INTER-HOSPITAL CONFERENCE

• 21 DEC.2007

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Physical examination

• Thai male, not pale, no jaundice
• v/s T 37C PR 80/min BP 120/80 mmHg
• Heart normal
• Lung clear
• Abdomen soft, not tender, no
  hepatomegaly
• Neuro sing WNL

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ENT Examination

• AR normal mucosa, no discharge
• PR no mass, no discharge
• OC ulcerative lesion at Lt. lateral tongue size
  0.5 x 0.5 cm.
• IDL no mass, TVC move bilateral
• Neck no palpable lymph node

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Management?
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• BIOPSY Negative for malignancy

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DIFFERENTIAL DIAGNOSIS
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ENT Examination

• OC ulcerative lesion at Lt. lateral tongue
  size 0.50.5 cm., submucosal lesion 23cm., no
  limited tongue movement

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INVESTIGATION
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INVESTIGATION

• A .
• B .
• C .
• D .
• E .

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DIAGNOSIS ANDMANAGEMENT
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DIAGNOSIS
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DIAGNOSIS

• CA Tongue T2N0M0

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MANAGEMENT

• Surgery?
• RT?

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MANAGEMENT

• Surgery?
• RT?

Wide excision?
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DIAGNOSIS AND MANAGEMENT

• Dx. CA Tongue T2N0M0
• Rx. Lt.Hemiglossectomy with primary closure with
  Lt. SND I-IV

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Surgical Pathology Report

• Tongue consists of Lt. half portion of tongue,
  measuring 532.5 cm. The outer surface reveals
  an ulcerated light tan firm mass, measuring
  2.71.80.8cm., occupying the Lt.half of tongue,
  0.5 cm.from medial resected margin and 0.5
  cm.from deep resected margin
• Lymph node group I-IV No evidence of malignancy

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Management

• Combine Post-Op. RT ?
• Combine Chemotherapy ?

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Management of the N0 Neck in CA Oral cavity
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Evaluation of the N0 Neck

• The reported false negative rate in assessing of
  cervical LN metastasis by palpation is 20-50
• Factor affecting
• The experience of the examiner
• The patients body
• The previous treatment Sx / RT

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Evaluation of the N0 Neck

• Structure in neck mistake
• Transverse process of atlas
• Carotid bifurcation
• Submandibular gland

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Evaluation of the N0 Neck

• Digital palpation
• CT / MRI
• Ultrasound
• Ultrasound guided FNAB

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Evaluation of the N0 Neck

• Malignancy criteria for CT/MRI
• LN gt 15 mm. in level II
• LN gt 10 mm. in other levels
• Group of 3 nodes ( 1-2 mm.)
• Central necrosis
• Loss of tissue planes ( fat plane)

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N0 Neck affecting the recurrent/survival rate

• Oral cavity CA
• Type
• N0
• 1 node
• 2 nodes
• 3 nodes

• 5 years survival
• 75
• 49
• 30
• 15

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Therapeutic modalities for the N0 neck

• Prophylactic Neck dissection
• Prophylactic Neck irradiation
• Observation with therapeutic ND once regional
  metastasis become appearance

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The N0 neck in oral cavity CA

• Byers et al the prediction of nodal metas. In
  primary oral tongue SCCA
• The depth of muscle invasion
• N stage
• The degree of differentiation of the 1 tumor
• T1N0 with muscle invasion lt 4 mm., WD
• ? 14 chance of nodal involvement

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The N0 neck in oral cavity CA

• SCCA of oral cavity the sites with lt 20 occult
  metastasis
• T1/T2 lip
• T1/T2 oral tongue lt 4 mm in thickness
• T1/T2 FOM lt 1.5 mm in thickness

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Surgical therapy in the N0 neck with oral cavity
CA

• SOHND
• Minimal morbidity
• Reduces the risk of occult disease
• Avoid the undesirable side effect of RT ( RT
  is reserved for possible future tx. of second
  primary tumor )

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RT in the N0 neck with oral cavity CA

• An alternative treatment to SOHND
• PORT of the surgically treated primary tumor
  site, the neck has not been dissected, and the
  risk of occult regional dz. is substantial
• Primary tumor is treated with RT and the risk of
  occult node gt 20

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Elective neck dissection VS Elective neck
irradiation

• ENI reduced neck failure rate in pt with control
  primary tumor and N0 neck from 18 to 1.9
• In T1N0 SCCA oral tongue, ENI provided 95
  control rate for neck recurrences compare with
  38 without ENI
• Modality is chosen to Tx primary cancer may also
  help in formulating a decision as to how to tx
  the neck

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Elective neck dissection VS Elective neck
irradiation

• Prophylactic neck RT provides equal control rate
  for neck metastasis to prophylactic ND

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THANK YOU FOR YOUR ATTENTION
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Combined modality of treatment

• perineural spread
• intravascular spread
• intralymphatic spread
• ve margin
• 2 histo. Positive LN
• multiple ve LN
• extracapsular spread

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Management of contralateral N0

• 14 incidence of involvement of contralateral
  neck node regardless of tumor stage
• If primary oral cavity cancer is midline
  location, bilaterally, along the tip of tongue or
  approaches or cross the midline

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BASIC LAB .

• CBC Hct. 36 WBC 11,200 ( N 72.2 L21 E
  2.1 M 3.9)
• BUN 5 Cr 0.5
• Na 137 K 4.3 Cl 106 CO2 25
• FBS 107
• LFT Alk.59 SGPT 12 SGOT 17 TB 0.63 TP 7.8
  Alb 4.6
• EKG Normal
• CXR No active pulmonaly lesion

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BIOPSY.

• Lt. Lateral tongue Squamous cell carcinoma,
  moderate differentiated

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_at_
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N0 in early SCCA oral cavity

• Most important prognostic factor in Mx of oral
  SCCA is status of cervical LN.
• Present of metastasis to cervical LN can reduce
  curative rate by 50
• 3 Tx options are available.
• Observation with therapeutic ND once regional
  metastasis become appearance
• Elective neck RT
• Elective neck dissection

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Morbidities of associated ENI

• Xerostomia
• Dsyphagia
• Increased oral passage time
• Mucositis
• Pain
• Increased complication if salvage sx.
• Long duration of tx.

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