INTER-HOSPITAL CONFERENCE

21 DEC.2007

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Physical examination

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

hepatomegaly• Neuro sing : WNL

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

Management?

BIOPSY : Negative for malignancy

DIFFERENTIAL DIAGNOSIS

ENT Examination

• OC : ulcerative lesion at Lt. lateral tongue size 0.5*0.5 cm., submucosal lesion 2*3cm., no limited tongue movement

INVESTIGATION

INVESTIGATION

• A .• B .• C .• D .• E .

DIAGNOSIS ANDMANAGEMENT

DIAGNOSIS

DIAGNOSIS

• CA Tongue T2N0M0

MANAGEMENT

• Surgery?• RT?

MANAGEMENT

• Surgery?• RT?

Wide excision?

DIAGNOSIS AND MANAGEMENT

• Dx. CA Tongue T2N0M0• Rx. Lt.Hemiglossectomy with

primary closure with Lt. SND I-IV

Surgical Pathology Report

• Tongue : consists of Lt. half portion of tongue, measuring 5*3*2.5 cm. The outer surface reveals an ulcerated light tan firm mass, measuring 2.7*1.8*0.8cm., 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

Management

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

Management of the N0 Neck in CA Oral cavity

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 patient’s body• The previous treatment – Sx / RT

Evaluation of the N0 Neck

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

Evaluation of the N0 Neck

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

Evaluation of the N0 Neck

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

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%

Therapeutic modalities for the N0 neck

• Prophylactic Neck dissection• Prophylactic Neck irradiation• Observation with therapeutic ND once

regional metastasis become appearance

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 < 4 mm., WD

14% chance of nodal involvement

The N0 neck in oral cavity CA

• SCCA of oral cavity the sites with < 20% occult metastasis :

• T1/T2 lip• T1/T2 oral tongue < 4 mm in thickness• T1/T2 FOM < 1.5 mm in thickness

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 )

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 > 20%

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

Elective neck dissection VS Elective neck irradiation

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

THANK YOU FOR YOUR ATTENTION

Combined modality of treatment

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

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

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

BIOPSY.

• Lt. Lateral tongue : Squamous cell carcinoma, moderate differentiated

@

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

Morbidities of associated ENI

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