Oral+Cavity

Oral cavity cancer is cancer formed in the mouth. 95% of these cases have a designation of squamous cell carcinoma, and are created from the thin, flat squamous cells that line the lips and the oral cavity. 1 These normally occurring squamous cells are influenced by carcinogenic factors such as smoking tobacco, consuming alcohol, exposure to human papillomavirus (HPV), specifically type 16, and exposure to natural and/or artificial sunlight for long periods of time. Males are more than two times more commonly diagnosed with cancers of the oral cavity than women. Also, patients after hematopoietic stem cell transplantation (HSCT), are at a higher risk for oral squamous cell carcinoma. 2
 * **Epidemiolgy:** || Megan

Nearly 37,000 Americans were diagnosed with oral or pharyngeal cancers in 2011. 2 Since these diagnoses are predominantly established at a later stage, 66% of the 37,000 effected will be termed late stage, causing 8,000 deaths. The life expectancy is less than 5 years for half of the 37,000. 2 This number places oral cancer as a higher killer not only over cervical cancer, but higher than Hodgkin’s lymphoma, testicular cancer, laryngeal cancer, thyroid and skin cancer. A primary reason for this is the low public awareness associated with oral cancers. A simple visit to the dentist or trained medical professional can alleviate concern and allow these cancers to be diagnosed much earlier. || The following are the most common symptoms of oral cavity cancer. 3 Although there are a variety of different methods for obtaining diagnostic imaging, one of the most common methods to early diagnosis is self-screening. Some of the early signs that could indicate further investigation can include a sore lesion in mouth, a lump or thickening in cheeks, a sore throat that will not go away, and chronic horseness. 5 With this area also being a commonplace for dental checks, your dentist can also check into any issues that may arise.
 * **Etiology:** || Kevin Tsai/Pablo
 * Smoking, cigarette and other Tabaco related products
 * Excessive alcohol abuse
 * Family History of cancer
 * Certain diets
 * Human Papilloma Virus (HPV)
 * Excessive sun exposure. 3 ||
 * **Signs & Symptoms:** || Erin/Pablo
 * Erythoplakia, (a red lesion in the oral cavity)
 * An ulcer that will not heal
 * A lump inside the oral cavity
 * Cervical lymph node enlargement and is palpable ||
 * **Diagnostic Procedures:** || Spencer

- CT: One of the first diagnostic procedures for oral cavity cancers is a Computed Tomography scan (CT). Although this scan allows great diagnostic visibility and possible future treatment planning information, it lacks the capability of viewing more than just the solid mass within the structure.

- Exfoliative Cytology: One of the less invasive procedures used for checking and diagnosing oral cancers is done by exfoliative cytology. This process involves the use of a cotton swab or wooden stick to obtain a sample of cells from the lip or mouth. The cells are then checked under a microscope to assess if anything is abnormal. 6

- MRI: The next diagnostic procedure used in these cases is the Magnetic Resonance Imaging (MRI). This scan allows for great diagnostic visibility of the tumor volume when contrasted against the area it is contained in. Sometimes this procedure is used solely in diagnostic imaging, or combined with future scan for treatment planning in radiation oncology.

- PET: Another form of diagnostic imaging within oral cancers is Positron Emission Tomography (PET). This type of diagnostic procedures involves the integration of actual metabolism and where in your body it is being taken up the most. 5 This process allows physicians to check different areas of the body and track down where they think the tumor is involved.

- Radionuclide Scanning: One of the last types of diagnostic procedures used in this form of cancer is radionuclide scanning. This process involves the patient either swallowing or getting an injection of a radioactive substance. The patient then receives a scan to determine if certain areas of the body have higher or lower readings. || There are many types of neoplasms that can arise in the oral cavity. Squamous cell carcinomas constitute over 90% of malignancies.6 Others less common neoplasms include carcinomas, lymphomas, sarcomas and melanomas. Squamous cell carcinomas are classified depending on their degree of cell differentiation. There are three subtypes of squamous cell carcinomas defined. 1) Well differentiated exhibiting over 75% keratinization, 2) moderately differentiated 25-75% keratinization, and poorly differentiated with less than 25% keratinization.4 Of the earliest morphological changes that are detected and associated with cancerous malignancies Leukoplakia is the most common. This condition is manifested by a persistent white plaque which is a hyperplasia of keratinocytes cells. Erythroplakia is a red lesion in the mouth that may also appear in the oral cavity as a precursor to oral cancer. || v The upper lip drains mostly to the submandibular nodes. v The lower lip lymphatics drain to the submandibular and posterior to subdiagastric lymph nodes. v Lower gingival drains to the submandibular and subdigastric lymph nodes. v Floor of mouth drains to the submandibular and subdigastric lymph nodes. v Oral tongue primary lymphatic drainage is to the subdigastric and submandibular lymph nodes. Lymphatic trunk drainage that bypasses the primary lymphatic drainage goes to the midjugular lymph nodes. v Buccal mucosa drains mainly to submandibular and subdigastric nodes. 4
 * **Histology** : || Pablo
 * **Lymph node drainage:** || Becky

|| Metastatic spread is a condition in which cancer cells from a particular site travel through the body and cause new tumors in other areas outside of the original disease. The cancer cells travel through the bloodstream or lymphatics, and while certain cancers have a tendency to metastasize in certain ways, there isn't always a reliable method of determining the origin. The oral cavity is a fairly uncommon region for metastases to spread to, and is usually a sign that the disease has already spread significantly. 7 Due to its infrequency, metastatic spread to the oral cavity can be difficult to diagnose. 7 For men, cancers of the lung, prostate, and kidney are the most common sources of metastasis to the oral cavity. For women, breast and adrenal cancers are the most common. 7 Image demonstrating the process of metastasis. 8 || The definitions of the G categories apply to all head and neck sites except thyroid. These are:
 * **Metastatic spread:** || Adam
 * **Grading:** || Megan

G - Histopathological Grading GX - Grade of differentiation cannot be assessed G1 - Well differentiated G2 - Moderately differentiated G3 - Poorly differentiated G4 - Undifferentiated

Differentiation: When grading a tumor of the oral cavity, a determination must be performed to establish the maturity or development of the cancer cells. Differentiated tumor cells look and act like normal cells and grow and spread at a slower rate than undifferentiated or poorly differentiated tumor cells, “which lack the structure and function of normal cells and grow uncontrollably.” 4 “In other words, poorly differentiated tumors are able to cross all boundaries of tissue types (muscle, soft tissue, etc.), even into bone.” 4

Invasive: Another term commonly used when describing a disease state is invasiveness. For instance, if the tumor is focally invasive, it means that the tumor is limited to a specific area. 4 || American Joint Committee on Cancer staging system for oral cavity cancer. 4  || Some of the most common side effects of radiation therapy to the oral cavity include. 4 Much of the prognosis of oral cancers depend on a few different factors: - Stage - Which stage the cancer is initially found in. - Location - Where the cancer is within the oral cavity. - Spread - The location where the cancer has spread to.
 * **Staging:** || Kevin Tsai/Pablo
 * **Radiation side effects:** || Erin/Pablo
 * Xerostomia, also know as cotton mouth or dry mouth
 * The mandible may become necrotic, depending on the field of treatment and dose given
 * Mucositis
 * Dysphasia
 * Trismus ||
 * **Prognosis:** || Spencer

From data that has been collected from 18 geographical areas and over the years of 2003-2009, the overall 5-year relative survival rate for oral cancer was 62.2%. 6 ||  ||   ||   || The choice of treatment for malignancies of the oral cavity depend on the type of cancer, the extent of the disease at the time of diagnosis, the possible side effects of treatment, if the treatment has palliative or curative intent and/or the patient’s preference. There are basically three modalities used to treat oral cavity cancer: Surgery, radiation therapy and chemotherapy. A combination of any of these modalities is also possible. Surgery is an option for when the disease has no distant metastasis such as carcinoma in situ. For Stages I and II, this may also be an option combined with radiation and or chemotherapy. Radiation therapy is employed for curative and or palliative cases. It can be delivered externally or via Brachytherapy depending on the particular disease and patient’s status. Patients must have dental clearance prior to receiving radiation therapy. Any dental care or tooth extractions must be addresses prior to treatment. Some of the most basic treatment techniques include lateral opposed fields. More recent techniques include Intensity Modulated Radiation Therapy (IMRT) and Volumetric Modulated Arc Therapy (VMAT). The following are general guidelines for external radiation therapy. Radiation therapy alone, 70 to 76 Gray (Gy) in 6 to 8 weeks, pre-operative radiation 46 to 50Gy in 5 to 6 weeks, post-operative radiation 60 to 66Gy in 6 to 7 weeks. Patients can also be treated using Brachytherapy. The following doses are usually followed when using brachytherapy. Alone 60 to 70Gy in 6 to 7 days, if a combination of external and Brachytherapy is used the patient usually receives 46 to 50Gy in 4 to 5 weeks externally and a boost of 20 to 30Gy in 2 to 3 days with Brachytherapy.³ Another treatment choice for patients with oral cancer is chemotherapy which uses cancer fighting drugs given intravenously and or by mouth that can be very effective at fighting cancer. Unfortunately these drugs have some unwanted side effects which can be severe and some patients may not be able to tolerate. Some of the most commonly used chemotherapy drugs include Cisplatin, 5-fluorouracil (5-FU), Carboplatin and Methotrexate among others.⁴
 * **Treatments:** || Pablo

The image above shows an oral cavity conventional radiation field. Submental, submandibular and subdigastric lymph nodes are included in the treatment field. A bite block is used to maintain the tongue in a desired position. || Tissue dose associated with 5% injury rate within 5 years. Ear: 3000cGy—Acute serous otitis Optic chiasma: 4500cGy—blindness Eye lens: 1000cGy—cataracts Optic nerve: 5000cGy—blindness Salivary gland: 5000cGy—Xerostomia Spinal cord: 4500cGy--Myelitis Oral cavity: 6000cGy--ulceration.9 ||
 * **TD 5/5:** || Becky
 * **References:** || Adam

> & Wilkins; 2002.
 * 1) National Cancer Institute. General Information about Lip and Oral Cavity cancer. Last modified May 9, 2013.http://www.cancer.gov/cancertopics/pdq/treatment/lip-and-oral-cavity/Patient/page1. Accessed May 30, 2013.
 * 2) Wikipedia. Oral Cancer. Last modified May 27, 2013. http://en.wikipedia.org/wiki/Oral_cancer. Accessed May 30, 2013.
 * 3) Oral Cancer Foundation. Stages of cancer of the lip and oral cavity. 2013. http://www.oralcancerfoundation.org/facts/stages_cancer.htm. Accessed May 30, 2013.
 * 4) Chao, K, Perez, C, Brady, L. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams
 * 1) National Cancer Institute. National Cancer Institute Web Site. http://www.cancer.gov/cancertopics/types/oral. Accessed May 28, 2013.
 * 2) The Oral Cancer Foundation. The Oral Cancer Foundation Web Site. http://oralcancerfoundation.org/. Accessed May 28, 2013.
 * 3) Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, Berger R. Metastatic tumors to the oral cavity - Pathogenesis and analysis of 673 cases. Oral Oncology. 2008; 44(8):743-752.
 * 4) Angiogenesis - National Cancer Institute. National Cancer Institute Web Site. http://www.cancer.gov/cancertopics/understandingcancer/angiogenesis/AllPages. Accessed May 28, 2013.
 * 5) Vonkadich AC. Overview of radiobiology. In: Washington CM, Leaver D, eds. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010:57-83. ||

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