Cancer, sarcoma of the soft tissues of the mouth and face, facial bones skull. Plastic defects of the jaws and soft tissues MFA. X-ray diagnosis of malignant tumors, differential diagnosis and treatment.
Facial Tumors
Malignant tumors of the lower and upper jaw among the malignant tumors of the maxillofacial area maxillary cancer occurs in 1-4 % of cases. In one case of sarcoma of the upper jaw have four cases of cancer of the same location. Cancer of the mandible occurs several times rarer than carcinoma of the maxillary jaw. In men cancer is more common , usually between the ages of 40-60 years. Cancerous lesions divided into primary and secondary. Primary cancer of the tissue of the jaw may develop from epithelial remnants Hertvigov membrane or perhaps element cyst wall . In secondary cancer primary focus for more than half the cases located in the maxillary sinus or oral mucosa . Therefore unlikely to enter properly , highlighting secondary malignant tumors of the jaws – in these cases, in fact it is a cancer of the mucous membrane of the alveolar ridge, floor of the mouth , palate and other surrounding organs and tissue that grows in the jaw , which is involved in the process later. Sometimes it is difficult to determine the origins of the original fireplace. Most affected area larger molars . The process extends to the bottom of the mouth, a branch of the mandible , the temporal and submaxillary area and neck. In the central cancer process is initially closed and sponge affected jaw. The surrounding soft tissues are involved in the process after the destruction of the cortical layer. Sarcomas can develop with the jaws periosteum, cortical layer of spongy material elements of the bone marrow , as well as odontogenic structures – ameloblast fibrosarcoma and ameloblast odontosarkoma . With a central location sarcoma sponge filled with tumor, bone gradually thickens and form areas of destruction. Sarcomas that developed from the periosteum, usually grow outward , pushing the soft tissue. Deformation of the bone does not occur immediately .Metastasis in cancer of the upper and lower jaws is rare and usually occurs lymphogenous . Metastases tend to occur in the submaxillary area and pretty soon fused with the lower jaw, and then infiltrate the skin. In advanced cases there is metastasis to the liver, spine, lungs and other distant organs . However, it is rarely metastasize to the lymph nodes of the neck and distant organs not observed. In sarcoma of the mandible metastases in distant organs are rare , and in regional lymph nodes are not usually occur. The secondary (metastatic) tumor of the mandible occurs much less frequently than primary, and are more common in women. Metastasis to the lower jaw can occur in breast cancer, lung, kidney, stomach, thyroid, prostate , colon and other organs. The clinical course of malignant tumors of the jaws is wide. In the central cancer tumor growth is hidden and this period lasts long enough. In other cases, the process is evident appearance of alleged gratuitous pain that are frequently shooting nature along the mandibular nerve or similar pain in pulpitis. Often the first sign of intraosseous malignant tumors are abnormal tooth mobility. All these symptoms can appear as if a small tumor, and with a significant distribution process. Described cases in which patients first turned to the doctor about pathological fracture of the mandible. From the mucous membrane of the alveolar margin is not rare to find a narrow ulcer, which is a long time not increasing, although the spread of tumors in the bone is very fast. Further process causes deformation of the face in the distribution of infiltration in the chin and the bottom of the mouth. In the later stages of the process involved submaxillary salivary gland, parotid then increases tumor ulceration of the mouth and align inflammation. Amplified pain, limited mouth opening . Then tumor infiltration extends to chewing and internal pterygoid muscles , the tonsils with arches and soft palate , the lateral wall of the pharynx. Disturbed digestion and develop cachexia .Development of sarcomas of the jaws is much faster than cancer. The displacement and deformation of the tissue is more pronounced because patients often go to the doctor with complaints of swelling in the region of the cheek or jaw . The tumor , which further increases , it becomes painful to the touch, having shooting pains. They rapidly increase and become extremely violent. Shakiness teeth – an early sign. Sometimes some osteogenic sarcoma of the jaws are characterized by a long course that is sometimes years. In such cases, metastasis to distant organs develop more than sarcoma with rapid clinical course. The lower jaw is sometimes develop chondrosarcoma or hondromiksosarkoma . They are also characterized by a rapid clinical course and are subject to significant spread to nearby tissues and organs.For efficient treatment and prognosis thoughts about the most important to have informatioot only on the morphological type of tumor , but its incidence. According to TNM system malignancies jaws are classified as follows:
The degree of spread of the primary tumor :
TI tumor affects one anatomical site;
T2 tumor affects no more than two anatomical parts;
TK tumor affects more than two anatomical parts;
T4 tumor affects most of the body and spreads to other systems .
The clinical course of cancer to surrounding tissues and organs of germination in the jaw depends on concomitant inflammation. Patients usually start early harass small ulcer on the mucous membrane of the alveolar region. They can look good and often immediately established causes of ulcers . Inflammatory changes may be caused by other factors: the presence of decayed teeth , dentures obsolete , and so on. Should immediately eliminate the cause of ulcers and to follow her healing . If this happens , you should suspect cancer development . This is especially true for patients who have pain in the ulcers grow out of it or recurrent bleeding. Later ulceration or infiltration increases over time begin to loose teeth. In most cases, these patients have dentists, conducted anti-inflammatory treatment because of them depends largely on early diagnosis of malignant tumors of the jaws. Unfortunately, clinical experience shows that the time between onset and holding special treatment is often calculated monthly. Diagnosis of malignant tumors of the jaws is based on a careful study of the clinical course of the disease, X-ray pattern and morphological data. In cancer of all departments jaws of great value represents X-ray technique that detects early advancing destructive changes in bone. X-rays in the early stages of cancer and sarcoma is usually thinning bones. The affected area has no clear boundaries, they seem washed out. With the localization of foci in the area of alveolar cortical plate of the walls destroyed, and the circle is defined by a broad zone of destruction spongy substance. In common processes observed on radiographs complete destruction of a section of bone. Osteogenic sarcoma iature has osteolytic destruction, osteoblast or mixed. Seal the affected bone and dense inclusion pozakistkovomu component of the tumor are also characteristic of chondrosarcoma. A punctate cytology and biopsy of the tumor . Are required to tell the mandatory morphological examination of tissue removed from the surface of the teeth in their mobility. Always try to find out why teeth are moving. Upon germination cancer mucosa or other tissues in the jaw when the lesion area by a well , you need to punctate cytology or biopsy impression and implement . X-ray method helps to determine the nature of the fracture zone and alveolar margin of the jaw.
Treatment
In the treatment of malignant tumors of the mandibular first need to dental health . Remove from the site and location of tumors driven by carious teeth should not be due to the danger dessimination cancer cells. In cases where the planned radiotherapy to prevent burns to remove metal prostheses.Small malignant tumors of the jaws when the process is limited to one anatomical part of the body and invades the periosteum is removed by resection with primary jaw bone plastic. When was performed preoperative radiation therapy after resection of the mandible should not be delayed bone plastic. However, the operation should be carried out not earlier than 3 weeks after exposure – in these terms creates best conditions to catch on bone graft. Many radiologists believe that the best method of treatment of malignant tumors of the mandible are combined: preoperative radiotherapy and radical surgery . However, a number of surgeons and dentists limited to surgery or radiotherapy is carried out after the operation. Preoperative irradiation is carried out by remote gamma- therapy. Radiotherapy is carried out daily , the number of fields defined depending on the size of the tumor and the presence of regional metastases. The total dose of 40-50 Gray. Surgery performed 3 weeks after irradiation , when radiation reaction is usually skin and oral mucosa are reduced. Before surgery required to produce tires or gears to maintain the correct position of the mandible fragments. Depending on the prevalence of the process must also determine the volume of removal of surrounding soft tissue and the ability to perform primary bone grafting .
Cancer of lower lip
Etiologic factors contributing to the occurrence of cancer of the lower lip , like insolation, wind , the effect of thermal factors . The incidence of cancer of the lower lip (WP ) is about 5 cases per 100 thousand population. Suffering from RG mostly men aged 50 – 60 years. As a result of various not good environmental factors , smoking cigarettes and breach of oral health on the red fringe lower lip there regenerative changes ( dyskeratoz ). This damage can take the red fringe the entire surface (diffuse dyskeratosis).
Hyperkeratosis of lower lip – or a part of it ( focal dyskeratosis ). The greatest potency to malignancy with focal dyskeratosis and papilloma . Fireplace dyskeratosis occur in two forms: productive and destructive . Productive forms are characterized by the presence of pockets of excessive keratinization and leukoplakia , otherwise it fires hyperkeratosis with finger appendages ( cutaneous horn) . For destructive forms of focal dyskeratosis characteristic appearance of erosions, fissures, ulceration of epithelial appendages around the edges.
Diagnosis
In erosive forms dyskeratoziv – smear marks. In other cases – incisional biopsy.
Treatment
Diffuse dyskeratoz – use protective ointments, and in the case heylita Manhanotti – sometimes excision red border . When dyskeratosis is focal cryosurgery performed. To distinguish between exophytic and endophytic form of WG. By exophytic forms are papillary and warty .
Lower lip cancer T1N0M0
By endophytic – ulcer. Lower lip cancer T2N0M0 , peptic form of lower lip cancer T3N0M0 , ulcerative infiltrative form.
Early signs of malignancy or papilloma dyskeratosis lips invisible. Slight compression basics there always. Later, progressive growth, ulceration and infiltration of underlying tissues is the hallmark of all forms of WG.
Lower lip cancer T1N0M0 , commissural form characteristic regional metastasis to the lymph nodes and submandibular submental sites.
Metastasis of cancer of the lower lip and submental area. The second stage of lymph outflow accordingly metastasis.
Metastasis of cancer of the lower lip deep cervical lymph nodes. Diagnosis is based on clinical data , conducted cytology ( smears , puncture site ), and the negative results produced incisional biopsy. Certain information metastasis to regional lymph nodes neck gives ultrasound of the neck. WP Treatment depends on the stage of growth and form tumors.
Stage I ( T1 ) – surgery ( rare) , mostly b / f X-ray therapeutic , cryosurgery . Stage II ( T2) – b / f X-ray therapeutic or resection of the lips. Deal with lower lip cancer . Phase III ( T3N1 ) – the first stage – irradiation of the tumor and regional lymph areas (40 – 50 Gy) , after 3 weeks – lips resection ( with obligatory plastic ) + Vanaha operation . Stage IV – distant metastases without treatment such as in stage III , radiotherapy combined with regional chemotherapy.
CANCER OF ORAL CAVITY AND Tongue. Cancer of the tongue is 2 % of all malignancies and approximately 60% of all malignant tumors of the oral mucosa . Cancer of the tongue is observed more in men aged 40 to 70 years. Found that most often it occurs in
Pathological Anatomy
Cancer usually affects the lateral parts of the tongue (65% ). The second frequency localized cancer is the root of the tongue (20 %). There are three major growth forms of tongue cancer : papillary , endophytic and stomach . Papillary form a kind of dense outgrowth of mucosa . Originally grow coated unchanged mucosa , and the further development of the tumor ulcer appears . Stomach cancer is more common form . It is characterized by ulcers with thick like platen thickened edges. Ulcer increases in size , area of compression along its edges expanded, but no deep infiltration of the underlying tissues . In infiltrative form of cancer in the thickness of the tongue palpation defined dense tumor without clear boundaries . Increasing the tumor affects muscle tissue, and ulceration of the mucous membrane appears much later. Infiltrative form of cancer occurs most malignant. Histologically, almost all forms of cancer of the tongue squamous , keratinizing , less – not sqaumous . Recently more common in the posterior part of the tongue.
CLASSIFICATION OF CANCER mucous membrane of oral cavityTNM
Clinical Classification
T – primary tumor
Tx – not enough data to assess the primary tumor ;
So – a primary tumor is not determined ;
Tis – carcinoma in situ;
TI – tumor 2 cm in greatest dimension ;
T2 – tumor 4 cm in greatest dimension ;
TC – Tumor more than 4 cm in greatest dimension ;
T4 – tumor which invades into adjacent structures such as cartilage, skeletal muscle , or bone.
Note: In case of multiple synchronous tumors indicated a tumor with the highest T category , and the number of individual tumors is indicated in parentheses, eg, T2 (5).
N – Regional lymph nodes
Nh – not enough data to assess the status of regional lymph nodes ,
Nr – no signs of regional lymph nodes;
N1 – existing metastases in regional lymph nodes.
M – distant metastases
Mx – ne enough data to identify distant metastases ;
Mo – distant metastases not detected ;
M1 – there are distant metastases .
Clinic.
Initial stages of cancer of the tongue goes unnoticed . The tumor may appear as a painless compression in the thickness of the tongue, in the form of warty seal papillomavirus , or in the form shallow ulcers. Sealing zone gradually increases ulcer is large, the bottom of it at first red- gray, necrotic appears bad tumor breaks . Joining inflammation causes pain that becomes unbearable when eating , when examining your mouth with your finger. Because of the pain, but also because of the germination of the tongue tumor moves his limited , patients refuse a meal, following exhaustion. Often soon after the onset of cancer in the neck appear painless enlarged lymph nodes. This process is called metastasis of cancer cells and the development of deep lymph node metastases or infection in the lymph nodes and development they hyperplasia. A distinctive feature is their metastases expressed density, painless , spherical shape. In the later stages of metastasis in the neck formed dense conglomerates fixed nodes , often with ulceration .Diagnosis . Cancer of the tongue is easy to diagnose . Diagnosis is based on the above symptoms. When examining a patient with a tumor of the tongue is mandatory palpation of all its departments and neck. The diagnosis of cancer of the tongue confirmed by biopsy, cytology scraping or reflection from the surface of tumor ulceration.To confirm metastases in the neck using the method punctate cytology of enlarged lymph nodes.
Treatment. In cancer of the tongue treatment by combined method consisting of two phases. Originally performed preoperative remote gamma- therapy. After 2-3 weeks held electrosurgical resection of the tongue. Volume of transactions depends on the stage of the disease. In stage I and II produced half of tongue resection (Figure ), and stage III – extended operation (Figure). In the second phase ( after treatment of the primary tumor ) is cover – fascial tissue removal with metastases or neck surgery Kraylya .Cancer is the root of the tongue is more sensitive to radiation therapy , because from the beginning she is appointed by the radical program. In the absence of complete tumor regression by extended operation. Results of treatment and prognosis in cancer of the tongue depends on the location, shape of tumor growth, disease stage . Best results are obtained when treatment exophytic tumors localized in the anterior tongue with stage I and II . 5-year survival after treatment of these patients is 50-70%. Infiltrative tumors localized in the posterior part of the tongue, with poor prognosis .
Skin Tumors
There are three well-known types of malignant skin tumors. In all of them the ultraviolet rays from the sun plays a significant etiological role. The most common one is basal cell carcinoma or basaloma, which does not metastasize and is the more benign of the three types. Sometimes it grows very aggressively with a great tendency for recurrence, and destroys underlying tissue, bone, cartilage etc., with pronounced cosmetic and functional defects as a consequence. Malignant melanoma is the type of tumor presently increasing the most in incidence. It spreads both through lymphatic pathways and hematogenously, and in the long term has a bad prognosis, especially if the tumor is not discovered until it has grown deep into the skin. It is usually pigmented by the melanin in the melanocytes. This may not always be the case, as so-called amelanotic , i e not blue or brown colored, melanomas exist. Squamous cell carcinoma, like the other two, has the face as the predictive location. It spreads to regional lymphatic glands and requires very vigorous surgical treatment and/or radiotherapy.
The majority of skin lesions in the face are benign and sometimes difficult to distinguish from the malignant variety. As a rule of thumb, new skin lesions that will not heal, and color changes in a lentigo, must be referred to a specialist. If the patient inquires about a skin lesion he should always be referred for evaluation, and usually, excision.
Lip Tumors
The lips are not defined as belonging to the oral cavity in the TNM-system, and are therefore mentioned separately here. Among the benign conditions hemangiomas are not unusual. They are found on the mucosal side of the lip, have a bluish hue and can be compressed to make the color disappear. They bleed when bitten, and are usually easy, if not too large, to remove surgically. Large hemangiomas may occasionally require radiotherapy or laser treatment.
Squamous cell carcinoma is considered to be the only malignant tumor on the lip, and has an incidence of more than 200 cases per year in
Salivary Gland Tumors
Mucocele is the most common lesion in the minor salivary glands with a prevalence of 0.1 per cent [3]. It is localized in the lips, mainly the lower lip and cheeks. It is not a real tumor, but rather mucus retention in one or several of the minor salivary glands in the lip mucosa. In the upper lip adenomas can be found, requiring fine-needle puncture to secure the diagnosis. The lesions are benign but often traumatized, e g when chewing or in connection with bad bite habits, and excision is recommended.
The minor salivary glands in the oral cavity can sometimes develop malignant tumors. As a rule, tumors in the minor salivary glands have a greater tendency towards malignancy compared to tumors in the major salivary glands (parotic, submandibular and lingual). They are usually covered by mucosa and mainly found in the hard palate. Adenocystic carcinoma dominates (50 %), followed by mucoepidemoid cancer while pleomorphous adenoma is a benign type of tumor that exists in only 10 per cent of the minor and in 85 per cent of the major salivary glands. Adenocystic carcinoma has a major recurrence tendency. Surgery entails resectioning of part of the soft and hard palate which communicates directly with the nose or jaw cavities.
Oral Cancer
Cancer is defined as the uncontrollable growth of cells that invade and cause damage to surrounding tissue. Oral cancer appears as a growth or sore in the mouth that does not go away. Oral cancer, which includes cancers of the lips, tongue, cheeks, floor of the mouth, hard and soft palate, sinuses, and pharynx (throat), can be life threatening if not diagnosed and treated early.
What Are the Symptoms of Oral Cancer?
The most common symptoms of oral cancer include:
Swellings/thickenings, lumps or bumps, rough spots/crusts/or eroded areas on the lips, gums, or other areas inside the mouth
The development of velvety white, red, or speckled (white and red) patches in the mouth
Unexplained bleeding in the mouth
Unexplained numbness, loss of feeling, or pain/tenderness in any area of the face, mouth, or neck
Persistent sores on the face, neck, or mouth that bleed easily and do not heal within 2 weeks
A soreness or feeling that something is caught in the back of the throat
Difficulty chewing or swallowing, speaking, or moving the jaw or tongue
Hoarseness, chronic sore throat, or change in voice
Ear pain
A change in the way your teeth or dentures fit together
Dramatic weight loss
If you notice any of these changes, contact your dentist or health care professional immediately.
Who Gets Oral Cancer?
According to the American Cancer Society, men face twice the risk of developing oral cancer as women, and men who are over age 50 face the greatest risk. It’s estimated that over 35,000 people in the U.S. received a diagnosis of oral cancer in 2008.
Risk factors for the development of oral cancer include:
Smoking. Cigarette, cigar, or pipe smokers are six times more likely than nonsmokers to develop oral cancers.
Smokeless tobacco users. Users of dip, snuff, or chewing tobacco products are 50 times more likely to develop cancers of the cheek, gums, and lining of the lips.
Excessive consumption of alcohol. Oral cancers are about six times more common in drinkers than in nondrinkers.
Family history of cancer.
Excessive sun exposure, especially at a young age.
It is important to note that over 25% of all oral cancers occur in people who do not smoke and who only drink alcohol occasionally.
What Is the Outlook for People With Oral Cancer?
The overall 1-year survival rate for patients with all stages of oral cavity and pharynx cancers is 81%. The 5- and 10-year survival rates are 56% and 41%, respectively.
How Is Oral Cancer Diagnosed?
As part of your routine dental exam, your dentist will conduct an oral cancer screening exam. More specifically, your dentist will feel for any lumps or irregular tissue changes in your neck, head, face, and oral cavity. When examining your mouth, your dentist will look for any sores or discolored tissue as well as check for any signs and symptoms mentioned above.
Dentist may perform an oral brush biopsy if he or she sees tissue in your mouth that looks suspicious. This test is painless and involves taking a small sample of the tissue and analyzing it for abnormal cells. Alternatively, if the tissue looks more suspicious, your dentist may recommend a scalpel biopsy. This procedure usually requires local anesthesia and may be performed by your dentist or a specialist. These tests are necessary to detect oral cancer early, before it has had a chance to progress and spread.
Around 1,900 people are diagnosed with cancer of the tongue each year in the
Mouth cancer is more common in people over 45 and it affects more men than women. Most mouth cancers develop from cells that line the mouth or cover the tongue and are called squamous cell cancers.
The area of the mouth (oral cavity) includes the:
lips
front two-thirds of the tongue
upper and lower gums
inside lining of the cheeks and lips
floor of the mouth, under the tongue
roof of the mouth (the hard palate)
area behind the wisdom teeth.
Causes of mouth cancer Back to top
The main causes of mouth cancers are smoking and drinking heavily, and the risk is greater if you do both. Other causes include chewing tobacco or chewing betel or paan, which is a cultural tradition in some Asian communities.
There are other things that may increase the risk of getting mouth cancer, such as eating a poor diet and not cleaning your teeth or seeing a dentist regularly enough. Having a weakened immune system or a virus called human papilloma virus (HPV) are also possible risk factors. Being exposed to sunlight over a long period of time is a risk factor for cancer of the lip.
Mouth cancer, like other cancers, isn’t infectious and can’t be passed on to other people.
Signs and symptoms of mouth cancer Back to top
The two most common symptoms of mouth cancer are:
an ulcer in the mouth that doesn’t heal
discomfort or pain in the mouth that doesn’t go away.
Not everyone has pain or an ulcer. Other symptoms include:
a white (leukoplakia) or red (erythroplakia) patch in the mouth or throat that doesn’t go away
a lump or thickening on the lip, or in the mouth or throat
difficulty or pain with chewing, swallowing or speaking
bleeding or numbness in the mouth
loose teeth for no obvious reason
a lump in the neck
a lot of weight loss over a short time
bad breath (halitosis).
These symptoms are common in conditions other than cancer. However, if you have any of these symptoms, it’s important to let your doctor or dentist know straight away. Mouth cancer can be treated more successfully when it’s diagnosed early.
Dentist will examine your mouth closely, especially the area under the tongue. They will refer you to a hospital for any further tests and for specialist advice and treatment.
The specialist will examine your mouth using a small mirror and light. A very thin, flexible tube with a light at the end (endoscope) can be used to get a better view of the back of the mouth and throat.
To make a diagnosis, your specialist will remove a small piece of tissue (biopsy) to be examined under a microscope. This is usually done under a general anaesthetic, so you may need to spend the night in hospital.
You’ll have blood tests, and possibly a chest x-ray, to check your general health. There are several other tests that may be used to help diagnose mouth cancer and to check whether or not the cancer has spread. The results of these tests will help your specialist decide the best type of treatment for you.
X-ray
The doctor may want to take x-rays of your face or neck to see whether any bones have been affected. A special x-ray known as an orthopantomogram (OPG) may be taken to look at your jaw and teeth.
MRI (magnetic resonance imaging) scan
This test uses magnetism to build up a detailed picture of areas of your body.
Before the scan, you may be asked to complete and sign a checklist. This is to make sure that it’s safe for you to have an MRI scan.
Before the scan, you’ll be asked to remove any metal belongings, including jewellery. Some people are given an injection of dye into a vein in the arm. This is called a contrast medium and can help the images from the scan to show up more clearly. During the test you’ll be asked to lie very still on a couch inside a long cylinder (tube) for about 30 minutes. It’s painless but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It’s also noisy, but you’ll be given earplugs or headphones.
CT (computerised tomography) scan
A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10-30 minutes. CT scans use a small amount of radiation, which is very unlikely to harm you and won’t harm anyone you come into contact with. You will be asked not to eat or drink for at least four hours before the scan.
You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you’re allergic to iodine or have asthma, you could have a more serious reaction to the injection, so it’s important to let the hospital doctor know beforehand.
Staging and grading of mouth cancer Back to top
Staging
The stage of a cancer is a term used to describe its size and whether or not it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment for you.
TNM staging
The most commonly used staging system is called the TNM system:
T refers to the size or position of the primary tumor (where the cancer first starts in the body).
N refers to which lymph nodes are affected, if any.
M refers to metastatic disease (when the cancer has spread to other parts of the body).
The T, N and M will often have numbers attached to describe the detail. For example, a T1 tumor may be very small and just in one layer of tissue, whereas a T4 tumor may be larger and spread through several layers of tissue.
The exact details of the T, N and M will depend on the type of cancer.
Number staging system
In addition to TNM staging, you’ll probably hear the doctors use a number staging system. There are usually three or four number stages for each cancer type.
Stage 1 describes a cancer at an early stage when it is usually small in size and hasn’t spread. Whereas stage 4 describes cancer at a more advanced stage when it has usually spread to other parts of the body. Stages 2 and 3 are in between these stages.
The number stages are made up of different combinations of the TNM stages. So, a stage 1 cancer may be described as either T1, N0, M0 or T2, N0, M0.
Number stages may also be subdivided to give more detailed information about tumor size and spread. For example, a stage 3 cancer may be subdivided into stage 3a, stage 3b and stage 3c. A stage 3b cancer may differ from a stage 3a cancer in either the tumor size or if the cancer has spread to lymph nodes.
Talking about staging
In the last few years, staging systems have become increasingly complex and they now describe the size and spread of different types of cancer in much greater detail. This can be very helpful in planning the details of treatment or predicting outcomes.
However, doctors will often use a much simpler approach when talking about staging. They might use words like ‘early’ or ‘local’ if the cancer hasn’t spread, ‘locally advanced’ if it has begun to spread into surrounding tissues or nearby lymph nodes, or ‘advanced’ or ‘widespread’ if it has spread to other parts of the body. Your doctors can give you more information about the stage of your particular cancer.
Grading
Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how the cancer may behave.
Low-grade means that the cancer cells look like normal cells. High-grade means the cells look abnormal. A low-grade tumor will usually grow more slowly and be less likely to spread than a high-grade tumor.
Treatment for mouth cancer Back to top
Your treatment will depend on the stage and grade of your cancer, as well as your general health. Your specialist will explain more about the most appropriate treatment for you. You may also be seen by a specialist nurse who will give you information and emotional support.
The usual treatments for mouth cancer include:
surgery
radiotherapy
chemotherapy
biological therapy.
Your doctor will recommend the treatment that is likely to be the most successful in treating your cancer. They will also consider the side effects you’re likely to have and how treatment will affect your ability to speak and swallow.
In early mouth cancer, both surgery and radiotherapy are equally effective. You’ll probably have radiotherapy if surgery is likely to seriously affect your speech and swallowing. Larger cancers will usually be treated with a combination of different treatments.
The following treatments can either be given separately or combined in a number of ways.
Surgery
The cancer is removed along with a margin of clear tissue. How much tissue is removed depends on the size of the cancer and where it is in your mouth.
Many mouth cancers spread to the lymph nodes in the neck, so these nodes are also usually removed (called a neck dissection) even if there is no evidence that they are affected. This is to reduce the chance of the cancer coming back.
The length of time you spend in hospital will depend on the extent of the surgery you need. Your surgeon will explain more about this to you.
People having more complicated surgery may be looked after in a high dependency unit or intensive care for a while after their operation.
Some people may need to have a larger operation that involves removing part of their jawbone or tongue. This will be done by a specialist head and neck surgeon.
The surgery will involve rebuilding the area using tissue, skin or bone taken from somewhere else in the body. People having this type of surgery may need to stay in hospital for up to a few weeks.
Mohs micrographic surgery (MMS)
This is a specialised type of surgery where the tumor is removed piece by piece and examined under a microscope straight away. Skin tissue is gradually removed until there are no signs of cancer cells. This type of surgery is often used in places where it’s important to remove as little healthy tissue as possible, such as the lips.
Side effects of surgery
These depend on the type and extent of surgery that you have. Side effects may affect your speech, swallowing or your sense of taste and smell. Some types of surgery may result in a change in your appearance.
You will usually see a dietitian and speech therapist after your operation. They will help you to cope with some of these changes.
You can read more detailed information about surgery and its effects in our section on head and neck cancers.
Radiotherapy
Radiotherapy treats cancer by using high-energy rays to destroy cancer cells, while doing as little harm as possible to normal tissue.
Radiotherapy can be given alone to treat early mouth cancers (radical radiotherapy). It can also be given after surgery to reduce the risk of the cancer coming back (adjuvant radiotherapy), or if the cancer comes back after previous surgery. Radiotherapy may also be given to any lymph nodes in the neck that have been affected by the cancer. This type of radiotherapy is called external radiotherapy. It is given from a radiotherapy machine, much like an x-ray machine. It does not make you radioactive.
Some people are given radiotherapy together with chemotherapy. This is called chemoradiation.
Internal radiotherapy, known as brachytherapy, is sometimes used to treat small cancers in areas such as the lip or tongue. With brachytherapy, a solid radioactive material is placed close to the tumor.
Side effects of radiotherapy
During radiotherapy the skin over your face and neck will usually redden or darken and become sore (like sunburn). This can start after about two weeks of treatment and may last for 2–4 weeks after treatment has finished. Sometimes your skin will peel or break. The radiotherapy team will tell you how to look after your skin.
Your mouth and throat will usually become sore and inflamed after a couple of weeks of treatment and you may develop some mouth ulcers. Your voice may also become hoarse. There may be changes to your sense of taste and smell. Eating food can become difficult and swallowing can be painful. Your doctor can prescribe some medicines to help improve this.
Occasionally, some people may need to have artificial feeding through a tube if they’re unable to eat and are losing a lot of weight. A tube may be passed through the nose and into the stomach (nasogastric tube), or passed directly into the stomach. This is only done for a short time until treatment is finished and your swallowing is back to normal.
Radiotherapy to this area can cause the salivary glands to produce less saliva. The lining of the mouth and throat may become dry and this can make eating and speech difficult. There are artificial saliva sprays that can help make your mouth feel more comfortable. You can read more about this in our information on coping with a dry mouth. Most of these side effects are usually temporary and will gradually improve once your treatment is over. However, many people continue to have problems with a dry mouth after their treatment is over. A specialised way of giving radiotherapy called Intensity-modulated radiation therapy (IMRT) is available in some hospitals. IMRT reduces the risk of damage to the healthy tissue surrounding the tumor, and so it can reduce the risk of long-term dry mouth.
You can read more information about the side effects and how to cope with them in our section on head and neck cancers, and our information on radiotherapy.
Chemotherapy
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.
They can be given:
before radiotherapy or (rarely) before surgery
at the same time as radiotherapy (chemoradiation)
after radiotherapy or surgery (adjuvant chemotherapy)
if the cancer has spread to other parts of the body, or has come back after earlier treatment.
After surgery, chemotherapy can reduce the chance of the cancer coming back. If the cancer does come back, chemotherapy can be used to control symptoms. Chemotherapy isn’t usually used to treat lip cancer.
Cisplatin and fluorouracil (5FU) are the two most commonly used chemotherapy drugs for mouth cancer. Different drugs are used if the cancer comes back. These can include docetaxel (Taxotere®), paclitaxel (Taxol®) or gemcitabine (Gemzar®).
The drugs are usually given by injection into a vein (intravenously). They can temporarily reduce the number of normal blood cells in your blood. When your blood count is low you’re more likely to get an infection. During chemotherapy your blood will be tested regularly. If necessary, you can have antibiotics to treat any infection. Blood transfusions may be given if you become anaemic (low number of red blood cells) due to chemotherapy.
Chemotherapy can also cause side effects such as feeling tired, a sore mouth, feeling sick (nausea) or being sick (vomiting), diarrhoea and hair loss. Let your doctor or nurse know about any side effects as they can often prescribe drugs to reduce these.
Chemoradiation
Chemoradiation (chemotherapy and radiotherapy together) may be used instead of surgery to treat some small mouth cancers. It has less of an effect on speech and swallowing than surgery. It’s important that you’re fit enough to cope with having the two treatments together.
The immediate side effects are worse when both chemotherapy and radiotherapy are given together. You may still need surgery afterwards if chemoradiation doesn’t completely get rid of your cancer.
Chemoradiation can also be given after surgery to reduce the chances of the cancer coming back.
Biological therapies
In order to grow and divide, cancer cells ‘communicate’ with each other using chemical signals. Biological therapies are drugs that interfere with this process and so affect the cancer’s ability to grow.
Cetuximab is the most commonly used biological therapy to treat mouth cancer. It’s given as a drip (infusion) into a vein.
It may be used:
in combination with radiotherapy for people who aren’t fit enough to cope with the side effects of chemoradiation
as part of a clinical trial in combination with chemoradiation
with palliative chemotherapy.
How cetuximab works
Most squamous cell cancers of the mouth have proteins called epidermal growth factor receptors (EGFRs) on their surface. When chemical messengers in the body called growth factors attach to these receptors, it stimulates the cancer to grow.
Cetuximab stops the growth factors from attaching to receptors on the cancer and so may stop it growing. It may also make the cancer more sensitive to the effects of radiotherapy.
grafts
Widespread use of plastic free skin graft is not accidental. On the one hand, after removal of skin tumors or trauma , especially on the face , often are extensive but superficial defects , reaching in most cases only the upper layers of subcutaneous fat. In the case of sprouting tumor in the subcutaneous tissue graft can be taken in the entire thickness of the skin , ensuring compliance with the depth of the defect thickness graft is necessary for a satisfactory cosmetic result. Split skin graft convenient to use the replacement of large shallow defects on the face, especially when the tumor removed along with those pathological lesions , against which developed cancer ( keloid , burns , traumatic scars, nevi , and others. ). The use of plastics free skin flap protects the wound from infection , scarring and rough significantly reduces its healing. Free skin graft is the best biological dressing for wounds. However , until recently, a single point of view on the possibility of a free skin flap plastic immediately after removal of malignant tumors of the skin there. First applied the method of free skin grafting German surgeon Hristian Bunher in 1823 : it is taken from the hip transplanted piece of skin containing epidermis and dermis full on the nose. The operation was successful . Later, he had many followers and they all emphasized the importance of complete removal of the fat layer.
ENGINEERING grafts The free skin grafting is carried out or the whole thickness , ie transplanted epidermis and dermis layer without under skin fat or transplanted pieces of medium thickness, which include the epidermis and different thickness of the dermis layer . After transplanting skin undergoes significant change. Some parts of the skin dysgenerate , necrotising . Regeneration may be incomplete . What living accompanied by inflammatory changes in the tissues , which was moved transplant . Tissue under the graft and the graft itself subject to multiple sclerosis , which causes secondary graft contraction . Restructuring graft ends before the end of the fifth week. By this time a new layer is formed and the fat graft is moving . Recovery of sensitivity occurs slowly and in full extent. Skin grafts average thickness, thicknes sand – 0.25-0.5 mm; b – 0,55-0,75 mm. Epithelial plate thickness less than 0.1 mm caot take any tools !
Benefits- Patches can be taken quickly and easily ;
– Graft is everywhere the same thickness , the surface smooth cutting ;
– Graft unpretentious , reliable living even infected perceiving bed ;
– Can be transplanted grafts unlimited size;
– Donor wound heals spontaneously and quickly;
– Donor area after 1-2 months can be used again for taking the flap .
Disadvantages- Graft more prone to shrinkage ( about 30% );
– You caot pre- determine the color of the graft ( available as hyper -and hypopigmentation ).
Transplants in the entire thickness of the skin thickness 0,8-1,1 mm
Benefits
– Graft less wrinkled ;
– Better resist mechanical stress ;
– In transplant subcutaneous layer is formed , it becomes loose and can collect in the fold ;
– Graft retains the original color.
Disadvantages
– Graft rather cranky, living only under aseptic conditions, on perceiving the bed with a good blood supply ;
– Can change only small grafts ;
– Donor wound to sew up or covered by plastic surgery.
Tools used to obtain the average thickness skin transplants The most important such tool is the STI . Dermatome graft is taken in the dermis layer , parallel to the skin surface. A common feature of all dermatomes is that they provide a uniform , metered flaking skin grafts at a certain layer of skin. This ensures the smooth healing of the graft and also a huge advantage and free skin grafts , which wound surface donor sites is often very large, fast epithealize spontaneously due to proliferation of the epithelium of the ducts of glands and hair follicles cover down by epithelium. A The oldest type of Paget dermatome is Dermatom – Huda , which was constructed in 1926 during the development of the method of skin grafting. There are many variations of this dermatome , but the mechanism of action of all of them is that the surface of the skin is fixed to the drum dermatome glutinous substance and graft excision is carried out manually by moving the knife or razor. The advantage of using dermatome is that it allows you to precisely adjust the size and shape of the graft. There is elektrodermatom has no adhesive material than it moves through an electric motor. Its disadvantage in comparison with Paget dermatome is the limited width of the grafts. The advantage is that with elektrodermatom grafts can carve any length and definitely set thickness. If at the end pull graft excision , then cut off his STI . Designed by a group of surgeons Dermatom with a simple blade for shaving. Simple Dermatom a dangerous blade for shaving, fixing clamp or needle – holder .
Taking a thin skin transplants
Placental grafts razor Tirsha . Anesthesia – local infiltration anesthesia . Flat surface of the razor is applied to the skin , heavily soaked with saline ( not recommended to use oil as it reaches the surface of the cut , preventing engraftment .) Than it should take lightly and do cut skin. Then pushing than Peel movements cut out graft . Its width adjusts surgeon who , depending on the need, more or less, to the skin presses the entire surface of the blade. When taking a small skin grafts , located below the knife, pull the hand in the capture of large grafts – used for this purpose wooden planks . Graft going to fold on the blade of a knife. Knife with flap transferred to the prepared bed. Press down the edges of the graft probe to the edge of the bed , and then from under him, gently pull out the knife. Skin graft detachment knife Hambo . With screws regulate laminated thickness skin graft . The surface of the operative field and knife abundantly moistened with saline .
1. Home detachment . The surgeon pulls through wooden planks skin located above the knife Assistant – skin below the knife. In the hip, from which cut flap, enclose pad in order to create a large flat surface of the skin . The knife is applied to the skin at an angle and hold a small cut . Then put the knife horizontally and proceed to cut the flap . To do than be a uniform pressure to the thickness flap was the same.2. The next stage of detachment . Create Graft dermoepidermal fairly large plane.3. Branches cut off the flap . With a knife you can cut pieces Hambo size 8 X 20 cm or more, depending on their place of capture. Taking the average thickness skin transplants Local anesthesia is as follows : first anaesthetize proximal part of the operative field , followed by another layer of subcutaneous infiltration in the distal direction and finally – Intradermal infiltration of the type ” lemon peel “. The donor area is reflected metal spatula to a uniform distribution of liquid analgesic and a flat surface. Before incision donor area lubricated with saline to become slippery. The bottom surface of the knife and smeared the liquid. Before you cut, the other side pulling device that meets the desired width of the graft is placed in the endpoint donor site. Operating surgeon places the other pulling device in the direction of the cut between them puts on a support than Hamby, and then pushing pulling device to support uniformly leads him to a blade that takes a cut. Operating surgeon uniform motion detach the flap , making sure to press the cutting device resistance was carried out with the same force . When the graft will end over the edge of the device , one of the assistants tweezers presses him to the anvil to prevent wrinkling of the skin.
