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171 Cards in this Set
- Front
- Back
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What are the most frequent sites in the mouth for SCC?
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Tongue and floor of the mouth. 30% of these pts will have cervical metastases.
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Which cervical node metastases have the worst prognosis?
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Lower nodes in level IV and V
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What determines risk of nodal metastases in oral cancers?
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The likelihood of nodal involvement increases the further posterior in the oral cavity the tumor is. So, lip cancer has better prognosis than oropharyngeal cancer
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What determines risk of nodal involvement in larynx and pharynx tumors?
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Going from the cetral compartments to the periphery the risk is greater and prognosis worse.
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T/F Exophytic tumors carry higher risk of nodal metastases than endophytic tumors
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False, endophytic are higher risk
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Which structures drain into level I nodes?
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Lower lip, floor of mouth, lower gum, face, nose, sinuses, submandibular gland
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Which structures drain into level II nodes?
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Oral cavity, oropharynx, nasopharynx, nasopharynx, hypopharynx, and supraglottic larynx
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Which structures drain into level III nodes?
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Thyroid, larynx, hypopharynx, cervical esophagus
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Which structures drain into level IV nodes?
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Intra abdominal organs, breasts, lungs, esophagus, and thyroid
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Which structures drain into level V nodes?
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Nasopharynx, thyroid, esophagus, lungs, breasts
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What is the most common site of cervical nodal metastases by all tumors?
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Ipsilateral level II nodes
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T/F Tumors of the anterior oral cavity are more likely to metastasize if the tumor is large
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True, however in the posterior oral cavity and pharynx this does not hold true...even small tumors may metastasize
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Which have higher level of metastases to level V nodes, oral cavity or oropharyngeal cancers?
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Oropharyngeal cancers, but still most common in level II nodes.
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What type of neck dissection do you do in a pt with metastatic squamous cell carcinoma w an occult primary site?
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Comprehensive neck dissection
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What are indications for surgery to resect a tumor?
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If you can achieve full or near complete resectability, to gain access to tissues for adequate staging, and if nodes are bigger than 2cm (so radiation prob won't work alone)
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How would you treat an N1 neoplasm?
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If nodes are 2 cm or smaller than surgery or radiation are equally effective. Nodes bigger than 2cm surgery is more effective.
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When would you do an upper cheek flap to resect a tumor?
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For large lesions of the hard palate, maxillary alveolus, cheek mucosa, or retromalar trigone.
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When would you do a lower cheek flap to resect a tumor?
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For tumors of the tongue, FOM, mandibular gingiva, buccal mucosa, or retromalar trigone
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When would you do a visor flap to resect a tumor?
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Mostly for tumors in the floor of the mouth or when a tongue tumor invades FOM.
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When would you do a mandibulotomy or paralingual extension to resect a tumor?
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For tumors located posteriorly that are close to or involve the mandible
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How would you treat an N1 neoplasm?
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If nodes are 2 cm or smaller than surgery or radiation are equally effective. Nodes bigger than 2cm surgery is more effective.
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When would you do an upper cheek flap to resect a tumor?
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For large lesions of the hard palate, maxillary alveolus, cheek mucosa, or retromalar trigone.
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When would you do a lower cheek flap to resect a tumor?
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For tumors of the tongue, FOM, mandibular gingiva, buccal mucosa, or retromalar trigone
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When would you do a visor flap to resect a tumor?
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Mostly for tumors in the floor of the mouth or when a tongue tumor invades FOM.
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When would you do a mandibulotomy or paralingual extension to resect a tumor?
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For tumors located posteriorly that are close to or involve the mandible
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How would you treat an early T1 or T2 tumor of the alveolar ridge?
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They can be manages by surgery alone, with preservation of structural integrity of mandible
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What makes primary radiation less feasible for early alveolar ridge carcinomas?
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The fact that they invade the mucoperiosteum and the tooth sockets
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How would you treat a more advanced tumor of the alveolar ridge or retromolar trigone?
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Radiation to shrink the tumor, then surgery to remove it. Usually mandibulectomy/maxillectomy and possibly neck dissection
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How do you treat early tumor of FOM?
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With surgery or radiation alone. May involve mandibulectomy or bilateral neck dissection if tumor is in midline
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How do you treat advanced tumor of FOM?
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Surgery and radiation, partial glossectomy and mandibulectomy and bilateral neck dissection
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How do you treat early oral lesions of the oral tongue?
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Hemiglossectomy done intraorally. If lesion is posterior, may require mandibulotomy. T1 lesions can be managed with brachytherapy alone
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What is brachytherapy?
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A form of radiotherapy where iridium seeds are planted in or near a tumor to deliver radiation. Commonly used in H&N cancers and prostate cancer
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What is teletherapy?
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It is external beam radiotherapy produced by linear accelerator. Very intense and pin-pointed
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How do you treat advanced tumor of oral tongue?
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Mandibulotomy or lingual releasing procedure to gain access to disease. Neck dissection elective
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What percent of cancers of the base of the tongue have metastasized to the neck nodes?
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80%, 20% bilateral
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How do you treat early stage cancer of base of tongue?
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Surgery or radiation give equal results. If stage 2, must radiate nodes
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How do you treat late stage cancer of base of tongue?
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Surgery followed by radiation. Neck dissection necessary for stage 2-4
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How do you treat stage 1-2 tonsil cancers?
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Radiation alone
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How do you treat stage 3-4 tonsil cancers?
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Surgical resection followed by radiation 6 weeks post-op. Neck dissection if nodal involvement
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How do you treat cancers of the hard palate?
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Early cancers may only need partial maxillectomy, but advanced disease will require total palatectomy followed by adjuvant radiotherapy.
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how do you treat cancers of buccal mucosa?
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Small T1-T2 lesions managed with either surgery or radiation. Advanced lesions total cheek resection with post-op radiation
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What does a radical neck dissection involve?
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Removal of nodal groups 1-5 with sternocleidomastoid, internal jugular vein, and spinal accessory nerve
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What is a modified radical neck dissection?
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All nodes are removed but some of the non-nodal structures are still removed
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What is preserved in a type 1 modified radical neck dissection?
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Spinal accessory nerve preserved
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What is preserved in a type 2 modified radical neck dissection?
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Sternocleidomastoid and spinal accessory nerve preserved
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What is preserved in a type 3 modified radical neck dissection?
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Internal jugular vein, sternocleidomastoid, and spinal accessory nerve preserved
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What is a selective neck dissection?
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Removal of one or more regional lymph nodes with preservation of all other structures
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Which nodes are removed in a supraomohyoid selective neck dissection?
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Nodal levels 1-3
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Which nodes are removed in a lateral jugular selective neck dissection?
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Nodal levels 2-4 are removed
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Which nodes are removed in a selective posterior lateral neck dissection?
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Nodal levels 2-5 are removed
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What does a sentinal lymph node acquisition involve?
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Intraoperative injection of methylene blue and technesium-99 to identify potential sites of nodal metastases in T1 or T2, N0 disease
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What are the effects of removal of the spinal accessory nerve?
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Destabilization of the scapula, denervation of trapezius and SCM. Leads to shoulder syndrome
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What is the cause of a chylous fistula?
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Results from injury to the thoracic duct during removal of zone 4 nodes
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How does chemotherapy work?
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It works by blocking mitosis and halting cell division so it works best on rapidly dividing cells, such as tumor cells
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Which cancers are most sensitive to chemotherapy?
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Acute myelogenous leukemias and aggressive lymphomas (Hodgkin's).
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T/F Chemo drugs are more effective against older less differentiated tumors
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False, more effective against younger more differentiated tumorsbecause some growth regulation mechanisms are still in tact
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T/F Over time, cancer cells become more resistant to chemotherapy tx
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True
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What is the membrane chemo efflux pump on tumor cells called?
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P-gylcoprotein. Inhibition of this pump makes chemo more effective because chemo drugs stay in the cell
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Is the p-glycoprotein (ABCB-1 pump) a passive or active pump?
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Its an ATP-dependent efflux pump with ATP binding cassette.
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T/F p-glycoprotein is expressed on the surface of many normal cells in the intestine, liver, kidney, and capillaries in CNS
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True
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How was the function of p-glycoprotein first elucidated?
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It was cloned from a tumor cell that had developed resistance to chemo drugs
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What are the different purposes for administering chemo tx?
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For curative purposes, to prolong life, and to palliate symptoms
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What is combined modality chemo?
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Use of drugs with either surgery or radiation
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What is combination chemo?
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When you treat a pt with several differrent drugs together. The advantage here is minimizing chances of resistance to any one drug
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What is neo-adjuvant chemo?
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It is preoperative tx with chemo drugs aimed at shrinking the primary tumor before surgery or radiation
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What is adjuvant chemo?
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Post-operative chemo used to reduce recurrence in high risk pts. May kill cancer cells that have spread to other parts of the body
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What is palliative chemo?
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It is given without curative intent, simply to decrease tumor load and increase life expectancy and alleviate symptoms.
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What is the main method of action of most chemo drugs?
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They inhibit synthesis of new DNA material and cause irreparable damage
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What are the main groups of chemo drugs?
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Alkylating agents, antimetabolites, plant alkaloids and terpenoids, antitumor antibiotics, and anthracyclines
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What are the alkylating agents and how do they work?
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Cisplatin, carboplatin, and oxaplatin (all have platinum). They work by adding alkyl groups to DNA in tumor cells
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What are anti-metabolite chemo drugs and how do they work?
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5-Fluorouracil, azathioprine, mercaptopurine. They are purine/pyrimidine analogs that get incorporated into DNA and arrrest cell division.
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How do anti-metabolite cehmo drugs affect RNA synthesis?
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Methotrexate is the drug that does this. It impairs function of folic acid. This drug is used for any lesion that is rapidly replicating
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What are the most widely used chemo drugs?
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The anti-metabolites, specifically Azathioprine. It is an immunosuppresice cytoxic substance, often used in transplant pts as well
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What are plant alkaloids and terpenoids and how do they work?
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Vinca alkaloids and taxanes are main ones. They block cell division by preventing microtubule function.
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What are the most important vinca alkaloids?
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Vincristine and vinblastine
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What is the cellular structure attacked by vinca alkaloids and taxanes?
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The mitotic spindle apparatus. Chromosomes are prevented from separating during anaphase
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Which plant alkaloid drugs stop viral cancers related to HPV?
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Podophyllotoxins (etoposide and teniposide). They prevent cell from entering G1 by inhibiting topoisomerase
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What are toposiomerases?
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They relieve torsional strain on DNA helix to allow transcription, replicatin, and repair. Inhibition of this enzyme leads to disruption of DNA structure
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What are the type 2 topoisomerase inhibitors?
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Etoposide and etoposide phosphate
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What are anti-tumor antibiotics and how do they work?
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Dactinomycin is the most important one. Potent immunosuppresant used in kidney transplant pts often
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What are anthracyclines and how do they work?
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Doxorubicin is the most important one. These drugs are very effective and have the broadest range of effect of any chemo drugs (used in many types of cancer)
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How are antibodies used to treat cancer?
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They taget specific tumor antigens to enhance the immune response. Examples are Trastuzumab, Cetuximab, and Rituximab
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Which antibody chemo drug blocks the formation of new tumor vessels?
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Bevacizumab
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What is dexamethasone?
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It is a steroid used to inhibit tumor growth and cause regression of lymph node malignancies. Also works as an antiemetic
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Why are many chemo drugs immunosuppressive?
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Because your white blood cells are rapidly dividing cells so are highly affected by chemo drugs
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What does "nadir" refer to?
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The period it takes following chemo for blood cells to reach a low point. Usually 7-10 days, for this reason doses of chemo are spaced about about 3 weeks apart
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What effects does chemo have on mucous membranes?
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It causes stomatitis, xerostomia, and esophagitis
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Why does ionizing radiation cause damage to tissues?
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Because it leaves a free electron and a positive ion that can damage cells
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What particles can produce ionizing radiation?
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Alpha and beta particles, neutrons, and heavy ions
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What is a Roentgen (R)?
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It is a unit of x or gamma radiation that ionizes a specific volume of air. It is a measure of exposure
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What is radiation absorbed dose (rad) and gray (Gy)?
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Units that express energy absorbed by target tissue from gamma and x-rays
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What units are used to express radiation dose?
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Rems and Curies
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What is linear energy transfer (LET)?
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It is used to express energy loss per unit of distance traveled as electron volts per micrometer. It different for each type of ionizing radiation
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Which cells are targeted by radiation tx?
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Tissues with a high rate of cell turnover, such as bone marrow, lymphoid tissue, and mucosa of GI tract
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What is the effect of radiation on vascular tissue?
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It damages vessels often leading to occlusion and subsequent ischemia. Repair is compromised and this can lead to osteoradionecrosis for example
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Explain the oxygen effect during radiation tx
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Radiant energy may interact with molecular oxygen to creat superoxide radicals that can then damage cells. The damage is significant
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What is better, small does of radiation to large areas or large doses to small areas?
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Large doses to small areas are best and cause least damage
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What intracellular effects does radiation have?
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Alters gene expression, induces cytokins and tumor suppressor genes, or can induce expression of protooncogenes
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What happens to cells with unreparable DNA damage?
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They undergo apoptosis by activation of the TP53 gene
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What happens to a cell following extremely high dosage of radiation?
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Nuclear pyknosis or lysis, which is a marker of cell death
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What are the histologic markers of cellular damage from radiation?
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Cellular pleomorphism, giant cell formation, and conformational changes in nuclei and mitotic figures
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T/F Cancerous cells and cells damaged by radiation have many similarities histologically
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True, this makes it difficult for pathologist to differentiate cancer cells following radiation tx
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Which blood cells are resistant to radiation and why?
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RBC's becuase they have no nucleus. Anemia can happen due to bone marrow damage though
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T/F Incidence of new neoplasms is decreased following radiation tx
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False, it is increased due to the ability of radiation to cause new mutations in normal cells
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How does radon cause tissue damage?
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It is an alpha emitting product of uranium. Two radon decay products or 'daughters' produce short range DNA damage in the lungs
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What is the second leading cause of lung cancer?
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Long term exposure to low dose radiation from radon particles
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What level of radiant energy does it take to induce acute radiation syndrome?
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Approx 100-300 rads if whole body is exposed
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What is a common dose used in radiotherapy when pt is shielded carefully?
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Could be as much as 4000 rads or more
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What three acute radiation syndromes are often fatal?
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Hematopoietic, gastrointestinal, and cerebral
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What percentage of pts will receive radiation as part of their tx for cancer?
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About 2/3
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What is brachytherapy?
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Application of a radioactive source within or adjacent to a tumor
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What sources or radiation are used in brachytherapy?
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Co 60, Cs 137, iridium 192, and iodine 125
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T/F Radiation causes hair loss and nausea similar to chemo
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False, it doesn't cause these sides usually.
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What is a typical approach for treating cancer with radiation?
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1.8 and 2.0 gray per day, 5 days per week. This allows you to catch more cells in a vulnerable position of cell cycle
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What is the overall goal of dental care for oncologic pts?
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Identify and eliminate possible sources of infection/disease that may delay or complicate therapy or creat problems post sx
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What are the main treatments you would give a cancer pt before therapy?
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Anything necessary to eliminate sources of odontogenic infection, ie extracting hopeless teeth and restoring all salvageable teeth. Also prophy
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How long before comencement of chemotherapy should you do any invasive procedures?
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1 week before, no later because you want to give them time to heal.
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What is the most important preventative measure for pts receiving head and neck radiation?
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Fluoride supplementation, probably indefinitely. CHX rinse would also be good.
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How long beforecomencement of radiation therapy should you do any invasive procedures?
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3 weeks before, no later because they need time to heal
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What type of treatments would you provide a cancer pt during their therapy?
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You only take action to get rid of acute infection, hopefully avoiding any invasice surgical procedures. Post tx antibiotic coverage important
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What is the incidence of oral complications relating to cancer treatments?
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About 10-75% of chemo pts and 75% of bone marrow transplant pts
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What are the 2 main oral complications relating to both chemo and radiation tx?
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Mucositis and hyposalivation (xerostomia)
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What are the risk factors for development of mucositis during anti-neoplastic tx?
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Young age, female, poor OH, infection, poor nutrition, tobacco and alcohol use
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What is the timeline for onset of mucositis?
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Within a few days for chemo, usually any non-keratinized mucosa. During the second week for radiation and usually only radiation portals involved
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What are the clinical features of mucositis?
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White areas of atrophic mucosa, diffuse ulceration, pain and burning, and bacterial infections common
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How long does it take for mucositis to resolve?
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Usually in 2-3 weeks after tx is complete. It is usually the first thing to resolve.
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How do you treat mucositis?
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Topical anesthetics, antimicrobials, salt and soda rinse, ice chips, and avoidance of acidic foods.
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What systemic treatments are available for mucositis?
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Morphine for pain, GM-CSF, IV keratinocyte growth factor
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What bleeding related issues can arise with chemo tx?
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Risk of DIC, and also petechiae and ecchymosis of the buccal mucosa, tongue, and gingiva.
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How can you prevent or treat hemmorhage issues related to chemo?
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Not much you can do, possibly platelet transfusion if necessary. Just need to avoid trauma to oral mucosa
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Which tx can cause dermatitis?
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Radiation causes it only in radiation portal areas.
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What happends in mild, moderate, and chronic dermatitis?
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Mild you get erythema, moderate you get erosions and ulcerations, and chronic you get smooth, shiny skin.
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How can you prevent and treat dermatitis?
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Avoiding sun exposure and skin irritants/trauma. Keeping areas clean is very important too.
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Which salivary gland is most radiosensitive?
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parotid gland, but will only be affected if its in the radiation portal
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Symptoms of xerostomia are related to decrease in what salivary component?
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Mucous secretions
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What are the main clinical features of xerostomia?
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Difficulty swallowing or wearing dentures, mucosal dryness, thich saliva, secondary candidiasis, and caries
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What is the most common radiological finding in xerostomia-related caries?
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Apple core radiolucencies at the CEJ (root caries)
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What are sialogogues?
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Pilocarpine and cevemline (both cholinergic agents). They only work if your salivary glands aren't totally destroyed already.
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What are the most important treatments for pts with xerostomia?
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Topical fluoride and frequent dental eval for caries.
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Sre the serous or mucous glands more effected by anti-neoplastic therapy?
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The serous glands have worse prognosis, more severely affected and damage is permanent.
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What kind of damage is done to bone in osteoradionecrosis?
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Hypoxic, hypovascular, and hypocellular damage. Also damage to osseous cells
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Is damage from ORN permanent?
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No, some recovery can occur
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What are the risk factors for ORN?
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Invasive procedures within 3 weeks of starting therapy or 4-12 monts after therapy. Also, high dose radiation or pre-existing infection
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T/F ORN is more common on the maxilla than mandible?
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False, much more common on the mandible due to its limited blood supply
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What are the radiographic features of ORN?
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Ill-defined radiolucency
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What is the best tx for ORN?
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Prevention is best, remove all hopeless teeth 21 days before therapy and eliminate all infection.
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What is the 'golden period' when you can do exts on a cancer pt post-tx?
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During the first 4 months after cessation of therapy. From 4-12 months post-tx is a bad time to do it
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What are the common secondary infections during anti-neoplastic therapy?
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Strep viridans, Strep mitis, Candidiasis, HSV
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When would you resume routine dental care following cancer tx?
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Typically 17-20 days after. Need to wait for oral complications to resolve and consult with physician about hematologic status first
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What are the requirements for invasive dental procedures post CT or RT?
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Absolute neutrophil count > 1000 and platelets > 50,000
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What kind of recall schedule is appropriate for a post chemo pt?
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Every 1-3 months for the first 2 years, then every 3-6 months for the next 3 years.
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What condition would contraindicate using sialogogues?
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Glaucoma mostly, but asthma and COPD, and ulcers.
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What's the differerence between autologous and allogenic bone marrow?
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Autologous it pts own stem cells and allogenic come from a healthy donor
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In what stage of bone marrow transplant does graft-versus-host disease become a problem?
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In the engraftment phase when WBC's start to rebound. It can turn into a chronic problem as well
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What is the incidence of graft versus host disease?
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Its much more common in allogenic grafts and occurs in about 50% of pts
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What are the symptoms of acute GVHD?
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Maculopapular rash, burn, diarrhea, nausea, vomiting, abdominal pain, and liver dysfunction
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What are the symptoms of chronic GVHD?
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Occurs >100 days after transplant. Mimics autoimmune diseases, especially SLE and systemic sclerosis. Also many of the same probs as acute GVHD?
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What are the oral manifestations of chronic GVHD?
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White striations surrounded by erythema (looks just like lichen planus). Also ulcers and lesions that resemble pyogenic granulomas
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Which class of bisphosphonate is associated with osteonecrosis?
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The N containing types
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Why can bisphosphonates cause osteonecrosis long after its discontinued?
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Because it has a strong affinity for hydroxyapatite and remains in bone for years.
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What is the mechanism of action of bisphosphonates?
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Reduction of bone turnover, inhibition of osteoclast activity and increased apoptosis.
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What are the indications for using bisphosphonates?
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Hypercalcemia of malignancy (if a malignancy is resorbing bone)
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What is a common site in the mouth for osteonecrosis caused by BPs?
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Site of previous tooth extraction, twice as often in the mandible as maxilla.
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Who is at risk for osteonecrosis?
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Usually people with hx of multiple myeloma or breast cancer or people with osteoporosis.
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Which form of BPs most often cause osteonecrosis?
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94% of cases are associated with IV therapy that is long term.
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What feature must be present in order to dx osteonecrosis?
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Mucosal ulceration with exposure of underlying bone
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What are the radiographic features of osteonecrosis?
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Ill-defined radiolucency, mottled looking bone
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What is the histologic appearance of osteonecrotic bone?
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Necrotic bone with empty lacunae (no visible osteocytes)
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How do you treat osteonecrosis?
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Its just better to prevent it, you need to eliminate all foci of oral infection, restore oral health, and avoid dentoalveolar trauma.
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How do you treat a pt that has been on BPs for over 3 years?
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You d/c the BPs 3 months before and 3 months after the procedure then give pts CHX rinse and follow up with them
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What is a CTX test?
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It is a test for a marker of bone metabolism to detect reduced bone turnover. This MAY predict risk of developing osteonecrosis
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