轉介個案處置與管理

1. 99年口腔黏膜健檢品質提升計畫 轉介個案處置與管理 陳信銘DDS, MS, PhD 口腔顎面外科專科醫師 台大醫院牙科部口腔顎面外科主治醫師 台大牙醫學院口腔生物科學研究所助理教授

2. 轉介個案處置與管理 • 待確診個案轉介醫療網（依個別區域分別介紹） • 口腔癌及其癌前病變處理流程 • 轉介常見或容易混淆之口腔癌及其癌前病變 • 口腔癌癌前病變治療共識與原則 • 口腔癌治療共識與原則 • 轉介個案之管理

3. 待確診個案轉介醫療網

4. 口腔癌確認診斷及治療醫院名單 http://www.bhp.doh.gov.tw/BHPnet/Portal/Them_Show.aspx?Subject=200712250030&Class=0&No=200712250204 • 確診醫院條件:口腔顎面外科或耳鼻喉科專科醫師一名及專任口腔病理科或病理專科醫師一名 • 治療醫院條件: 口腔顎面外科或耳鼻喉科專科醫師、口腔病理科或病理專科醫師、整形外科專科醫師、放射腫瘤科專科醫師、及腫瘤內科專科醫師至少各一名 註：完整名單可至國民健康局網站癌症防治組查詢

5. 口腔癌確認診斷及治療醫院名單(99.04)

6. 口腔癌確認診斷及治療醫院名單(99.04)

7. 口腔癌及其癌前病變處理流程

9. 口腔癌篩檢流程圖 口腔癌及其癌前病變篩檢 ABC 是 否 有可疑症狀 疑口腔檳榔病變 疑陽性個案 非口腔檳榔病變 轉介確診醫院 其它疾病 正常 需切片 不需切片 治療建議 衛教 非口腔癌及其癌前病變 陰性個案 定期追蹤 口腔癌及其癌前病變 部份切除 進一步治療或觀察追蹤 陽性個案 完全切除 定期追蹤

10. 轉介常見或容易混淆之口腔癌及其癌前病變

11. Outcome Following a Population Screening Programme for OralCancer and Precancer in Japan All adults over the age of 40 years resident in Tokoname city 19 056 subjects (5885 male, 13 171 female: mean age 60.7±11.3 years) Oral mucosal lesions in 783(4.1%) subjects 200 (25.5%) were referred 137 (68.5%) attended for follow up examination in hospital departments by specialists 39 subjects were confirmed as having oral cancer or precancer (2 squamous cell carcinomas, 37 leukoplakias) 40 with lichen planus Oral Oncology 36 (2000) 340-6. Oral Oncology 36 (2000) 340-6

12. Outcome Following a Population Screening Programme for OralCancer and Precancer in Japan Oral Oncology 36 (2000) 340-6

13. Outcome Following a Population Screening Programme for OralCancer and Precancer in Japan Oral Oncology 36 (2000) 340-6

14. Outcome Following a Population Screening Programme for OralCancer and Precancer in Japan Oral Oncology 36 (2000) 340-6

15. 口腔癌癌前病變治療共識與原則 原則

16. Management of PMD

17. Treatment of Oral Potentially Malignant Disorders • Wide excision of the lesion • CO2 laser surgery • Photodynamic therapy • Cryotherapy

18. Treatment of OSF • Non-surgical treatment • Corticosteroid • Hyaluronidase • Interferon-g • Surgical treatment • Graft • Split thickness skin graft (STSG) • Bucaal fat pad graft • Placental membrane • Xenograft (TerudermisTM) • Flap • Nasolabial flap • Palatal island flap • Superficial Temporal fascia flap • Fore arm flap • Coronoidectomy and myotomy

19. Treatment of Lichen Planus • Submucous injection of Kenacort A • Cryotherapy (Lichenoid leukoplakia)

20. 口腔癌治療共識與原則

21. Staging 2002 American Joint Committee on Cancer (AJCC) TNM Staging System for the Lip and Oral Cavity Primary Tumor (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor 2 cm or less in greatest dimension T2 Tumor more than 2 cm but not more than 4 cm in greatest dimension T3 Tumor more than 4 cm in greatest dimension T4(lip) Tumor invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (ie, chin or nose) T4a (oral cavity) Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of tongue [genioglossus, hyoglossus, palatoglossus, and styloglossus], maxillary sinus, skin of face) T4b Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery *Note: Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify as T4. Regional Lymph Nodes (N) NX Regional nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N2a Metastasis in single ipsilateral lymph node more than 3cm but not more than 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3 Metastasis in a lymph node more than 6 cm in greatest dimension Distant Metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis ST-1

22. Staging Stage Grouping Histologic Grade (G) Stage 0 Tis N0 M0 GXGrade cannot be Stage I T1 N0 M0 assessed Stage II T2 N0 M0 G1 Well differentiated Stage III T3 N0 M0 G2 Moderately T1 N1 M0 differentiated T2 N1 M0 G3 Poorly differentiated T3 N1 M0 Stage IVA T4a N0 M0 T4a N1 M0 T1 N2 M0 T2 N2 M0 T3 N2 M0 T4a N2 M0 Stage IVB AnyT N3 M0 T4b AnyN M0 Stage IVC AnyT AnyN M1 Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York. (For more information, visit (www.cancerstaging.net) Any citation or quotation of this material must be credited to the AJCC as its primary source. The inclusion of this information herein does not authorize any reuse or further distribution without the expressed, written permission of Springer-Verlag New York, Inc., on behalf of theAJCC. ST-2

23. 口腔癌的治療模式 第一期 第二期 第三期 第四期 早期口腔癌 晚期口腔癌 手術治療 手術治療 放射線治療 放射線治療 化學治療 標靶治療

24. Radiotherapy

25. Adjuvant Chemoradiation for Resected High-Risk Disease

26. Concurrent Chemoradiotherapy for Unresectable Head & Neck Cancer

27. Target Therapy for Head & Neck Cancer Erbitux is a chimaeric monoclonal antibody (MAb) specific for the EGFR. Adapted from Bonner JA, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med. 2006;354:567-578.

28. Cetuximab

29. The Follow-up Strategy of Oral Cancer • Physical examination: • Year 1, every 1-3 mo • Year 2, every 2-4 mo • Year 3-5, every 4-6 mo • >5 yr, every 6-12 mo • Chest imaging • Annually • Or earlier if clinically indicated • TSH every 6-12 mo, if neck irradiated.

30. 轉介個案之管理

31. Annual Screening for Oral Cancer Detection: Japanese Experience Cancer Detect Prev 2003;27:333-7.

32. Annual Screening for Oral Cancer Detection: Japanese Experience Cancer Detect Prev 2003;27:333-7.

33. Annual Screening for Oral Cancer Detection: Japanese Experience The number of new oral cancers detected in the program was too low to determine the optimal frequency for oral cancer screening but new oral lerkoplkias were found in annual re-screening: the data indicate that the interval between two screens for this population should not be greater than 12 months. Cancer Detect Prev 2003;27:333-7.

34. Annual Screening for Oral Cancer Detection: Japanese Experience • Compliance rates to re-attend were lower in the youngest and oldest age groups. • Females were also more likely to re-attend compared with males. Cancer Detect Prev 2003;27:333-7.

35. The Rate and the Time to Transformation in Patients with Potentially Malignant Oral Epithelial Lesions • The 1458 patients with histological diagnoses of various premalignant oral lesions were followed up between 1991 and 2001. • Within the cohort of 1458 patients, 44 patients progressed to oral cancer in the same site as the initial lesions with an overall transformation rate of 3.02% and a mean follow-up time of 42.64 months. J Oral Pathol Med 2007;36:25–9.

36. 不同口腔癌前病變的惡性轉變率 • Hyperkeratosis/epithelial hyperplasia (29.01%) • Submucous fibrosis (27.57%) • Verrucous hyperplasia (22.22%). • Epithelial dysplasia with hyperkeratosis/epithelial hyperplasia (8.85%) • Lichen planus (9.80%) • Epithelial dysplasia with submucous fibrosis (2.54%) J Oral Pathol Med 2007;36:25–9.

37. 個案管理原則 • 建立高危險群資料庫 • 確立癌前病變回診再檢查模式 • 選擇適當回診時間