INTER-HOSPITAL CONFERENCE

1. INTER-HOSPITAL CONFERENCE 21 DEC.2007

2. ผู้ป่วยชายไทยคู่ อายุ 40ปี อาชีพ ข้าราชการครูภูมิลำเนา จ. ปทุมธานี CC: เจ็บที่ลิ้นด้านซ้าย 2สัปดาห์ ก่อนมา ร.พ. PI : ~ 2 สัปดาห์ ก่อนมา ร.พ. มีแผลที่ลิ้นด้านซ้าย, เจ็บ, ไม่มีเลือดออก, ทำงานหนักพักผ่อนน้อย PHx. : - ปฏิเสธโรคประจำตัว - ปฏิเสธแพ้ยา - ดื่มสุรา, สูบบุหรี่เล็กน้อย หยุดมา 2 สัปดาห์

3. ประวัติเพิ่มเติม • ได้รับการรักษาโดยแพทย์ หู คอ จมูก จากต่างจังหวัด โดยการจี้ยา และได้ยาทา • ปฏิเสธฟันผุ, การใส่ฟันปลอม • ปฏิเสธประวัติโรคมะเร็งในครอบครัว

4. Physical examination • Thai male, not pale, no jaundice • v/s T 37˚C PR 80/min BP 120/80 mmHg • Heart : normal • Lung : clear • Abdomen : soft, not tender, no hepatomegaly • Neuro sing : WNL

5. ENT Examination • AR : normal mucosa, no discharge • PR : no mass, no discharge • OC : ulcerative lesion at Lt. lateral tongue size 0.5 x 0.5 cm. • IDL : no mass, TVC move bilateral • Neck : no palpable lymph node

6. Management?

7. BIOPSY : Negative for malignancy

8. DIFFERENTIAL DIAGNOSIS

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

11. INVESTIGATION

12. INVESTIGATION • A . • B . • C . • D . • E .

13. DIAGNOSIS ANDMANAGEMENT

14. DIAGNOSIS

15. DIAGNOSIS • CA Tongue T2N0M0

16. MANAGEMENT • Surgery? • RT?

17. MANAGEMENT • Surgery? • RT? Wide excision?

18. DIAGNOSIS AND MANAGEMENT • Dx.CA Tongue T2N0M0 • Rx.Lt.Hemiglossectomy with primary closure with Lt.SND I-IV

19. Surgical Pathology Report • Tongue : consists of Lt. half portion of tongue, measuring 5*3*2.5 cm. The outer surface reveals an ulcerated light tan firm mass, measuring 2.7*1.8*0.8cm., occupying the Lt.half of tongue, 0.5 cm.from medial resected margin and 0.5 cm.from deep resected margin • Lymph node group I-IV : No evidence of malignancy

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

21. Management of the N0 Neck in CA Oral cavity

22. Evaluation of the N0 Neck • The reported false negative rate in assessing of cervical LN metastasis by palpation is 20%-50% • Factor affecting : • The experience of the examiner • The patient’s body • The previous treatment – Sx / RT

23. Evaluation of the N0 Neck • Structure in neck mistake • Transverse process of atlas • Carotid bifurcation • Submandibular gland

24. Evaluation of the N0 Neck • Digital palpation • CT / MRI • Ultrasound • Ultrasound guided FNAB

25. Evaluation of the N0 Neck • Malignancy criteria for CT/MRI • LN > 15 mm. in level II • LN > 10 mm. in other levels • Group of ≥ 3 nodes ( 1-2 mm.) • Central necrosis • Loss of tissue planes ( fat plane)

26. Oral cavity CA Type N0 1 node 2 nodes ≥ 3 nodes 5 years survival 75% 49% 30% 15% N0 Neck affecting the recurrent/survival rate

27. Therapeutic modalities for the N0 neck • Prophylactic Neck dissection • Prophylactic Neck irradiation • Observation with therapeutic ND once regional metastasis become appearance

28. The N0 neck in oral cavity CA • Byers et al : the prediction of nodal metas. In primary oral tongue SCCA • The depth of muscle invasion • N stage • The degree of differentiation of the 1˚ tumor • T1N0 with muscle invasion < 4 mm., WD  14% chance of nodal involvement

29. The N0 neck in oral cavity CA • SCCA of oral cavity the sites with < 20% occult metastasis : • T1/T2 lip • T1/T2 oral tongue < 4 mm in thickness • T1/T2 FOM < 1.5 mm in thickness

30. Surgical therapy in the N0 neck with oral cavity CA • SOHND • Minimal morbidity • Reduces the risk of occult disease • Avoid the undesirable side effect of RT ( RT is reserved for possible future tx. of second primary tumor )

31. RT in the N0 neck with oral cavity CA • An alternative treatment to SOHND • PORT of the surgically treated primary tumor site, the neck has not been dissected, and the risk of occult regional dz. is substantial • Primary tumor is treated with RT and the risk of occult node > 20%

32. Elective neck dissection VS Elective neck irradiation • ENI reduced neck failure rate in pt with control primary tumor and N0 neck from 18% to 1.9% • In T1N0 SCCA oral tongue, ENI provided 95% control rate for neck recurrences compare with 38% without ENI • Modality is chosen to Tx primary cancer may also help in formulating a decision as to how to tx the neck

33. Elective neck dissection VS Elective neck irradiation • Prophylactic neck RT provides equal control rate for neck metastasis to prophylactic ND

34. THANK YOU FOR YOUR ATTENTION

35. Combined modality of treatment • perineural spread • intravascular spread • intralymphatic spread • + ve margin • 2 histo. Positive LN • multiple +ve LN • extracapsular spread

36. Management of contralateral N0 • 14% incidence of involvement of contralateral neck node regardless of tumor stage • If primary oral cavity cancer is midline location, bilaterally, along the tip of tongue or approaches or cross the midline

38. BASIC LAB . • CBC : Hct. 36% WBC 11,200 ( N 72.2% L21% E 2.1% M 3.9%) • BUN 5 Cr 0.5 • Na 137 K 4.3 Cl 106 CO225 • FBS : 107 • LFT : Alk.59 SGPT 12 SGOT 17 TB 0.63 TP 7.8 Alb 4.6 • EKG : Normal • CXR : No active pulmonaly lesion

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

40. @

42. N0 in early SCCA oral cavity • Most important prognostic factor in Mx of oral SCCA is status of cervical LN. • Present of metastasis to cervical LN can reduce curative rate by 50% • 3 Tx options are available. • Observation with therapeutic ND once regional metastasis become appearance • Elective neck RT • Elective neck dissection

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