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
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
BIOPSY : Negative for malignancy
ENT Examination •OC : ulcerative lesion at Lt. lateral tongue size 0.5*0.5 cm., submucosal lesion 2*3cm., no limited tongue movement
•A.. •B.. •C.. •D.. •E..
DIAGNOSIS AND MANAGEMENT
•CA Tongue T2N0M0
MANAGEMENT •Surgery? •RT?
MANAGEMENT •Surgery? •RT? Wide excision?
DIAGNOSIS AND MANAGEMENT •Dx. CA Tongue T2N0M0 •Rx. Lt.Hemiglossectomy with primary closure with Lt. SND I-IV
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
Evaluation of the N 0 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
Evaluation of the N 0 Neck •Structure in neck mistake •Transverse process of atlas •Carotid bifurcation •Submandibular gland
Evaluation of the N 0 Neck •Digital palpation •CT / MRI •Ultrasound •Ultrasound guided FNAB
Evaluation of the N 0 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)
N 0 Neck affecting the recurrent/survival rate Oral cavity CA Type N0 1 node 2 nodes ≥ 3 nodes 5 years survival 75% 49% 30% 15%
Therapeutic modalities for the N0 neck •Prophylactic Neck dissection •Prophylactic Neck irradiation •Observation with therapeutic ND once regional metastasis become appearance
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
The N 0 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
Surgical therapy in the N 0 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 )
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%
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
Elective neck dissection VS Elective neck irradiation •Prophylactic neck RT provides equal control rate for neck metastasis to prophylactic ND
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
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 CO 2 25 •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
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
Morbidities of associated ENI •Xerostomia •Dsyphagia •Increased oral passage time •Mucositis •Pain •Increased complication if salvage sx. •Long duration of tx.