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Soft Tissue Sarcoma
41
Figure 7. SFTS of lower extremity treated with 60 Gy using IMRT.
Conclusion
• The proximal lower extremity is the most common site for STS and surgery alone is
not ideal for tumors with high risk features.
• Coordinated multimodality local therapy in the form of surgery and radiation is often
critical to local control, limb preservation, and functional outcome in these patients.
• Preoperative radiation may provide a functional benefit in long-term survivors
without compromising local control.
• In select circumstances, adjuvant chemotherapy may augment local management.
• Technical advances in surgery and radiotherapy hold promise both in the primary
setting and in managing the difficult scenarios of reirradiation and unresectable
tumors.
Section - II. Head and Neck Cancer
Oral Cavity Cancer
Tumors of the oral cavity are relatively less common compared to other head
and neck sites such as the larynx.
Tumors from oral cavity may present with nonhealing mouth ulcers, loosening
of teeth, ill-fitting dentures, dysphagia, odynophagia, weight loss, or referred
otalgia.
More than 60 % of patients with primary tongue lesions have cervical nodal
involvement, while the incidence is substantially lower in patients with hard
palate and lip cancers.
A physical examination should be focused upon the head and neck area with
special attention to tongue mobility, extension to adjacent sites including the
nasopharynx, larynx or hypopharynx, and involvement of the primary echelon
nodal drainage levels I and III for oral cavity.
Squamous cell carcinomas account for more than 90 % of the lesions in the oral
cavity.
The patient with a clinically negative neck is at highest risk of metastasis to
levels I–III while about 15% patient with an N+ neck are at risk of developing
metastases at level IV in addition to the upper three levels.
In general early stage oral cavity cancer can be treated with either surgery or
radiation alone. Surgery is preferred for small lesions without significant
functional deficits.
Patients with locally advanced (stage III or IV) oral cavity cancer, should be
submmited to a functional organ preservation strategy rather than surgical
resection.
Chapter 4
Abstract
Introduction
Oral cavity cancer is the sixth most common cancer worldwide. Incidences vary widely
across geographical areas. Risk factors for squamous cell cancer (SCC) of oral cavity such as
high tobacco and alcohol consumption may be responsible for some of these geographical
variations. Recently infection with human papilloma virus has been showed as a causal factor
Gustavo Arruda Viani
46
Age and gender
Predisposition in males for oral cavity cancer patients, especially those who are
smokers and older than 50 years. Distinct subset of young, female nonsmokers
who have oral tongue cancer without clear etiology
Cigarette smoking
There is an increased risk of HNC, ranging from a 5- to 25-fold, in heavy
smokers compared to nonsmokers.
Alcohol
Alcohol intake and tobacco smoking appear to have an interactive and
multiplicative effect on the risk of developing HNC.
Human papilloma
virus (HPV)
Molecular and epidemiologic evidence points to a causal role for human
papillomavirus (HPV), primarily type 16, in a subgroup of HNCs, namely
invasive tumors of the oropharynx and oral cavity.
for the rising incidence of oropharyngeal cancers in non-smokers. However, the relationship
with oral cavity cancer is not yet established. External beam radiotherapy is used in the
treatment of SCC from oral cavity. Radiotherapy can be used as primarily as in the postoperative setting, but also as first definitive treatment like surgery is felt to be inappropriate.
In this chapter we will revise all these points about SCC from oral cavity.
1. Epidemiology
• Tumors of the oral cavity are relatively less common compared to other head and
neck sites such as the larynx.
• Approximately 275,000 cases of oral cavity cancer are diagnosed worldwide each
year, which represents nearly half of the head and neck squamous cell carcinomas
diagnosed.
• There are 137,000 deaths globally every year. Oral cavity tumors have a propensity
for local invasion and tissue destruction, and the development of early nodal
metastases. They rarely present with distant metastases.
• The male:female ratio has decreased steadily over recent decades as the incidence
rate in men has fallen more sharply relative to that in women. The male:female
mortality ratio has similarly come down from 5:1 50 years ago to less than 2:1 at
present.
Reference
Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin.
2005;55(2):74.
2. Risk factors
Several risk factors have been identified for oral cavity head and neck cancer (Table-1).
Table 1. Risk factors for oral cavity cancer
Oral Cavity Cancer
47
These risk factors are associated with overexpression, amplification, deletion and
inactivation of several genes. These events contribute with molecular progression model of
head and neck cancer carcinogeneses, according to figure-1.
Figure 1. Molecular progression model of head and neck cancer.
References
Gandini S, Botteri E, Iodice S, Boniol M, Lowenfels AB, Maisonneuve P, Boyle P. Tobacco
smoking and cancer: a meta-analysis. Int J Cancer. 2008;122(1):155.
Hashibe M, Brennan P, Benhamou S et al. Alcohol drinking in never users of tobacco,
cigarette smoking in never drinkers, and the risk of head and neck cancer: pooled analysis
in the International Head and Neck Cancer Epidemiology Consortium. J Natl Cancer
Inst. 2007;99(10):777.
3. Anatomy
The oral cavity includes the upper and lower lips, buccal mucosa, gingivobuccal sulcus
upper and lower gingiva (including alveolar ridge), retromolar trigone, hard palate, floor of
mouth, and anterior two-third of the tongue. Figure 2 shows each site included in oral cavity.
4. Clinical Features
• Tumors from oral cavity may present with nonhealing mouth ulcers, loosening of
teeth, ill-fitting dentures, dysphagia, odynophagia, weight loss, or referred otalgia.
• In addition, pain (e.g., during chewing, swallowing, throat pain,), bleeding, speaking
disorders, and dyspnea may also be seen.
Gustavo Arruda Viani
48
• More than 60 % of patients with primary tongue lesions have cervical nodal
involvement, while the incidence is substantially lower in patients with hard palate
and lip cancers.
• Tongue cancer grows as an exophytic and infiltrative lesion. The presenting
symptom is often pain, with or without dysarthria.
• There may be a history of longstanding leukoplakia.
• Lip cancer, the most common site of HNC (excluding skin cancer), usually presents
as an exophytic or ulcerative lesion of the lower lip, occasionally associated with
bleeding or pain.
• Some patients complain of numbness of the skin of the chin due to involvement of
the mental nerve.
Figure 2. Oral cavity anatomy.
5. Diagnosis and Evaluation
• Diagnosis and evaluation of cancers of the oral cavity begin with a complete history
and physical examination.
• History of tobacco and/or alcohol frequently is the major risk factors for these
tumors; tobacco use has the greatest impact and should be recorded.
• These lesions may be preceded or associated with leukoplakia and erythroplakia
which represent premalignant epithelial changes.
• A physical examination should be focused upon the head and neck area with special
attention to tongue mobility, extension to adjacent sites including the nasopharynx,
larynx or hypopharynx, and involvement of the primary echelon nodal drainage
levels I and III for oral cavity.
• CT scans of the neck and chest are appropriate to evaluate and stage head and neck
cancer. MRI may be useful to improve tumor delineation, especially the extent of
soft tissue extension (such as depth of muscle invasion) in oral cancer patients with
dental amalgam. FDG-PET/CT scan is recommended for diagnosis and staging of
head and neck cancer (figure-3).
Oral Cavity Cancer
49
Type
Description
Leukoplakia.
It is the most common premalignant lesion in the head–neck region.
The white macules may have several histological features, from simple
hyperkeratosis, dysplasia and carcinoma in situ to invasive carcinoma. The risk
of malignant transformation in these lesions is higher in smokers and in women.
Erythroplakia.
It is less common than leukoplakia. The risk of malignant transformation is much
higher, and biopsy is essential for histological evaluation.
Lichen planus.
Erosive lichen planus in the oral cavity may transform into malignancy. The
erosive type is seen in the floor of the mouth. Biopsy is essential to determine
lichen type and for differential diagnosis from leukoplakia.
• The results of a prospective study demonstrated that FDG-PET had higher
sensitivities than CT or MRI for both primary tumor detection and cervical node
detection, although the specificities were not different.
Figure 3. Lateral tongue lesion seen in the physical exam and CT.
Reference
National Comprehensive Cancer Network (NCCN) guidelines. Available at:
www.nccn.org (Accessed on May 15, 2012).
6. Pathology
Squamous cell carcinomas account for more than 90 % of the lesions in the oral
cavity.
These tumors can be categorized as well differentiated (greater than 75 %
keratinization), moderately differentiated (25 to 75 % keratinization) and poorly
differentiated (less than 25 % keratinization) tumors.
Other less common histologies include verrucous carcinoma, a variant of squamous
cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid
carcinomas. In additional, some premalignant lesions of the oral cavity have a
potential for malign transformation (table-2).
Table 2. Premalignant lesions of oral cavity
Gustavo Arruda Viani
50
Reference
World Health Organization Classification of Tumors: Pathology and Genetics: Head and
Neck Tumors, Barnes L, Everson JW, Reichart P, Sidransky D (Eds), WHO Press,
Switzerland 2005
7. Routes of Spread
• Lymphatic spread of the tumour from the oral cavity into the neck generally follows
an orderly and predictable fashion.
• The patient with a clinically negative neck is at highest risk of metastasis to levels I–
III while about 15% patient with an N+ neck are at risk of developing metastases at
level IV in addition to the upper three levels (figure-4).
• Skip metastases to level IV may occur without compromising of levels II and III,
mainly for cancer of the anterior tongue.
• Metastases to level V are however seen in only about 1% of patients with clinically
palpable nodes at other levels and are almost never seen as skip metastases.
• This understanding of the patterns of nodal metastasis from lesions of the oral cavity
has practical implications in the design of radiotherapy fields.
Figure 4. Incidence of occult lymph node involvement in the clinically node negative patient with
cancer of the oral tongue.
Reference
Lindberg RD: Distribution of cervical lymph node metastases from squamous cell carcinoma
of the upper respiratory and digestive tracts, Cancer 29:1448, 1972.
8. Staging
The tumor node metastases (TNM) system of the American Joint Committee on Cancer
(AJCC) and the International Union for Cancer Control (UICC) has been used to stage
hypopharyngeal cancers (table-3).