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Oral Cavity Cancer

Oral cavity cancers include a set of malignancies, mainly carcinomas that originate from the mucous membranes (95%), but also tumours of salivary origin, connective tissue or melanomas (5%) that originate at the level of the lip, tongue, floor of the mouth, cheeks, gums, palate (hard and soft) and the anterior tonsil pillars (mouth opening).

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IN SHORT

Oral cavity cancer, or just oral cancer, is cancer that starts in the mouth (also called the oral cavity).

STAFF

At the IEO oral cavity cancer is treated by a multidisciplinary team consisting of specialists in:



RISKS OF ORAL CAVITY CANCER

Oral cavity cancer risk factors are related to lifestyle habits, especially the abuse of tobacco and alcohol. Also a poor diet and poorly-conditioned teeth seem to act as co-factors. The role of viruses (HPV Papillomavirus) is currently under investigation. Cancers of the oral cavity are manifested primarily by a lesion of the mucous membrane. This initially superficial lesion appears like a milky white or red spot as well as a small ulceration that does not usually spontaneously heal, and sometimes bleeds on rubbing.  

The most important characteristic differentiating this lesion from other inflammatory and traumatic lesions (for example ulcer or biting injury) is that it is completely asymptomatic, at least initially. In more advanced stages it may appear as an ulceration, submucosal nodule, more or less hard, florid, cauliflower-like vegetating lesion. In some cases, a pain may occur that radiates to the ear, with difficulty swallowing, bad smell of the mouth, whereas in others, there may be a swelling of the neck.

 

PREVENTION AND DIAGNOSIS

Diagnosis of oral cavity cancer is easy, given the accessibility of the mouth. Histological diagnosis can be made by a simple biopsy under local anaesthesia, a procedure with minimal pain that can be performed in a few minutes. An early diagnosis of vocal cord cancers can be made using a fibro-laryngeal endoscopy with NBI and iSCAN. These very sophisticated instruments allow us to diagnose lesions at the onset stage or when they are very small and hardly recognisable with traditional standard methods. Ultrasound, magnetic resonance and PET (or even a total body CT) allow correct staging. There are no blood tests that can detect the presence of a cancer of the oral cavity.

Good standards for prevention

  • Adopting a healthy lifestyle, not smoking and limiting alcohol intake.
  • Adopting a few precautions in eating habits: eating fruit, vegetables, and foods rich in carotenoids, such as tomatoes, carrots, sweet and spicy peppers, pumpkin, apricots, herbs (probable evidence).
  • Keeping a careful eye on oral hygiene.
  • Not underestimating any injury of the mouth although small or painless (nodules, small ulcers, white or red patches, growths).
  • After the age of 60 in subjects with risk factors, examination of the oral cavity and pharyngeal-laryngeal district is recommended.
  • Undergoing regular visits, if already affected in the past by a carcinoma of the head and neck district.

The most common symptoms and signs are small ulcers of the lip or mouth, a white or red spot in the oral mucosa, frequent epistaxis (nosebleeds), nasal respiratory obstruction, hoarseness, persistent sore throat, feeling of closed ears, pain radiating to the ear, blood in sputum, difficulty chewing, swallowing or breathing, numbness of the tongue, painless and persistent swelling in the neck. The durability of these disorders should be considered as an alarm bell; if they have not resolved spontaneously or with treatment within 3 weeks, a specialist should be consulted.


TREATMENTS AND CLINICAL TRIALS

The first approach to treatment is essential. Cure is the main goal, and is considered as important as the quality of life and functionality of the treated organs, such as the voice, language, swallowing, taste and breathing. IEO provides patients with a multidisciplinary team dedicated to diagnosis, treatment and rehabilitation.

Innovative and minimally invasive therapies: over the years the Division has developed some original techniques and minimally invasive approaches to improve the oncological and functional results of interventions, so that patients have more therapeutic options with less surgical impact. Some of these therapies are available only here in IEO.

Surgery: our head and neck surgeons perform the highest number of operations for malignant tumours each year than any other center in Italy (AGENAS data). Moreover, for more than 20 years we have been conveying the message of Prof Veronesi, that is, "the minimum effective therapy" also for head and neck lesions. We were the first in Italy to offer conservative thyroid surgery, with over 15 years of experience in hemi-thyroidectomy even for malignant tumours. We were among the first to perform endoscopic conservative surgery of the larynx with over 250 procedures a year, we were pioneers in functional tongue surgery allowing a near normal post-op quality of life. Finally, for over 20 years we have been performing very delicate salivary gland surgery. This is the only recognised head and neck surgery department in Italy

Compartmental tongue surgery: a technique devised and developed at IEO in 2000 which has revolutionized the oncological surgery of tongue carcinomas, drastically improving patien' prognosis even in advanced cases.[1]



[1] Calabrese L, Giugliano G, Bruschini R, Ansarin M, Navach V, Grosso E, Gibelli B, Ostuni A, Chiesa F.: Compartmental surgery in tongue tumours: description of a new surgical technique. Acta Otorhinolaryngol Ital. 2009 Oct;29(5):259-64.

Calabrese L1, Bruschini R, Giugliano G, Ostuni A, Maffini F, Massaro MA, Santoro L, Navach V, Preda L, Alterio D, Ansarin M, Chiesa F. Compartmental tongue surgery: Long term oncologic results in the treatment of tongue cancer. Oral Oncol. 2011 Mar;47(3):174-9. doi: 10.1016/j.oraloncology.2010.12.006. Epub 2011 Jan 22

Ansarin M, Bruschini R, Navach V, Giugliano G, Calabrese L, Chiesa F, Medina JE, Kowalski LP, Shah JP. Classification of GLOSSECTOMIES: Proposal for tongue cancer resections. Head Neck. 2019 Mar;41(3):821-827. doi: 10.1002/hed.25466. Epub 2019 Jan 2.


THE VALUE OF A MULTIDISCIPLINARY TEAM

Our multidisciplinary team is dedicated to the diagnosis, treatment and rehabilitation of patients with tumors of the head and neck, and to the study of these diseases. Our team includes over thirty oncology professionals with expertise in various specialties, such as ENT, maxillofacial surgery, emergency surgery, plastic-reconstructive surgery, radiotherapy, medical oncology, radiology, pathology, nuclear medicine, nutrition, physiotherapy, endocrinology, dentistry, voice therapy, speech therapy, psychology, and biology.

The integration of various skills can address complex clinical problems, from diagnosis and treatment planning, to the functional recovery (speech, breathing, swallowing) in order to achieve the best results with cancer and adequate quality of life. The cervicofacial surgery program consists of the medical-surgical team, Radiotherapy and Medical Oncology specialists, dedicated radiologists, endocrinologists, nuclear physicians and pathologists. The team works in harmony and meets on a weekly basis to discuss cases of patients who trust in our structure. They develop comprehensive personalized care plans considering all aspects of treatment and rehabilitation, considering the different treatment options, taking into account the needs of individual patients in accordance with internal, national and international guidelines.

The team, in close collaboration with the Scientific and Health Management Board, monitors the results of treatment and the quality of the performances in real time in order to point out critical issues and identify areas for improvement and development. The multidisciplinary meetings are an opportunity for professional development based on the exchanges in the group, the evidence in the literature, and the critical review and update of guidelines as well as diagnostic and therapeutic approaches. The information obtained from the critical review of the clinical activities, from technological innovations, from the study of the evolution of the cancers treated, and from continuous updating are used to identify open issues and propose research activities. Thanks to this approach, clinical research activities and institutional research projects in collaboration with national and international institutions have been put in place.

Oral cavity cancers

 

Therapy is primarily surgery. The earlier the diagnosis, the lighter the surgery will be and the milder the consequences on functionality. In more advanced cases, larger removals are necessary, followed by sophisticated reconstructions through autografts, and rehabilitations of variable duration after surgery. Radiotherapy and chemotherapy are only used as complementary to surgery in selected cases, or as curative therapies in cases where surgery cannot be performed or when it is refused by the patient. 

At IEO, a new method has been developed for the surgical removal of the oral cavity and oropharynx tumours, called compartmental surgery, which allows an significant improvement in prognosis in over 400 cases of advanced tongue cancer treated.

Distant metastases of head and neck carcinoma

Distant metastases are defined as tumor spread to other organs. Lung, liver, and bone are the most common sites for hematogenous metastases of head and neck squamous cell carcinoma. The incidence of distant metastasis in head and neck squamous cell carcinoma is low for the general head and neck squamous cell carcinoma population: generally below 5% at presentation. Head and neck squamous cell carcinoma patients with distant metastases are generally candidates for palliative treatment scenarios only, because currently no systemic therapy has curative potential in head and neck squamous cell carcinoma patients with distant disease. Consequently, extensive locoregional treatment is usually considered futile in these patients. Particular attention is paid to our collaboration with CNAO, National Centre of Oncology Hadrontherapy) for Phase II, the clinical trial on radiotherapy boost, using protons (hadron therapy) for locally advanced tumours of the cervical-cephalic region.

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Cancers of the oral cavities 

Particular attention is paid to the reconstruction of post-surgical defects. The experience of more than 600 autografts of micro-vascularised flaps and the development of new models of functional reconstruction put us as leaders in this field.

 

Attention to the patient and his quality of life: since 2003, the department has been equipped with a speech therapy service, one of the best in Italy, which deals with the rehabilitation of swallowing, phonation and the articulation of the word. The division also has a dentistry service that deals with the preparation for surgery and postoperative dental rehabilitation. The IEO also has a physiotherapy service for motor and respiratory rehabilitation and a dietician for the management of nutritional aspects.  Pain management and Psychological support services are also offered. A holistic approach which takes care of all the needs of the patient, allowing a more rapid return to normal life.

Clinical nutrition

Stage and location of the disease, anatomical changes resulting from any surgical procedure, and the acute and late toxicity of chemo-radiotherapy are all factors that may contribute to the impairment of swallowing and create deficiency in the oral protein-calorie intake.

Artificial Nutrition (AN) is indicated in cases of cancers that cause a stenosis (narrowing), severe dysphagia (difficulty in eating that contraindicate oral feeding), or in the case of evident malnutrition or in the patient who, although feeding through the mouth, takes on a calorie-protein amount <50% of nutritional needs. AN must also be started when you expect a period of severe dysphagia longer than 7 days or inadequate intake (<60% of the nutritional requirements) for at least 10 days.

In patients with cancer of the cervical-facial district, Enteral Nutrition (EN) represents the primary route of choice when the gastrointestinal tract is accessible and functioning. It can be performed via nasogastric tube or via Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy Nutrition, in case of expected duration of nutritional support greater than 3-4 weeks. EN is effective in containing the decline in body weight, preventing dehydration and interruptions of the radio-chemotherapy treatment, reducing the frequency and duration of hospitalisations, and improving the quality of life.

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CREDITS

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