ORAL-ONCOLOGY SURGERY SERIES : ORAL CAVITY CANCER / kanker rongga mulut ( definition, sign, symptoms, etiology, diagnosis and management)

CHAPTER I

INTRODUCTION

Diseases of the oral soft tissues has been a serious concern by experts, especially with the rising cases of deaths caused by cancer in the oral cavity particularly in countries that are developing.

Oral cavity cancer is approximately 5% of all malignancies occurring in men and 2% in women (Lynch, 1994). It has been reported that oral cancer is the leading cancers in India especially in Kerala where the incident was reported at an average height, about 20% of all cancers (Balaram and Meenattoor, 1996).

Although there are developments in the diagnosis and therapy, abnormalities and mortality resulting from oral cancer is still high and has long been a problem in the world. Several reasons are put forward for this is mainly due to the lack of early detection and identification of high risk groups, as well as failure to control the primary lesion and cervical lymph node metastasis (Lynch, 1994; and Meenattoor Balaram, 1996).

To overcome the problems caused by oral cancer, WHO has made instructions to control oral cancer, especially for countries that are developing. Control is based on primary prevention measures where the main principle to reduce and prevent exposure to substances that are carcinogens. The second approach is through the implementation of secondary prevention, ie early detection of cancerous lesions and precancerous oral cavity (Subita, 1997). Folson et al, 1972, estimates that 80% of all cases of oral cancer deaths can be prevented with early detection of malignancies in the mouth (Folson et al, 1972).

In general, for the early detection of malignancies in the mouth can be done through anamnese, clinical examination and confirmed by additional tests in the laboratory. In this paper will put forward measures that can be done by the dentist to detect early malignant processes in the mouth. It is expected to find a dentist suspected lesions as malignant process early so that the prognosis of oral cancer is better.

CHAPTER II

Oral cavity cancer

II.1 DEFINITIONS

A. Restriction

Oral cavity cancer is cancer that originates in either coming from the mucosal epithelium or the salivary glands in the oral cavity wall and organs in the mouth.

   

The boundaries of the oral cavity are:

• Home: the edge of the upper lip vermilion and lower lip

• Top: the hard palate and Molle

• Lateral: right and left buccal

• Below: The floor of the mouth and tongue

• Rear: faringeus anterior arch of the left and right uvula, arch

                           glossopalatinus either side, the lateral edge of the tongue,

                           sirkumvalata papillae of the tongue.

The scope of oral cavity cancer include the following specific areas:

a. lip

b. tongue 2/3 anterior

c. buccal mucosa

d. floor of the mouth

e. upper and lower gingival

f. retromolar trigone

g. the hard palate

h. soft palate

Excluding cancers of the oral cavity are:

a. Sarcoma and malignant tumors in the maxilla or mandible odontogen

b. Soft tissue sarcoma and peripheral nerves in the lip or cheek.

c. Carcinoma of the skin of the lips or cheeks.

II.2 EPIDEMIOLOGY

1. Incidence and relative frequency

How much of the oral cancer incidence in Indonesia we do not know for sure. Relative frequency in Indonesia is estimated to 1.5% -5% of all cancers. The incidence of oral cancer in men who are high in France is 13.0 per 100,000, and is low in Japan is 0.5 per 100,000, was higher in women in India is 5.8 per 100,000 and are low in Yugoslavia which is 0.2 per 100,000 (Renneker , 1988). The incidence of oral cancer in India by 20-25 per 100,000 or 40% of all cancers, while in the U.S. and Europe at 3-5 per 100,000, or 3-5% of all cancers. Oral cavity cancer most often on the tongue (40%), then the floor of the mouth (15%), and the lips (13%).

2. Distribution of sex

Oral cavity cancer is more abundant in males than females with a ratio of 3/2 - 2/1

3. Age distribution

Oral cavity cancer mostly occurs in the age above 40 years (70%).

4. Geographic distribution

Oral cavity cancer is widespread throughout the world. Insidensnya high in France and India, are low in Japan.

5. Etiology and risk factors

Etiology of oral cancer is exposure to carcinogens, there is lots of cigarettes or tobacco.

High risk for oral cancer have found in people who are smokers, nginang / quid, alcohol consumption, dental caries, poor oral hygiene

II.3 Classification Histopathology

A. Histology type

Most ( 90%) cancers originate from the mucosa of the oral cavity in the form of epidermoid carcinoma or squamous cell differentiation skwamosa with good, but can also berdiferensiasinya moderate, bad or anaplastic. When the pathological picture showed a rabdomiosarkoma, fibrosarcoma, malignant fibrohistiocytoma or other soft tissue malignant tumor, need to be carefully examined whether the tumor was actually a malignant tumor of the oral cavity (C00-C06) or a malignant tumor on the cheek soft tissue, skin or bone invasion held into the oral cavity.

B. Degree of differentiation

C. Standard Pathology Report

To report on the results of pathologic examination of specimens of operation include:

1. histologic type of tumor

2. degree of differentiation (grade)

3. examination to determine the TNM stage

 pathological (pTNM)

T = primary tumor

- Size of tumor

- The invasion into blood vessels / lymph

- Operation of radicalism

N = regional nodes

- The size of the KGB

- The number of nodes that are found

- Level of positive nodes

- The number of positive nodes

- The invasion of the tumor out kapsel KGB

- The existence of extra-nodal metastases

M = distant metastasis

II.4 CLINICAL CLASSIFICATION OF STADIUM

Determine the stage of oral cancer are encouraged to use the TNM system of UICC, 2002. Treatment of therapy depends on the stage. In place of the stage to describe the severity of cancer can be also used widely extension of disease.

Stage carcinoma of the oral cavity:

Wide extension of cancer:

CLINICAL I1.5

Most patients have a history of oral cancer lesions / oral precancerous condition before, such as leukoplakia, eritrplakia, submukus fibrosis and others. For that dentists should recognize the clinical picture of these lesions (Balaram and Meenattoor, 1996).

Generally, early stage oral cavity cancers cause no symptoms, less than 2 cm in diameter, mostly red with or without white components, slick, smooth and showed minimal elevation (Lynch, 1994). Often the beginning of malignancy characterized by the presence of ulcers. If there is an ulcer does not heal within 2 weeks, then this situation can already be suspected as early in the process of malignancy. Other signs of malignancy include ulcer process painless ulcer, rolled edge, higher than the surrounding areas and induration (harder), essentially berbintil-nodule and may flake off. Carcinoma growth form of ulcer is called a growth endofitik (Williams, 1990; Tambunan, 1993). Besides oral carcinoma is also seen as a growth eksofitik (superficial lesions) that can form a cauliflower or papillary, bleed easily. Eksofitik lesions are more easily recognized its existence and has a better prognosis (Williams; 1990; Tambunan, 1993).

Clinical picture of oral cancer at various sites of the oral cavity may have some differences (Daftary, 1992). For more details, clinical features will be discussed separately by location.

Cancer of the tongue.

Nearly 80% of cancers of the tongue is located at 2/3 of the anterior tongue (usually on the lateral edge and under the tongue) and in small amounts in the posterior tongue (Daftary, 1992; Tambunan, 1993; Pinborg, 1986). Symptoms in people depending on the location of the cancer. When located on the 2/3 of the anterior tongue, the main complaint is the emergence of a mass that often feels no pain. When it occurs in 1/3 posterior, the cancer is not always known by the patient and the pain experienced is usually associated with throat pain.

Cancer that is 2/3 more anterior tongue can be detected earlier than now located at 1/3 posterior tongue. Sometimes regional node metastases limph first may be an indication of small cancers of the tongue: Pinborg, 1986).

In the early stages, cancer of the tongue can be clinically manifested in various forms, may be patches of leukoplakia, thickening, development endofitik eksofitik or ulcers form. But mostly in the form of ulcers: Daftary, 1992). Ulcers in the long run it will have deeper infiltration of the edges do not have an induration (Pinborg, 1986). Generally do not cause pain unless there is secondary infection.

Cancer of the lips.

Lip cancer is always associated with people who have outside activities such as fishing and farming. Sunlight may be involved in cancer Datogenese lip. Generally occurs more frequently in the lower lip upper lip jaripada (Daftary, 1992; Pinborg, 1986; Smith, 1989).

At the beginning of growth, the lesion may be a small nodule or ulcer does not heal. Tumor detection in this situation provides an opportunity to find an early carcinoma (Daftary, 1992; Pinborg, 1986, Tambunan, 1993). Lesions that may further shape papillari, ulcerative or infiltrative. Papilomatous type can be initiated from a thickened epithelium and part of this epithelium remain on the superficial. Ulcerative lesions and infiltrative beginning of the thickened epithelium but subsequently experienced a deeper infiltration (Daftary, 1992). The most important sign is that there is induration obtained on the outskirts of the ulcer.

Floor of mouth cancer.

On the basis of oral cancer is usually associated with the use of alcohol and tobacco. At the initial stage may not cause symptoms. When the lesions of patients will complain of developing a clot in the mouth, or discomfort (Pinborg, 1986; Daftary, 1992).

Clinically the most common form of ulceration of the lesion with hardened edges that arise and are located near the lingual frenulum (Pinborg, 1986). Another form is the thickening of the mucosal redness, nodules are not sick or can be derived from the leukoplakia (Daftary, 1992). In the advanced stages of cancer can occur eksofitik or infiltrative growth.

Cancer in the cheek mucosa.

In developing countries, cancers of the cheek mucosa associated with the habit of chewing a mixture of areca nut, betel leaf, lime and tobacco. The contact with the fringe left and right cheek mucosa for several hours (Daftary, 1992).

At first the lesions do not cause symptoms, seen as an erythematous area, ulceration of the small, red areas with induration and sometimes associated with the type of nodular leukoplakia (Daftary, 1992; Pinborg, 1986). With increasing tumor size, will be the target of trauma at the time to chew, so it tends to become ulcerated and infiltrating.

Cancer in the gingiva.

Cancer in the gingiva generally come from areas where the tobacco quid is placed on people who have this habit. Areas involved are more often than the mandibular gingiva in the maxillary gingiva (Daftary, 1992; Pinborg, 1986).

Ulger early lesions seen as indolent, a small granuloma or as nodules. Lesions at a glance looks similar to lesions produced by chronic trauma or inflammatory hyperplasia (Daftary, 1992). More advanced lesions of infiltrative growth or growth eksofitik deeper. Growth eksofitik like cauliflower, bleeds easily. Infiltrative growth usually grow invasively on the mandibular bone and cause desdruktif (Tambunan, 1993).

Cancer on the palate.

In areas where people have the habit of smoking cigarettes in reverse, on the palate cancer is cancer of the oral cavity are common of all cancers of the mouth. Changes that occur in the oral mucosa associated with cigarette smoking is inversely ulceration, erosion, the nodules and patches. Reddy et al, 1974. described a microinvasive carcinoma to describe an initial lesion in the form of small, oval or round reddish colored, smooth erosion with hyperkeratosis areas surrounding these lesions usually occur in the glandular zone of the hard palate and asymptomatic. If a pressure can bleed (Daftary, 1992).

Most cancers of the palate is eksofitik growth and a broad base to the surface bernodul. If the lesion continues to grow will probably fill the entire palate. Cancer in the palate can cause perforation of the palate and extending to the nasal cavity (Daftary, 1992).

Predilection.

In addition to recognizing the clinical features of malignancy and malignancy early in the process, the dentist should know the factors predilection for age, sex and place of oral cavity cancer. As with cancer in other body parts, most cases of oral cancers occur in old age over 40 years. This situation is linked to the immune system decreases with increasing age. Men are more often affected, possibly associated with smoking and drinking alcohol.

Although oral cancer can occur in all the oral mucosa, it is important to know the predilection place. Asymptomatic early cancer that is localized essentially on three specific points in the oral cavity, including the floor of the mouth, soft palate complex and the ventral surface of the tongue and the middle third and posterior one-third of the lateral aspect of the tongue (Pinborg, 1986; Lynch, 1994).

DIAGNOSTIC PROCEDURES II.6

A. Clinical Examination

a. Anamnesa

Kwesioner way to diagnose a patient or family.

1. Complaint

2. Course of the disease

3. Etiology and risk factors

4. What treatment has been given

5. How the results of treatment

6. How long the delay

b. Physical examination

1) the general status

    General examination from head to toe Determine: 

a. appearance

b. general state of

c. distant metastases

2) Status of local

By the way: 

1. Inspection

2. Bimanual palpation

Abnormalities in the oral cavity is checked by inspection and palpation with the help of the tongue and lighting spatel use a flashlight or head lamp. Full-mouth views, from the lips to the posterior oropharynx. Tactile lesions of the oral cavity is done by inserting one or two fingers into the mouth. To determine which lesions are made by touching bimanuil. One or two finger right or left hand is inserted into the oral cavity and the other fingers touching the outside of the mouth lesions.

To be an inspection of the tongue and oropharynx is the tip of the tongue that has been wrapped with 2x2 inch gauze held by the examiner's left hand and pulled out the mouth and directed to right and left to see the surface of the dorsal, ventral, and lateral tongue, floor of the mouth and oropharynx. Inspections can be even better if the examiner uses the help of a mirror

Determine where the primary tumor site, how it would look, how much in centimeters, how extensive infiltration, how operabilitasnya

3) The status of regional

Palpation if there is an enlarged cervical lymph nodes ipsilateral and contralateral neck. If there is enlargement specify the location, number, size (the largest), and mobility.

2. Radiography Examination

a. X-plain

o X-mandibular photo AP, lateral, Eisler, panoramic, occlusal, mandibular gingiva is done on the tumor or tumor is attached to the mandible

o X-lateral head photograph, Waters, occlusal, gingival done on the tumor, maxillary or maxillary tumor is attached to

o X-Hap photos done on hard palate tumor

o X-thorax images, to determine the presence of lung metastases

b. Imaging (made only on indication)

o Hepatic ultrasound to look at the hepatic metastases

o CT-scan or MRI to assess tumor extension area lokoregional

o A bone scan, if there is suspected metastasis to bone

3. Laboratory

Routine laboratory tests, such as blood, urine, SGOT / SGPT, alkaline phosphatase, BUN / creatinine, albumin, globulin, serum electrolytes, physiology hemostasis, to assess the general condition and preparation of operating

4. Pathology examination

All patients with oral cavity cancer or suspected cancer of the oral cavity should be carefully examined pathologically.

Tumor biopsy specimens taken from

Fine-needle biopsy (FNA) for cytological examination can be performed on the primary tumor or lymph node metastases in the neck.

Excision biopsy: when a small tumor, excision of 1 cm or less done

                      is wide excision as definitive surgery (1 cm

                      from the edge of the tumor)

Cakot incisional biopsy or biopsy (punch biopsy) using alligator forceps:

                      when the tumor is large or inoperable

Which should be examined in the preparation of the histopathologic type is, differentiation and extensive invasion of the tumor.

Large tumors are expected to remain operabel:

Biopsy should be done under general anesthesia and can be done simultaneously exploring bimanuil to determine the extent of tumor infiltration (staging)

    

Large inoperable tumor thought:

A biopsy is done with local anesthetic blocks in the normal tissue around the tumor. (Anesthetic infiltration at the tumor should not be made to prevent the spread of cancer cells).

KIND OF DIAGNOSIS upheld

A. Primary diagnosis

Is the macroscopic picture of the cancer disease itself, which is a clinical diagnosis

2. Diagnosis of complications

Another disease is caused by the cancer

3. Secondary diagnosis

Is another disease that has nothing to do with the cancer that affects, but may affect the treatment or prognosenya.

4. Diagnosis of pathology

Is a microscopic picture of the cancer

II.7 THERAPY PROCEDURES

Oral cavity cancer treatment should be multidisciplinary involving several specialist areas are:

- Oncologic Surgeon

- Plastic & Reconstructive Surgeon

- Radiation oncologist

- Medical oncologist

- Dentists

- Rehabilitation specialists

Some things to consider in the treatment of oral cancer is the eradication of the tumor, the return function of the oral cavity, as well as cosmetic aspects / appearance of the patient.

Some factors to consider in determining the kind of therapy is

a) Age of patients

b) the general state of the patient

c) The facilities available

d) The ability of doctors

e) Choice of the patient.

For small lesions (T1 and T2), surgery or radiotherapy alone can provide a high cure rate, with a note that radiotherapy alone in T2 gives a higher recurrence rate than surgery.

For T3 and T4, surgery and radiotherapy combination therapy gives the best results. Provision of neo-adjuvant radiotherapy and or chemotherapy before surgery can be provided in the cavity cancer locally advanced (T3, T4).

Interstitial radiotherapy can be administered or external, eksofitik tumors with small size will be more successful than endofitik tumors with large size.

The role of chemotherapy in the treatment of cancer of the oral cavity is still not much, in the research phase of chemotherapy is only used as neo-adjuvant pre-operative or post-operative adjuvant for the sterilization of the possibility of micro-metastasis.

As a guideline for oral cavity cancer therapy is recommended as table 9 below:

The recommended therapy for oral cancer

Carcinoma of the lip
T1: wide excision or radiotherapy
T2: wide excision
When the komisura, radiotherapy will provide relief to the function and better cosmetic
          T3, 4: wide excision + + deseksi suprahioid postoperative radiotherapy

Carcinoma of the floor of the mouth
T1: wide excision or radiotherapy
T2: not attached periosteum  wide excision
Periosteum attached  wide excision with marginal mandibulektomi
T3, 4: wide excision with marginal mandibulektomi dissection +
            supraomohioid + postoperative radiotherapy
                       
Carcinoma of the tongue
T1, 2: wide excision or radiotherapy
T3, 4: wide excision + + deseksi supraomohioid postoperative radiotherapy

Carcinoma of the buccal
T1, 2: wide excision
When the komisura oris, radiotherapy provides relief to the function and better cosmetic
T3, 4: wide excision + + radioterapipasca different supraomohioid deseksi

Gingival carcinoma
T1, 2: wide excision with marginal mandibulektomi
T3: wide excision with marginal mandibulektomi dissection +
                      supraomohioid + postoperative radiotherapy
T4 (infiltration of the bone / tooth extraction after a tumor):
wide excision with segmental mandibulektomi dissection supraomohioid + + postoperative radiotherapy

Carcinoma of the palate
T1: wide excision to periost
T2: wide excision to bone underneath
T3: wide excision to underlying bone dissection +
      supraomohioid + postoperative radiotherapy
T4 (infiltration of the bone):
            Maksilektomi infrastructural partial / total lesion area + dependent
            dissection supraomohiod + postoperative radiotherapy
                       
Carcinoma of the retromolar trigone
T1, 2: wide excision with marginal mandibulektomi
T3    : wide excision with marginal mandibulektomi
                     Supraomohioid dissection + + postoperative radiotherapy
T4 (infiltration of the bone): Wide excision with segmental mandibulektomi dissection supraomohioid + + postoperative radiotherapy

For carcinoma of the oral cavity T3 and T4, N0 handling can be done deseksi selective neck or regional radiotherapy after surgery. While N1 is obtained at each T to do a radical neck deseksi. Where possible, wide excision of the primary tumor and neck deseksi need to do it en-block.
Provision of postoperative regional radiotherapy depending on the results of pathological examination of lymph nodes metastases (the number of positive lymph nodes metastases, lymph node capsule penetration / extra lymph nodes

A. Curative Therapy
Curative therapy for cancer of the oral cavity is given in oral cavity cancer stage I, II, and III.
A. Primary therapy
Primary therapy for stage I and II surgery or radiotherapy is that each has its pros and cons of each. Whereas for stage III and IV are still operabel is a combination of surgery and postoperative radiotherapy
In the curative therapy should be considered:
a) The correct procedure, because if one result is not to be
    curative.
b) The function of the mouth to speak, eat, drink, swallow, breathe, stay well.
c) Cosmetic is quite acceptable.
a. Operation
Indications of operation:
1) Case operabel
2) Age is relatively young
3) the general state of good
4) There were no severe co-morbidities
The basic principle is that oral cancer surgery:
1) The opening should be large enough to be able to see the entire tumor
    with extension
2) Exploration tumor: to determine the extent of tumor extension
3) wide excision of tumor
o The tumor does not invade the bone, wide excision of 1-2 cm beyond the tumor
o invade the bone, wide excision with resection of the invaded bone
4) regional lymph nodes dissection (RND = Radical Neck Disection or
    modification), if there are regional lymph nodes metastases.
    Dissection is done with the primary tumor when enblok
    allows.
5) Determine the operating radicalism Durante from the edge of the incision surgery
    by examination of frozen pieces. Otherwise create a line of radical
    new wider incision to free the tumor.
6) Reconstruction of defects that occur.

b. Radiotherapy
Indications of radiotherapy
1) The case of inoperable    2) T1, 2 certain places (see above)
3) Cancer of the tongue      4) Age is relatively old
5) Reject the operation       6) There is a severe co-morbidities

Radiotherapy can be given by:
1) teletherapy using: ortovoltase, Cobalt 60, with a dose Linec
    5000 - 7000 rads.
2) Brachytherapy: a booster with intratumoral implantation of a needle
    Irridium Radium 192 or 226 at a dose of 2000-3000 rads.
2. Additional therapy
a. Radiotherapy
Additional radiotherapy treatment is given in the case of a major operation.

(1) post-surgical radiotherapy
Given to the T3 and T4a after surgery, a case that radical excision is not feasible, radikalitasnya doubt, or the operating field contamination by cancer cells.
(2) pre-surgical radiotherapy
Pre-surgical radiotherapy is given in cases of inoperable or operabilitasnya doubt.
b. Operation
Operations carried out in cases of therapy after primary radiotherapy or radiotherapy to operabel residif arising after radiotherapy.
c. Chemotherapy
Chemotherapy is given in the case of the operating field contamination by cancer cells, cancer stage III or IV or residif arise after surgery and or radiotherapy.
3. Complications of therapy
 a. Complications of therapy
In general, stage I to II has been no complications, but complications can occur due to therapy.
Therapy depends on the complications that exist, for example:
1) pain: analgesic 2) Infection: antibiotics
3) Anemia: haematinic 4) Etc.
b. Treatment of complications of therapy
1) Complications of surgery: by type of complication
2) Complications of radiotherapy: by type of complication
3) Complications of chemotherapy: by type of complication
4. Assisted therapy
         Can be given proper nutrition, vitamins, etc..
5. Secondary therapy
 If there are secondary diseases are given according to the type of therapy
                illness
B. Palliative therapy
Palliative therapy is to improve the quality of life of patients and reduce complaints, especially for patients who have no longer curable.
Given palliative therapy in patients with oral cavity cancer:
A. Stage IV distant metastases who have demonstrated
2. There is a severe co-morbidity with shorter life expectancy
3. Curative therapy fails
4. Very advanced age
Complaints that need dipaliasi include:
1. Loko regional
    a) ulcers in the mouth / neck  b) Pain              c) It is hard to eat, drink, swallow
    d) The mouth smells              e) Anorexia       f) oro-cutaneous fistula
2. Systemic:
   a) Pain          b) Shortness of breath   c) It is difficult to talk
   d) Coughing  e) The care of the          f) A weak

(1) the primary therapy

A. Without meta far: Radiotherapy dose 5000-7000 rads.

    If you need to combine with the operation

2. There is much metastases: Chemotherapy

    Chemotherapy can be used include:

1) epidermoid carcinoma:

Drugs that can be used: Cisplatin, Methotrexate, Bleomycin, Cyclophosphamide, Adryamycin, with numbers 20 -40% remission. For example:

     a) a single drug: Methotrexate 30 mg/m2 2x a week

     b) Drug combinations:

V = vincristine: 1.5 mg/m2 hl

B = Bleomycin: 12 hl + 12 mg/m2 repeated every hour 

M = Methotrexate: 20 mg/m2 h3, 8 2-3 weeks

2) adeno carcinoma:

Drugs that can be used include: Flourouracil, Mithomycin-C, Ciplatin, Adyamycin, the remission rate 20 - 30%. For example:

            

       a) a single drug: Flourouracil:

Beginning dose: 500 mg/m2

Maintenance dose: 20 mg/m2 every 1-2 weeks

      b) Drug combinations:

F = Flourouracil: 500 mg/m2, hl, 8,14,28

A = Adryamycin: 50 mg/m2, hl, 21  repeated every

M = Mithomycin-C: 10 mg/m2, h1 6 weeks

(2) additional therapy

     If necessary: ​​surgery, chemotherapy, or radiotherapy

(3) Treatment of complications

1. Pain: analgesic in accordance with the "step ladder WHO"

2. Shortness of breath: tracheostomy

3. Difficult to eat: gastrostomi

4. Infection: antibiotic

5. Halitosis: mouthwash

6. And so on.

(4) Therapy aid

1. Good nutrition

2. Vitamin

(5) Secondary Treatment

      If there is a secondary disease, treatment according to disease concerned.

                                           

                                                   

* Suprahioid dissection for carcinoma of the lip

   Supraomohioid dissection for carcinoma of the oral cavity

   Bilateral dissection for lesions in the midline

The lesion in the middle (midline): For T 3.4 N  handling bilateral negative
Bilateral positive N: RND can be done to preserve a one-stage internal v.jugularis stage 2 or treated with a distance of 3-4 weeks.

*) Indication of adjuvant radiotherapy to the neck after RND:

1. Lymph nodes that contain metastases> 1 piece

2. Lymph node diameter> 3 cm

3. There is a growing ekstrakapsuler

4. High grade malignancy

Residif local / regional / distant (metastases)  handling referred to the handling of T / N / M as the scheme in question

II.8 FOLLOW UP PROCEDURES

Follow-up schedule is recommended as follows:

 1) In the first 3 years: every 3 months

 2) In the next 3-5 years: every 6 months

 3) After 5 years: once every year for life

At annual follow-up, the patient is checked in a complete, physical, X-ray images, ultrasound liver, and bone scan to determine whether the patient completely free of cancer or not.

At follow-up is determined:

1) Long life in years and months

2) Older cancer-free interval in years and months

3) Complaints of patients

4) the general status and appearance

5) Status of disease

   (1) cancer-free (2) Residif

   (3) metastases (4) Incurred cancer or a new

6) Complications of therapy

7) The act or therapy given

CHAPTER III

CONCLUSION

Oral cancer at an early stage is difficult to detect clinically, because it often causes no symptoms in the patient or the changes that accompany it may not be so obvious, only produce minor changes in terms of functionality, color, texture, continuity or consistency of the network that are . As a result, patients often come to the dentist with a cancerous lesion that has been in a state of advanced stage. It required an act by the dentist to detect precancerous lesions and oral cancer at an early stage. Cancerous lesions at an early stage can not be adequately identified only by visual examination alone. Knowledge of the clinical picture is good even from a dentist has not been able to establish a proper diagnosis of cancerous lesions at an early stage, because there has been no definitive clinical indicators to determine the severity of a lesion or benign. But even so, the dentist should know the symptoms and the clinical picture of oral cancer lesions at an early stage, so that will be able to plan the next stages of the examination. The following are signs to watch out for the dentist to the possibility of a new oral cancer from occurring or in

advanced stage (Bolden, 1982):

1. White patches, scaly, persistent.

2. Pigment spots which suddenly increase in size.

3. Ulcer that does not heal.

4. Swollen and bleeding gums are not connected with drugs.

5. Progressive facial asymmetry.

6. Teeth all of a sudden, without any history of trauma to the jaw.

7. Parastesi, anesthesia and numbness in the oral cavity.

8. Trismus and pain when moving the jaw.

9. Lumps in the neck, face or mouth tissue.

10. Revocation of the wound does not heal.

11. Change

If there are one or more of these signs, the dentist must immediately conduct a further examination for early detection of cancerous lesions at an early stage, the results could support the clinical features present in the oral cavity. Histopathological examination is usually performed. The results of histopathologic examination and accurate diagnosis depends on the cooperation between the clinician and pathologist, especially in terms of collecting and processing the material accuracy of the examination and identify gels.

REFERENCE

Balaram, P; Meenattoor,G. 1996. Imunology of Oral Cancer-A Review. Singapore Dental Journal. Vol.21. No.1. 36. 

Bolden, T.E. 1982. The Prevention and Detection of Oral Cancer, dalam Stallard,R.E. A Textbook of Preventif Dentistry. Ed. Ke.2. Philadelphia. W.B. Sainders Company. 277-306. 

Coleman, G.C; Nelson,J.F. 1993. Principles of Oral Diagnosis. St. Louis Mosby Year Book. 211-214. 

Daftari, D.K: Mukti,P.R; Bhonsle, R.B [et.al]. 1992. Oral Squamus Cell Carcinoma, dalam Prabhu S.R. Oral Diseases in the Tropics. New York. Oxford Medical Publications. 429 -446. 

Folson, T.C; White, C.P; Broner,l. [et,al]. 1972. Oral Exfoliatif Study. Review of the Literature and Report of Three Year Study. Oral Surgery. 33. 61-64. 

Kerr, D.A; Ash,M.M; Dean,M.H.1978.Oral Diagnosis. Ed. Ke-5 St. Louis. C.V.Mosby Company.336-338. 

Lynch, M.A.1994. Burket's Oral Medicine. Diagnosis and Treatment. Ed.Ke-9. Philadelphia. J.B.Lippincott Company. 203-213. 

McKinney,R.V; Singh,B.B; Schafmer,D.L. 1985. Biopsi Techniques for the General Practioner, dalam Clark,J.W. Clinical Dentistry Vol Philadelphia. Haeper dan Row Publisher.9-14. 

Pedersen,W.G. 1996. Buku Ajar Praktis Bedah Mulut, alih bahasa drg. Purwanto dan drg. Basoeseno. Ed.Ke-1. Penerbit Buku KeJokteran EGC. Jakarta. 147-150 . 

Pinborg,J.J. 1986. Oral Precancer and Cancer, dalam Levine ,N. Current Treatment in Dental Practice. Philadelphia. W.B. Saunders Company. 8-13. 

Pinborg, J.J. 1991. Kanker dan Prakanker Rongga Mulut, alih bahasa drg.Lilian Yuwono.Ed.ke-1. Penerbit Buku Kedokteran EGC. Jakarta. 21-93,125. 

Sciubba, J.J. 1999. Improving Detection of Precancerous and Cancerous Oral lesions. JADA. Vol.130. 1445-1457. 

Scully, C. 1992. Oncogen, Onco-Supressor, Carcinogenesis and Oral Cancer. British Dental Journal. 173. 53. 

Skhlar, G.1984. Oral Cancer. The Diagnosis, Therapy, Management and Rehabilitation of The Oral Cancer Patient. Philadelphia. W.B. Saunders Company. 63-70. 

Subita, G.P. 1997. Kemopreventif Sebagai Satu Modalitas Pengendalian Kanker Mulut. Jurnal Kedokteran Gigi Universitas Indonesia. Ed. Khusus KPPIKG XI.582-585. 

Tambunan, G. W. 1993. Diagnosis dan Tatalaksana Sepuluh Jenis Kanker Terbanyak di Indonesia. Editor dr. Maylani Handoyo. Ed.Ke-2. Penerbit Buku Kedokteran EGG. Jakarta. 185-198. 

Williams, J.H. 1990. Oral Cancer and Precancer: Cliniccal Features. British Dental Journal.168.13-17.