buccal cancer

8/3/2019 Buccal Cancer

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Tobacco and alcohol use are the main etiologic agents associatedwith the development of buccal carcinoma.

In Asia, betel nut is a significant etiologic agent, in addition to

tobacco and alcohol.

In India, over 90% of patients with buccal carcinoma have a historyof using betel nut.

Other suspected but not confirmed etiologic agents include:

human papilloma virus,

poor oral hygiene,

and chronic irritation.


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It occurs more often in men, male:female ratio of 3-4:1most commonly in the 7th or 8th decade of life.

incidence of buccal carcinoma is much higher in Asia. In Southeast

Asia, the disease is the most common form of oral cavity

cancer.In India, buccal carcinoma is the most common cancer in men and

the third most common cancer in women.

widespread practice of betel nut chewing.


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Betel nut, composed

mainly of the fruit of the

Areca Palm and often

mixed with tobacco, is

placed along the buccal

mucosa to induce a

feeling of euphoria.Buccal carcinoma

related to betel nut

chewing tends to

develop at an earlierage, with most cases

occurring between the

ages of 40-70.


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No symptoms in the early stageWhite or red lump in the mouth that does not go away aftertwo weeks (Leukoplakia)

A red, raised patch in the mouth that bleeds easily

A lump or thickening in the mouthPain increases when eating or drinkingSoreness or a feeling that something is caught in the throatDifficulty chewing or swallowing

Severe ear painDifficulty moving the jaw or tongueHoarsenessNumbness of the tongue or other areas of the mouthDentures fit poorly or become uncomfortable because the

jaw is swollen


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Buccal carcinoma commonly presents as a slow-growing mass on the buccal mucosa. Smalllesions tend to be asymptomatic and are often

noted incidentally on dental examination.

Pain commonly occurs as the lesion enlarges andulceration develops. Oral intake may worsen the

pain and lead to malnutrition and dehydration.Associated symptoms include bleeding, poordenture fit, facial weakness or sensory changes,dysphagia, odynophagia, and trismus.


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A doctor will examine the inside of the mouth and back of thethroat to check the location and size of the tumor. Examination

of the ears, nose and neck are needed to help determine if the

tumor has spread.

CBC count,electrolytes, BUN and creatinine

Prothrombin time (PT), Partial thromboplatin time

Liver function test: used to increased for alcoholic liver

damage

Blood typing and cross matching

X-rays to determine if the tumor has spread to the lung.Fine Needle Aspiration Biopsy (FNAB)

Computerized tomography (CT) scan.

Magnetic resonance imaging (MRI).

Positron emission tomography (PET) scan.


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ANATOMY & PHYSIOLOGY


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1.Mouth (oral cavity, buccal cavity)Histology: stratified squamous epithelium, except on gums, hard palate, tongue dorsum (these are keratinized);

bound by lips anteriorly, cheeks laterally, palate superiorly, tongue inferiorly functions:

ingestion: intake of food

mechanical digestion: chewing of food

chemical digestion: enzymatic breakdown of food

2. Teeth (will be covered in lab) grinding of foodincisors blade shaped; function in clipping and cutting

cuspids (canines) conical with sharp ridgeline and pointed tip; function in tearing and slashing

bicuspids (premolars) 1-2 roots with flattened crowns and prominent ridges; function to crush, mash, and grind

molars flattened crowns with prominent ridges with 3+ roots; function in crushing and grinding

3. Tongue - functions to manipulate food while chewing & swallowing

4. Salivary glandstypes: (will be studied further in lab)

parotid glands anterior to ear; between masseter muscle and skin; contain only serous glands (water secretion with

little mucus)

submandibular glands along the mandibular body; equal numbers of serous and mucus gland cells

sublingual glands anterior to submandibular gland and under tongue; equal numbers of serous and mucus gland

cells

Saliva contents and their functions:

mucus and water coating and putting food into solution

salivary amylase digests complex carbohydrates

antibacterial proteins lysozymes and defensins; inhibit bacterial growth


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The American Joint Commission on Cancer

defines the buccal mucosa as the membrane lining of

the inner surface of the cheeks from the line of contact

of the opposing lips anteriorly to the line of thepterygomandibular raphe (lateral to retromolar trigone)

posteriorly. The medial boundary is the line of

attachment of the buccal mucosa to the upper and

lower alveolar ridges.


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The layers of the cheek from medial to lateral include themucosa, pharyngobasilar fascia, buccinator muscle,

buccinator fat pad, subcutaneous tissue and skin. Sensory

innervation of the buccal mucosa and cheek skin is from the

maxillary and mandibular branches of the trigeminal nerve.

The buccinator muscle is innervated by the facial nerve. The

parotid duct (Stenson duct) pierces the buccinator muscle

and buccal mucosa opposite the maxillary second molar.


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The buccal region lacks anatomic barriers beyond the

buccinator muscle and its fascia to prevent the spread ofcancer. Buccal cancer can spread laterally to extend through

the skin of the cheek; medially to involve the alveoli, palate,

tongue, and floor of the mouth; posteriorly to involve the

retromolar trigone mucosa, the ascending ramus of the

mandible, and the masseter and pterygoid muscles; andanteriorly to involve the oral commissure and lips.


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The primary-echelon lymphatics of the buccal mucosa drain to

the facial and submandibular lymph node basins prior to theupper jugular nodes. The lymphatics may occasionally drain to

the upper jugular nodes via the parotid nodes.


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PATHOPHYSIOLOGY

PREDISPOSING FACTORS

-age

-gender

-race

PRECIPATING FACTORS

-Smoking,

-Chewing betel nut,

-Alcoholism,

-poor oral health

-HPV and chronic irritation


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Radiation therapyIndications for radiation orchemoradiation therapy inthe postoperative setting

include large or deeplyinvasive tumors, close orpositive margins, multiple

lymph nodes with

metastatic cancer, lymphnode extracapsularspread, or perineural

invasion.


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Chemotherapy

The role of induction

chemotherapy in the

treatment of advanced stage

head and neck squamouscell carcinoma is

controversial and is often

recommended for clinical

trials.Chemotherapy may also be

indicated in the palliative

setting for recurrent or

distantly metastatic disease.


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CHEMOTHERAPY PROCEDURE

Once IVF inserted, please give pre medications

and may start chemotherapy.

PRE-MEDS:

Diphenhydramine 50 mg

Ranitidine 50 mg

Dexamethasone 5mg

Gravisetron (Sancuso) 1 amp IV push


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Run the following as side drips:1. Carboplatin 450mg in 250cc D5W x 30mins.

2. Docetaxel 100 mg in 250cc D5W x 1hr.

then discontinue.

Once docetaxel drip is consumed please request MROD tocorporate Nimotuzumab 50 mg, 4 vials in 60 cc PNSS in soluset.Run soluset content (100ml)

Gravisetron patch (Sancuso) attached.

PRN drugs:

Hydrocortisone 100mg for allergic reaction.

Give Neulastyl(Pegfilgastrim) 1 pre filled syringe SQ

24 hours after the end of nimotuzumab infusion.

-CBC with WBC and platelet count monitoring was ordered.

-Continue Erythropoietin 10,000 U SQ 3x a wk


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DRUG MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONSNURSING

RESPONSIBILITIES

CARBOPLATIN

(Naproplat)

450 mg

Cytotoxic

Chemotherapy

Carboplatin is second-

generation platinum

compound that may be

classified as a non-

classical alkylating agent

and is cell-cycle

nonspecific. It is cytotoxic

platinum complex that

reacts with nucleophilic

sites of DNA. This causes

interstrand and

interstrand cross links

and DNA protein cross

links, which inhibit DNA,

RNA and protein

synthesis.

Treatment of advanced

ovarian cancer, small-

cell lung cancer, head

and neck cancer and in

genito-urinary cancer,

particularly in testicular,

bladder and cervical

cancers. Antitumor

activity of carboplatin

has also been observed

in pediatric brain tumor

(meduloblastoma).

Patients with a history

of severe allergic

reaction to cisplatin or

other platinum

containing compounds

and patients with

severe bone marrow

depression or significant

bleeding.

Hematologic Toxicity: Bone

marrow suppression is the dose-

limiting toxicity of carboplatin.

Thrombocytopenia, neutropenia,

leucopenia, a higher incident of

severe leucopenia and

thrombocytopenia. Anemia, Bone

marrow depression.

Gastrointestinal Toxicity:

Vomiting, Nausea, diarrhea,

constipation.

Neurologic Toxicity: Peripheral

neuropathies with mild

paresthesias, visual disturbances

and change in taste occur rarely.

Nephrotoxicity: Development ofabnormal renal function test

results is uncommon with

carboplatin.

Hepatic Toxicity: Abnormal liver

function tests in patients may be

found with normal value.

Electrolyte Changes: The

abnormally decreased serum

electrolyte values may be foundin some patients.

Allergic Reactions: rash, urticaria,

erythema, pruritus and rarely,

bronchospasm and hypotension.

Others: Pain and asthenia occurs

most frequently. Alopecia,

cardiovascular, respiratory ,

genitorurinary.

Carboplatin should be

administered under the

supervision of a qualifies

physician experienced in

the used of cancer

chemotherapeutic agents.

Appropriate management

of therapy and

complications is possible

only when adequate

diagnostic and treatment

facilities are readily

available.

Ensure patients safety.

Watch of for adverse

reaction.Refer patient's tolerance

to chemotherapy

accordigly to the

physician.

Secure accuracy of drug

dose and infusion.


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DRUGMECHANISM OF

ACTIONINDICATION CONTRAINDICATION ADVERSE REACTIONS

NURSING

RESPONSIBILITIES

Docetaxel

(Hentaxel)

80mg

Cytotoxic

Chemotherapy

Docetaxel is an

antineoplastic agent

belonging to paclitaxel

family. It acts by

disrupting the

microtubular networkin cells. Such action is

essential for mitotic

and interphase

cellular functions.

Docetaxel binds to

free tubulin thereby

resulting in the

formation of stablemicrotubules and

subsequently into

microtubule bundles

without normal

function. This leads to

the inhibition of

mitosis in cells.

Docetaxel's binding to

microtubules does not

alter the number of

protofilaments in the

bound microtubules, a

characteristic not

found in most spindle

poisons currently in

clinical use.

Treatment of lcoally

advanced or

metastatic breast

cancer & non-small

cell lung cancer, after

failure of priorchemotherapy.

Patients who have a

history of severe

hypersensitivity

reactions to

docetaxel or to other

drugs formulatedwith polysorbate 80.

Patients with

leukocyte counts of


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DRUGMECHANISM OF


NURSING

RESPONSIBILITIES

Gravisetron

(Sancuso)

Antiemetic

Granisetron is a

selective 5-

hydroxytryptamine3 (5-

HT3) receptor

antagonist with little or

no affinity for other

serotonin receptors

including 5-HT1, 5-

HT1A, 5-HT1B/C, 5-HT2;

for 1-, 2-, or -

adrenoreceptors; for

dopamine-D2; or for

histamine-H1;

benzodiazepine;

picrotoxin or opioidreceptors.

Serotonin receptors of

the 5-HT3 type are

located peripherally on

vagal nerve terminals

and centrally in the

chemoreceptor trigger

zone of the area

postrema. Duringchemotherapy that

induces vomiting,

mucosal

enterochromaffin cells

release serotonin,

which stimulates 5-HT3

receptors. This evokes

vagal afferent

discharge, inducing

vomiting.

Prevention of nausea

and vomiting in

patients receiving

moderately and/or

highly emetogenic

chemotherapy

regimens of up to 5

consecutive days

duration.

Known

hypersensitivity to

granisetron or to any

of the components of

Sancuso.

Constipation, abdominal pain,

diarrhea, headache, arrythmias.

elevation of ALT and AST levels,

nausea and vomiting.

Cardiovascular: Hypertension,

hypotension, angina pectoris,

atrial fibrillation and syncope

have been observed rarely.

Central Nervous System:

Dizziness, insomnia, headache,

anxiety, somnolence and

asthenia.

Hypersensitivity: Rare cases of

hypersensitivity reactions,

sometimes severe (eg,anaphylaxis, shortness of

breath, hypotension, urticaria)

have been reported.

Ensure patchs location.

Assess skin status on

patchs location.

Monitor patients

hydration and

Gastrointestinal status.

Watch out for adverse

reactions and refer

accordingly to physician.


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DRUGMECHANISM OF


NURSING

RESPONSIBILITIES

Pegfilgrastim

(neulastyl)

1 ampule

Hematopoietic

agent

Hematopoietic growth

factor.

Reduction in the

duration of

neutropenia and the

incidence of febrile

neutropenia inpatients treated with

cytotoxic

chemotherapy for

malignancy (with the

exception of chronic

myeloid leukemia

and myelodysplastic

syndromes).

Hypersensitivity to

pegfilgrastim,

filgrastim, E. coli-

derived proteins or

to any excipients ofNeulastyl.

Allergic-type reactions,

including anaphylaxis, skin

rash, urticaria, angioedema,

dyspnoea and hypotension,

occurring on initial orsubsequent treatment have

been reported both with

pegfilgrastim and with the

parent compound of

pegfilgrastim, filgrastim.

Isolated cases of splenic

rupture have been reported

during treatment with

pegfilgrastim.

Reversible, mild to moderate

elevations in uric acid,

alkaline phosphatase and

lactate dehydrogenase, with

no associated clinical effect.

Very common:

Musculoskeletal: Skeletal

pain.

Common: Application Site:

Injection site pain. Body as a

Whole: Chest pain (non-

cardiac), pain. CNS/PNS:

Headache. Musculoskeletal:

Arthralgia, myalgia and pain

in the back, limb,

musculoskeletal and neck.

Before administration,

pegfilgrastim solution

should be inspected

for visible particles.

Only a solution that isclear and colourless

should be injected.

Excessive shaking may

aggregate

pegfilgrastim,

rendering it

biologically inactive.

Monitor CBC levels

especially WBC. Watch

out for adverse

reactions. Refer to

physician accordingly.


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DRUGMECHANISM OF


NURSING

RESPONSIBILITIES

Nimotuzumab

Targeted Cancer

Therapy

Antiepidermal

growth factor (EGF)

receptor.

Nimotuzumab binds

with intermediate

affinity and high

specificity to the

extracellular domain

of epidermal growth

factor receptor

(EGFR, HER1, c-Erb-

1). Nimotuzumab

blocks the binding ofthe EGF and other

ligands

Nimotuzumab has a

potent anti-

angiogenic,

antiproliferative and

pro-apoptotic

effects, and also

decreases motility,

cell invasion and

metastasis in those

tumors that

overexpress the

EGFR.

Treatment of

glioma in adults

and children.

Contrindicated to

hypersensitivity to

the drug and its

component

Common adverse events

with recommended dose

reported following

administration of

nimotuzumab include chills,

fatigue, headache, nausea,

pyrexia, tremors and

vomiting.

Monitor patients

status frequently.

Watch out for

adverse reactions.

Refer to physician

accordingly.


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Surgical TherapySurgery is the preferred treatment

for early and advanced buccal

carcinoma. Patients with advanced

disease should receive

postoperative radiation orchemoradiation. Surgical approach

depends on the size of the tumor

Metastatic neck disease (N+

disease) requires either a modified

radical neck dissection or radicalneck dissection depending on the

extent of disease.


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NURSING INTERVENTIONS

Instruct the patient to avoid exposing themselves to sunlight because ofthe harmful rays.

Instruct patient refrain from smoking and consuming moderate to alcohol.

Encourage good oral hygiene.

Instruct patient to have oral check-ups to help detect the early signs of

cancer. Encourage to eat nutritious foods and must these dietary guidelines

include these seven basic recommendations: Eat a variety of foods.

Control your weight.

Eat a low-fat, low-cholesterol diet.

Eat plenty of vegetables, fruits, and grains. Eat sugar in moderation.

Use salt in moderation.

If you drink alcohol, do so in moderation; no more than two drinks per day ofwine, beer, or spirits.

buccal cancer

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