oral cancer
TRANSCRIPT
Oral Oral CancerCancer
By Dr.Jyotindra SinghBy Dr.Jyotindra Singh
SEMINAR PLANSEMINAR PLAN INTRODUCTIONINTRODUCTION ANATOMYANATOMY RISK FACTORSRISK FACTORS PRE MALIGNANT CONDITIONPRE MALIGNANT CONDITION INDIVIDUAL CARCINOMASINDIVIDUAL CARCINOMAS VARIOUS SURGICAL APPROACHESVARIOUS SURGICAL APPROACHES RECONSTRUCTION/PALLIATIVE CARERECONSTRUCTION/PALLIATIVE CARE RECENT ADVANCESRECENT ADVANCES STUDIES/ONGOING RESEARCH WORKSTUDIES/ONGOING RESEARCH WORK REFERENCES/REFERENCES/ TAKE HOME MESSAGETAKE HOME MESSAGE
FEW FACTSFEW FACTS
There are about There are about 7,00,0007,00,000 new cases of new cases of cancers diagnosed every year in India.cancers diagnosed every year in India.
Out of which Out of which TobaccoTobacco related cancers related cancers are about are about 3,00,0003,00,000
Cancer of uteri are 1,00,000 Cancer of uteri are 1,00,000
80,000 breast cancer. 80,000 breast cancer.
.
ANATOMYANATOMYThe oral cavity is lined by The oral cavity is lined by stratified stratified squamous squamous epithelium. epithelium.
BOUNDARIES BOUNDARIES
lips anteriorly, lips anteriorly, cheeks laterally, cheeks laterally, palate superiorly, palate superiorly, the tongue inferiorly. the tongue inferiorly.
Posteriorly, the oral cavity is Posteriorly, the oral cavity is continuous with the oropharynx. continuous with the oropharynx.
Risk FactorsRisk Factors Tobacco:Tobacco: About 90% of people with oral About 90% of people with oral
cavity and oropharyngeal cancer use tobacco cavity and oropharyngeal cancer use tobacco
Alcohol:Alcohol: Drinking alcohol strongly increases Drinking alcohol strongly increases a smoker's risk of developing oral cavity and a smoker's risk of developing oral cavity and oropharyngeal cancer. oropharyngeal cancer.
Ultraviolet light:Ultraviolet light: More than 30% of patients More than 30% of patients with cancers of the lip have outdoor with cancers of the lip have outdoor occupations associated with prolonged occupations associated with prolonged exposure to sunlight. exposure to sunlight.
Irritation:Irritation: Long-term irritation to the lining of Long-term irritation to the lining of the mouth caused by poorly fitting dentures the mouth caused by poorly fitting dentures
Risk Factors Cont…Risk Factors Cont… Poor nutrition: A diet low in fruits and vegetables Poor nutrition: A diet low in fruits and vegetables
is associated with an increased risk is associated with an increased risk
Mouthwash: Some studies have suggested that Mouthwash: Some studies have suggested that mouthwash with a high alcohol content mouthwash with a high alcohol content
Human papillomavirus (HPV) infection: Human papillomavirus (HPV) infection:
Immune system suppression:Immune system suppression:
Age: The likelihood of developing oral and Age: The likelihood of developing oral and oropharyngeal cancer increases with age, oropharyngeal cancer increases with age, especially after age 35. especially after age 35.
Gender: Oral and oropharyngeal cancer is twice Gender: Oral and oropharyngeal cancer is twice as common in men as in women as common in men as in women
Smoking and other tobacco use are Smoking and other tobacco use are associated with most cases of oral associated with most cases of oral
cancercancer.
Mubin - Suffering from mouth cancer. His tongue and throat were removed, drinks only liquid from a hole in his throat.
Could not speak and doctors gave him 6 month to live
HISTOLOGICAL STAGINGHISTOLOGICAL STAGING AcanthosisAcanthosis ParakeratosisParakeratosis Widening of rete pegsWidening of rete pegs DyskeratosisDyskeratosis DysplasiaDysplasia Carcinoma in situCarcinoma in situ
Oral Cancer-Oral Cancer-ProgressionProgression
Reference: Kumar: Robbins and Cotran: Pathologic Basis of Disease, 7th ed., Copyright © 2005 Saunders, An Imprint of Elsevier
PRE MALIGNANT PRE MALIGNANT CONDITIONSCONDITIONS
HIGH RISKHIGH RISK LEUKOPLAKIALEUKOPLAKIA ERYTHROPLAKIAERYTHROPLAKIA Chronic Hyperplastic candidiasisChronic Hyperplastic candidiasis
MEDIUM RISKMEDIUM RISK Oral Submucous FibrosisOral Submucous Fibrosis Syphilitic glossitisSyphilitic glossitis Sideropenic dysphagiaSideropenic dysphagia
PRE MALIGNANT PRE MALIGNANT CONDITIONSCONDITIONS Equivocal Risk lesionEquivocal Risk lesion
Oral lichen planusOral lichen planus Dyskeratosis congenitalDyskeratosis congenital Discoid lupus erythematosusDiscoid lupus erythematosus
LEUKOPLAKIALEUKOPLAKIA It is a white patch in the mucosa of the oral cavity It is a white patch in the mucosa of the oral cavity
that cannot be characterised clinically or that cannot be characterised clinically or pathologically to any other disease.pathologically to any other disease.
Incidence- smokers – Incidence- smokers – 20 %20 % , ,1%1% in non-smokers in non-smokers
Incidence of turning to malignancy- Incidence of turning to malignancy- 2-4 %2-4 %
Buccal mucosa and oral commissures –common sitesBuccal mucosa and oral commissures –common sites Histology- Parakeratosis with widening of rete pegsHistology- Parakeratosis with widening of rete pegs
Types- HOMOGENOUS / NODULAR / Types- HOMOGENOUS / NODULAR / SPECKLEDSPECKLED
LeukoplakiaLeukoplakia
Homogeneous LeukoplakiaHomogeneous Leukoplakia
Verrucous or Nodular Verrucous or Nodular LeukoplakiaLeukoplakia
Leukoplakia with early squamousLeukoplakia with early squamouscell carcinomacell carcinoma
TREATMENTTREATMENT Tobacco abuse has to be stoppedTobacco abuse has to be stopped
Excision,if required skin graftingExcision,if required skin grafting
Regular follow upRegular follow up
Isoretinoin is helpfulIsoretinoin is helpful
COCO2 2 laser excision laser excision
ERYTHROPLAKIAERYTHROPLAKIA It is red velvety appearance of the mucosa which It is red velvety appearance of the mucosa which
cannot characterise any recognised conditioncannot characterise any recognised condition..
17-20 times more potentially malignant17-20 times more potentially malignant
Histo- parakeratosis with severe epithelial Histo- parakeratosis with severe epithelial dysplasiadysplasia
Site- lower alveolus mucosa,gingivo buccal Site- lower alveolus mucosa,gingivo buccal sulcus, floor of mouthsulcus, floor of mouth
Treatment- biopsy and surgical excision.Treatment- biopsy and surgical excision.
ErythroplakiaErythroplakia
Oral submucous FibrosisOral submucous Fibrosis It is progressive fibrosis deep to the mucosa of It is progressive fibrosis deep to the mucosa of
the oral cavity which causes trismus and the oral cavity which causes trismus and ankyloglossia.ankyloglossia.
Alteration to collagen metabolism.Alteration to collagen metabolism. Incidence- 4-7%, prevalence- 5 per 1000Incidence- 4-7%, prevalence- 5 per 1000 4.5 – 7.6 % turn into malignancy4.5 – 7.6 % turn into malignancy Initial red area – turns into superficial ulcers- Initial red area – turns into superficial ulcers-
later forms stiff fibrotic bands and scarring.later forms stiff fibrotic bands and scarring. Shows epithelial atrophy,hyperplasia,dysplasia Shows epithelial atrophy,hyperplasia,dysplasia
and fibrosis.and fibrosis. Treatment- local injection of dexamethasone ( 4 Treatment- local injection of dexamethasone ( 4
mg ) with hyalase ( 1500 units ) mg ) with hyalase ( 1500 units ) Surgical wide excision and skin grafting.Surgical wide excision and skin grafting.
Oral Sub Mucous FibrosisOral Sub Mucous Fibrosis
This patient of SMF has so much of limitation in opening of mouth that it is difficult to put even 2 fingers in the mouth
Smf is equally common in gutka eating ladies
The next stage after the precancerous lesion is the Cancerous lesions.
Oral cancer imagesOral cancer images
MALIGNANCIES OF ORAL MALIGNANCIES OF ORAL CAVITYCAVITY SQUAMOUS CELL CARCINOMA- SQUAMOUS CELL CARCINOMA-
commonestcommonest
Minor Salivary gland tumoursMinor Salivary gland tumours
MelanomasMelanomas
Adenocarcinomas-rareAdenocarcinomas-rare
Sarcomas- rareSarcomas- rare
SITES OF CARCINOMA-in SITES OF CARCINOMA-in orderorder IN INDIA IN WESTIN INDIA IN WEST
CHEEK- commonest CHEEK- commonest TONGUETONGUE TONGUE FLOOR OF TONGUE FLOOR OF
MOUTHMOUTH FLOOR OF MOUTH LIPFLOOR OF MOUTH LIP PALATE PALATE CHEEKCHEEK LIPSLIPS
Symptoms Symptoms a sore in the mouth that does not heal (most a sore in the mouth that does not heal (most
common symptom) common symptom)
pain in the mouth that doesn't go away (also pain in the mouth that doesn't go away (also very common) very common)
a persistent lump or thickening in the cheek a persistent lump or thickening in the cheek
a persistent white or red patch on the gums, a persistent white or red patch on the gums, tongue, tonsil, or lining of the mouth tongue, tonsil, or lining of the mouth
a sore throat or a feeling that something is a sore throat or a feeling that something is caught in the throat that doesn't go away caught in the throat that doesn't go away
More SymptomsMore Symptoms difficulty chewing or swallowing difficulty chewing or swallowing
difficulty moving the jaw or tongue difficulty moving the jaw or tongue
swelling of the jaw that causes dentures to fit swelling of the jaw that causes dentures to fit poorly or become uncomfortable poorly or become uncomfortable
loosening of the teeth or pain around the teeth or loosening of the teeth or pain around the teeth or jawjaw
voice changes voice changes a lump or mass in the neck a lump or mass in the neck weight loss weight loss persistent bad breath persistent bad breath
Tools and TimeTools and Time
Proper lightingProper lighting Dental mouth mirrorDental mouth mirror Gauze squaresGauze squares GlovesGloves 5 minutes5 minutes
Extraoral ExaminationExtraoral Examination
Perioral and Intraoral Soft Perioral and Intraoral Soft Tissue Examination: LipsTissue Examination: Lips
Perioral and Intraoral Soft Perioral and Intraoral Soft Tissue Examination: Labial MucosaTissue Examination: Labial Mucosa
Perioral and Intraoral Soft Perioral and Intraoral Soft Tissue Examination: Labial MucosaTissue Examination: Labial Mucosa
Perioral and Intraoral Soft Perioral and Intraoral Soft Tissue Examination: Buccal MucosaTissue Examination: Buccal Mucosa
Perioral and Intraoral Soft Perioral and Intraoral Soft Tissue Examination: GingivaTissue Examination: Gingiva
Dorsum of the TongueDorsum of the Tongue
: Left Margin of the Tongue: Left Margin of the Tongue
Right Margin of the TongueRight Margin of the Tongue
Ventral Surface of the TongueVentral Surface of the Tongue
Floor of the MouthFloor of the Mouth
Hard PalateHard Palate
OropharynxOropharynx
Individual CaIndividual Ca
Carcinoma CheekCarcinoma Cheek They are fleshy flaps on either side of face.They are fleshy flaps on either side of face. Nasolabial fold-demarcation between lip & cheekNasolabial fold-demarcation between lip & cheek
Composed of- skin,superficial fossa with parotid Composed of- skin,superficial fossa with parotid duct, buccinator muscle,submucosa with buccal duct, buccinator muscle,submucosa with buccal glands.glands.
Lymphatics-Lymphatics-Submandibular & pre-auricular Submandibular & pre-auricular nodesnodes
RETROMOLAR TRIGONE-mucosa on the anterior RETROMOLAR TRIGONE-mucosa on the anterior surface of the ascending ramus of the mandible. surface of the ascending ramus of the mandible.
Carcinoma CheekCarcinoma Cheek Squamous cell carcinoma - most commonSquamous cell carcinoma - most common
Adenocarcinoma-from minor salivary Adenocarcinoma-from minor salivary gland.gland.
Melanoma- rarely.Melanoma- rarely.
Types- Ulcerative Types- Ulcerative Proliferative ( Exophytic )Proliferative ( Exophytic ) Verrucous ( locally malignant )Verrucous ( locally malignant )
Biological behaviourBiological behaviour Common in Common in posterior half of cheekposterior half of cheek than anterior. than anterior.
Spreads into deeper plane- involve Spreads into deeper plane- involve buccinator,pterygoidsbuccinator,pterygoids, , retromolar trigone,base retromolar trigone,base of skull,pharynxof skull,pharynx
Outward- involve skin- fungation/ulceration/fistulaOutward- involve skin- fungation/ulceration/fistula Mandible- Mandible- Subperiosteal lymphatic plexusSubperiosteal lymphatic plexus
Lymphatic- submental,submandbular ,deep Lymphatic- submental,submandbular ,deep cervical and lateral pharyngeal groups.cervical and lateral pharyngeal groups.
Later- spread to Later- spread to alveolusalveolus
CANCER LESION COMING OUTSIDE THE MOUTH
Cancer Of Cheek after tobacco quid habit
SAME PATIENT WITH THE CANCER LESION COMING EXTRA ORALLY
Dr Suwas DarvekarDr Suwas Darvekar
Cancer of buccal mucosa after tobacco habit going extra-orally
CANCER STARTING FROM BUCCAL VESTIBULE FOLLOWING HABIT OF PAN WITH TOBACCO
Cancer of Buccal mucosa invading extra-oral tissues following tobacco quid habit
Clinical Clinical feature/progressfeature/progress
Ulcer – everted edge/indurationUlcer – everted edge/induration Pain/ referred pain- involv. of Pain/ referred pain- involv. of lingual nervelingual nerve Trismus/ dysphagia- involv. of pterygoidsTrismus/ dysphagia- involv. of pterygoids Extend to upper alveolus and Extend to upper alveolus and maxillamaxilla- -
swelling pain and tendernessswelling pain and tenderness Mandible examined bidigitally for Mandible examined bidigitally for
thickening tenderness and irregularity.thickening tenderness and irregularity. Involvement of retromolar trigone- Involvement of retromolar trigone-
advanced stage advanced stage
Lymphatic SpreadLymphatic Spread Submandibular & upper deep cervical Submandibular & upper deep cervical
involvedinvolved Initally mobile- hard and nodularInitally mobile- hard and nodular Later fixed to deeper structureLater fixed to deeper structure Infiltrate into hypoglossal nerveInfiltrate into hypoglossal nerve Infiltrate into spinal accesory nerveInfiltrate into spinal accesory nerve Cervical sympathetic chain – Cervical sympathetic chain – Horners Horners
syndromesyndrome Compression on External carotid arteryCompression on External carotid artery Carotid blow outCarotid blow out
Features of advanced Features of advanced Ca Ca
Involvement of retromolar trigone.Involvement of retromolar trigone.
Extension into the base of skull and Extension into the base of skull and pharynx.pharynx.
Fixed neck lymph nodes.Fixed neck lymph nodes.
Extension to the opposite side.Extension to the opposite side.
TNM STAGINGTNM STAGING T is the size of the tumorjT is the size of the tumorj T1 is <2 cmT1 is <2 cm T2 is >2 cm but < 4 cmT2 is >2 cm but < 4 cm T3 is >4 cm T3 is >4 cm T4 is >4 cm with involving bone T4 is >4 cm with involving bone soft tissue, musclessoft tissue, muscles
TNM STAGINGTNM STAGING N1is single ipsilateral node < 3cmN1is single ipsilateral node < 3cm N2a single ipsilateral node > 3 cm N2a single ipsilateral node > 3 cm but < 6 cmbut < 6 cm
N2b multiple ipsilateral node <6cmN2b multiple ipsilateral node <6cm N2c bilateral or contra lateral N2c bilateral or contra lateral nodes < 6 cmnodes < 6 cm
N3a ipsilateral node > 6 cmN3a ipsilateral node > 6 cm N3b bilateral nodes > 6 cmN3b bilateral nodes > 6 cm M0 is no metastasis and M1 is M0 is no metastasis and M1 is metastasis present.metastasis present.
STAGINGSTAGING StagingStaging
Stage I T1 N0 M0Stage I T1 N0 M0 Stage II T2 N0 M0Stage II T2 N0 M0 Stage III T3 N0 M0;Stage III T3 N0 M0; any T1 T2 T3, N1 M0any T1 T2 T3, N1 M0 Stage IV T4 any N, M0; any T,Stage IV T4 any N, M0; any T, N2 or N3 N2 or N3 ANY T OR N WITH M1ANY T OR N WITH M1
NECK NODESNECK NODES
Face and Scalp Anterior Facial, Ib
Lateral Parotid
Posterior Occipital, V
Eyelids Medial Ib
Lateral Parotid, II
Chin Ia, Ib, II
External Ear Anterior Parotid, II
Posterior Post auricular, II, V
Middle Ear Parotid, II
Floor of mouth Anterior Ia, Ib, IIa > IIb
Lower incisors Ia, Ib, IIa > IIb Lateral Ib, IIa > IIb, III
Teeth except incisors Ib, IIa > IIb, III
Nasal Cavity Anterior Ib
Posterior Retropharyngeal, II, V
Common Nodal Drainage Common Nodal Drainage PatternsPatterns
Nasal Cavity Posterior Retropharyngeal, II, V
Nasopharynx Retropharyngeal, II, III, V
Oropharynx IIb > IIa, III, IV, V
Larynx Supraglottic IIa > IIb, III, IV
Subglottic VI, IVCervical
esophagus IV, VI
Thyroid VI, IV, V, Mediastinal
Tongue Tip Ia, Ib, IIa > IIb, III, IV
Lateral Ib, IIa > IIb, III, IV
Common Nodal Drainage Common Nodal Drainage PatternsPatterns
ClassificationClassification RadicalRadical
– Gold standard operationGold standard operation Modified radicalModified radical
– Preservation of non lymphatic structuresPreservation of non lymphatic structures SelectiveSelective
– Preservation of lymph node groupsPreservation of lymph node groups ExtendedExtended
– Removal of additional lymph node Removal of additional lymph node groups or non lymphatic structuresgroups or non lymphatic structures
Investigations- EDGE BIOPSYInvestigations- EDGE BIOPSY
Usually taken from two sitesUsually taken from two sites Malignant squamous cells with epithelial Malignant squamous cells with epithelial
pearlspearls Borders gradingBorders grading
Well differentiated > 75% EPWell differentiated > 75% EPModerately differentiated – 50-75%EPModerately differentiated – 50-75%EPPoorly differentiated – 25-50% EPPoorly differentiated – 25-50% EPVery poorly differentiated- < 25% EPVery poorly differentiated- < 25% EP
OTHER INVESTIGATIONSOTHER INVESTIGATIONS FNAC from lymph nodesFNAC from lymph nodes
CT SCAN – to assess the extension of CT SCAN – to assess the extension of tumourtumour
Orthopantomogram- to look for Orthopantomogram- to look for involvement of mandibleinvolvement of mandible
PLAN YOUR TREATMENT PROTOCOLPLAN YOUR TREATMENT PROTOCOL
TREATMENT STRATEGYTREATMENT STRATEGY SURGERYSURGERY- WIDE EXCISION - WIDE EXCISION HEMIMANDIBULECTOMYHEMIMANDIBULECTOMY Neck lymphnode block Neck lymphnode block
dissectiondissection
RADIOTHERAPY-RADIOTHERAPY- CURATIVE/PALLIATIVE CURATIVE/PALLIATIVE External/ brachytherapyExternal/ brachytherapy
CHEMOTHERAPYCHEMOTHERAPY- intraarterial/ IV or orally- intraarterial/ IV or orally
Radical Neck DissectionRadical Neck Dissection Removes Removes
– Nodal groups I-VNodal groups I-V– SCM, IJV, XISCM, IJV, XI– Submandibular gland, tail Submandibular gland, tail
of parotidof parotid PreservesPreserves
– Posterior auricularPosterior auricular– SuboccipitalSuboccipital– RetropharyngealRetropharyngeal– PeriparotidPeriparotid– PerifacialPerifacial– Paratracheal nodesParatracheal nodes
RemovesRemoves– Nodal groups I-VNodal groups I-V
PreservesPreserves– SCM, IJV, XI (any SCM, IJV, XI (any
combination)combination)
Notate according to Notate according to which structures are which structures are preservedpreserved
Modified Radical Neck Modified Radical Neck DissectionDissection
Specialised Techniques in SurgerySpecialised Techniques in Surgery
CASE 1CASE 1 EARLY GROWTH WITHOUT BONE INVOLVEMENTEARLY GROWTH WITHOUT BONE INVOLVEMENT
Curative radiotherapy using Curative radiotherapy using CAESIUM CAESIUM 137 137 needles or needles or IRIDIUM IRIDIUM 192 192 wires- wires- BRACHYTHERAPYBRACHYTHERAPY
PATTERSON OPERATION-PATTERSON OPERATION- wide excision with 1-2 cm wide excision with 1-2 cm
clearance - approach is by raising the cheek flap clearance - approach is by raising the cheek flap outside – after excision flap is replaced back.outside – after excision flap is replaced back.
Advanced EXTERNAL RADIOTHERAPY Advanced EXTERNAL RADIOTHERAPY complication like osteoradionecrosis of complication like osteoradionecrosis of
mandible has been reducedmandible has been reduced
CASE 2CASE 2 GROWTH WITH MANDIBLE GROWTH WITH MANDIBLE
INVOLVEMENTINVOLVEMENT
WIDE EXCISION OF PRIMARY TUMOURWIDE EXCISION OF PRIMARY TUMOUR
HEMIMANDIBULECTOMY / SEGMENTAL HEMIMANDIBULECTOMY / SEGMENTAL RESECTION / MARGINAL RESECTION / MARGINAL MANDIBULECTOMYMANDIBULECTOMY
CASE 3CASE 3 OPERABLE GROWTH WITH MANDIBLE OPERABLE GROWTH WITH MANDIBLE
INVOLVEMENT AND MOBILE LYMPH INVOLVEMENT AND MOBILE LYMPH NODES ON THE SAME SIDENODES ON THE SAME SIDE
WIDE EXCISION OF PRIMARY TUMOURWIDE EXCISION OF PRIMARY TUMOUR HEMIMANDIBULECTOMYHEMIMANDIBULECTOMY RADICAL NECK LYMPH NODE RADICAL NECK LYMPH NODE
DISSECTION IS DONEDISSECTION IS DONE
CASE 4CASE 4 Operable growth with Mandible Operable growth with Mandible
involvement mobile lymph nodes on the involvement mobile lymph nodes on the same side and opposite sidesame side and opposite side
WIDE EXCISION OF PRIMARY TUMOURWIDE EXCISION OF PRIMARY TUMOUR HEMIMANDIBULECTOMYHEMIMANDIBULECTOMY RADICAL NECK LYMPH NODE RADICAL NECK LYMPH NODE
DISSECTION DISSECTION IS DONE on same sideIS DONE on same side FUNCTIONAL BLOCK DISSECTION FUNCTIONAL BLOCK DISSECTION ON ON
OPPOSITE SIDEOPPOSITE SIDE
Case 5Case 5 Operable primary tumour with mobile Operable primary tumour with mobile
lymph nodes on same side but without lymph nodes on same side but without mandibular involvementmandibular involvement
WIDE EXCISION OF PRIMARY TUMOURWIDE EXCISION OF PRIMARY TUMOUR RADICAL NECK LYMPH NODE RADICAL NECK LYMPH NODE
DISSECTION DISSECTION IS DONE on same sideIS DONE on same side HEMIMANDIBULECTOMY not doneHEMIMANDIBULECTOMY not done
Case 6Case 6 Fixed primary tumour or advanced neck Fixed primary tumour or advanced neck
lymph node secondarieslymph node secondaries
Only Only palliative external radiotherapy palliative external radiotherapy is is given to palliate pain,fungation and to given to palliate pain,fungation and to prevent anticipated torrential prevent anticipated torrential haemorrhage.haemorrhage.
Case 7Case 7 If growth is extending to Upper alveolusIf growth is extending to Upper alveolus
Partial maxillectomy or total Partial maxillectomy or total maxillectomy may be requiredmaxillectomy may be required
TREATMENT TREATMENT MODALITIESMODALITIES Postoperative radiotherapy is given in T3 Postoperative radiotherapy is given in T3
and T4 tumours.and T4 tumours.
Role of chemotherapy- intraarterially through Role of chemotherapy- intraarterially through ECAECA
CHEMORADIOTHERAPY is used in CHEMORADIOTHERAPY is used in unresectable tumours.unresectable tumours.
Role of Role of Prophylactic block dissectionProphylactic block dissection
APPROACHES TO Ca CHEEKAPPROACHES TO Ca CHEEK Transoral / Intraoral approachTransoral / Intraoral approach
Lip split incisionLip split incision
Patterson approachPatterson approach
Visor approachVisor approach
Cancer Institute (WIA)Cancer Institute (WIA)
CARCINOMA LIPCARCINOMA LIP It is common in men-common in lower lip- It is common in men-common in lower lip-
90%90% Upper lip - 5 to 10 %Upper lip - 5 to 10 %
Mostly due to sunlight exposure/pipe smokersMostly due to sunlight exposure/pipe smokers
Usually it is a well differentiated squamous Usually it is a well differentiated squamous cell carcinomacell carcinoma
It spreads to submental nodes and later to It spreads to submental nodes and later to other neck nodes on both sidesother neck nodes on both sides
PREDISPOSING FACTORSPREDISPOSING FACTORS CheilitisCheilitis
Solar keratosisSolar keratosis
PapillomaPapilloma
LeukoplakiaLeukoplakia
Smoking,U-V raysSmoking,U-V rays
Tobacco+ lime usersTobacco+ lime users
CANCER OF LOWER LIP
CLINICAL FEATURESCLINICAL FEATURES1.1. Non healing progressive ulcer ,initially painless Non healing progressive ulcer ,initially painless
2.2. Everted edges with indurationEverted edges with induration
3.3. Growth moves with the lipGrowth moves with the lip
4.4. Submental,submandibular and upper deep Submental,submandibular and upper deep neck nodes may get enlarged.neck nodes may get enlarged.
5.5. Half the cases nodes are enlarged due to Half the cases nodes are enlarged due to infection or reactive processinfection or reactive process
6.Fungation,bleeding6.Fungation,bleeding
Differential diagnosisDifferential diagnosis KeratocanthomaKeratocanthoma
Basal cell carcinomaBasal cell carcinoma
Minor salivary gland tumorsMinor salivary gland tumors
Carcinoma lip extension from Ca cheekCarcinoma lip extension from Ca cheek
Pyogenic granuloma in early casesPyogenic granuloma in early cases
Diagnosis Diagnosis Edge biopsyEdge biopsy
FNAC of lymph nodesFNAC of lymph nodes
TreatmentTreatment Lesion < 2cm Lesion < 2cm curative curative
radiotherapy-brachytherapy/external beam radiotherapy-brachytherapy/external beam radiotherapyradiotherapy
Lesion > 2cm – WIDE EXCISIONLesion > 2cm – WIDE EXCISION excision of lower lip upto one-third can be excision of lower lip upto one-third can be
sutured primarilysutured primarily
Excision more than one –third of the lip Excision more than one –third of the lip requires reconstruction using different requires reconstruction using different flapsflaps
Lip reconstructionLip reconstruction Estlanders rotating flap- from the upper Estlanders rotating flap- from the upper
lip- based on upper labial artery- used lip- based on upper labial artery- used when defect less than one half of lipwhen defect less than one half of lip
Fries modified Bernard facial flap- uses Fries modified Bernard facial flap- uses lateral facial flaps – when defect is more lateral facial flaps – when defect is more than one half of lip and in midlinethan one half of lip and in midline
Microvascular flapMicrovascular flap
Lip reconstructionLip reconstruction Nasolabial flap- used when defect is one Nasolabial flap- used when defect is one
half laterallyhalf laterally
Abbe flap- used in upper lip lesion defect-Abbe flap- used in upper lip lesion defect-taken from lower lip –inferior labial artery taken from lower lip –inferior labial artery as baseas base
Gilles fan flap- it is a cheek flap usually Gilles fan flap- it is a cheek flap usually bilaterally- flap based on labial vesselsbilaterally- flap based on labial vessels
LIP LIP RECONSTRUCTIONRECONSTRUCTION
Karapandzic flap- modified version of Karapandzic flap- modified version of Gillies flap used for lower lip defectGillies flap used for lower lip defect
Johansen stepladder procedure- for Johansen stepladder procedure- for extensive carcinoma of lower lip.extensive carcinoma of lower lip.
Treatment Treatment ModalitiesModalities
Lymph nodes–Radical neck dissection-one Lymph nodes–Radical neck dissection-one side side
functional block or supraomohyoid block functional block or supraomohyoid block dissection on other sidedissection on other side
N0 TUMOURS- Placed centrallyN0 TUMOURS- Placed centrally b/l supraomohyoid dissection b/l supraomohyoid dissection N0 tumors- placed laterallyN0 tumors- placed laterally ipsilateral supraomohyoid dissectionipsilateral supraomohyoid dissectionPost op radiotherapy- when lymph nodes Post op radiotherapy- when lymph nodes
involved involved
PrognosisPrognosis Lip has best prognosisLip has best prognosis
5 year survival is 70 %5 year survival is 70 %
Dr Suwas DarvekarDr Suwas Darvekar
TONGUETONGUE Tongue is the muscular organ located in the Tongue is the muscular organ located in the
floor of the mouth.floor of the mouth.
Tip- anterior free end lies behind the upper Tip- anterior free end lies behind the upper incisor teethincisor teeth
Root- Attached to the mandible above and Root- Attached to the mandible above and hyoid bone belowhyoid bone below
Body- Dorsal surface is rough due to papillaeBody- Dorsal surface is rough due to papillae divided into anterior 2/3 and posterior divided into anterior 2/3 and posterior
1/3 by sulcus terminalis1/3 by sulcus terminalis
Dr Suwas DarvekarDr Suwas Darvekar
Base of tongue landmarksBase of tongue landmarks The sulcus terminalis (V-shaped The sulcus terminalis (V-shaped
furrow on dorsal surface of tongue) furrow on dorsal surface of tongue) divides anterior/posterior tonguedivides anterior/posterior tongue
Foramen cecum – area where thyroid Foramen cecum – area where thyroid descends.descends.
Taste papillae, mucus glandsTaste papillae, mucus glands Lingual tonsilsLingual tonsils
Base of tongue – blood Base of tongue – blood supplysupply
Lingual arteries supply the tongueLingual arteries supply the tongue Enter the tongue base medial to the Enter the tongue base medial to the
hyoglossal musclehyoglossal muscle Septum linguae – near bloodless Septum linguae – near bloodless
plain in the midline of tongueplain in the midline of tongue Submandibular arteries provide Submandibular arteries provide
important anastomosis to important anastomosis to contralateral tonguecontralateral tongue
MusculatureMusculature Intrinsic musclesIntrinsic muscles Extrinsic musclesExtrinsic muscles
– GenioglossusGenioglossus– HyoglossusHyoglossus– StyloglossusStyloglossus– ChondroglossusChondroglossus
Movements of Movements of tonguetongue
Forward Protrusion- GENIOGLOSSUSForward Protrusion- GENIOGLOSSUS
Backward movement- STYLOGLOSSUSBackward movement- STYLOGLOSSUS
Elevation of tongue- PALATOGLOSSUSElevation of tongue- PALATOGLOSSUS
Depression of tongue- HYOGLOSSUSDepression of tongue- HYOGLOSSUS
Dr Suwas DarvekarDr Suwas Darvekar
Cancer of Tongue
D/D of tongue ulcersD/D of tongue ulcers Dental ulcers- PainfulDental ulcers- Painful Aphthous ulcers- PainfulAphthous ulcers- Painful Ulcers in lichen planus- PainlessUlcers in lichen planus- Painless Syphilitic ulcers- PainlessSyphilitic ulcers- Painless Tuberculous ulcers- PainfulTuberculous ulcers- Painful Malignant ulcers- PainlessMalignant ulcers- Painless
Carcinoma TongueCarcinoma Tongue GrossGross PAPILLARYPAPILLARY ULCERATIVE OR ULCERATIVE OR
ULCEROPROLIFERATIVEULCEROPROLIFERATIVE FISSURE WITH INDURATIONFISSURE WITH INDURATION LOBULATEDLOBULATED HistologicallyHistologically Squamous cell carcinomaSquamous cell carcinoma AdenocarcinomaAdenocarcinoma MelanomasMelanomas
Cancer of Tongue following tobacco consumption
Clinical featuresClinical features PainPain Excessive salivationExcessive salivation DysphagiaDysphagia Visible ulcerVisible ulcer AnkyloglossiaAnkyloglossia Foetor (halitosis)Foetor (halitosis) Change in voiceChange in voice Palpable lymph nodes in the neckPalpable lymph nodes in the neck Features of bronchopneumoniaFeatures of bronchopneumonia
Spread of Ca Tongue-LOCALSpread of Ca Tongue-LOCAL Anterior two-thirdAnterior two-third
genioglossus,floor of mouth,opposite genioglossus,floor of mouth,opposite side and mandibleside and mandible
Posterior third of tonguePosterior third of tongue
tonsil,side of pharynx,soft tonsil,side of pharynx,soft palate,epiglottis,larynx and cervical spinepalate,epiglottis,larynx and cervical spine
Lymphatic SpreadLymphatic Spread Tip of tongue- Submental lymph nodeTip of tongue- Submental lymph node Lateral Margin- Submandibular lymph nodeLateral Margin- Submandibular lymph node Upper deep cervical lymph Upper deep cervical lymph
nodenode
Lymphatics in midline freely cross Lymphatics in midline freely cross communicate with each othercommunicate with each other
Posterior third of tongue- Pharyngeal group Posterior third of tongue- Pharyngeal group of lymph node / Upper deep cervical of lymph node / Upper deep cervical lymphnode.lymphnode.
TREATMENTTREATMENT SURGERYSURGERY
RADIOTHERAPYRADIOTHERAPY
CHEMOTHERAPYCHEMOTHERAPY
SURGERYSURGERY WIDE EXCISIONWIDE EXCISION Early growth < 2cm in size,growth in tip Early growth < 2cm in size,growth in tip
of tongueof tongue Hemiglossectomy- growth > 2cm in sizeHemiglossectomy- growth > 2cm in size
Commando operation- hemiglossectomy+ Commando operation- hemiglossectomy+ hemimandibulectomy+radical neck dissectionhemimandibulectomy+radical neck dissection
B/l mobile lymph nodes- one side radical B/l mobile lymph nodes- one side radical block and other side functional block block and other side functional block dissection.dissection.
This is a patient who has undergone a commando operation for oral cancer
Dr Suwas DarvekarDr Suwas Darvekar
This is a patient who has undergone a commando operation for oral cancer
Dr Suwas DarvekarDr Suwas Darvekar
This is a patient who has undergone a commando operation for oral cancer
Dr Suwas DarvekarDr Suwas Darvekar
This is a patient who has undergone a commando operation for oral cancer. Because of the operation he has lost control on his left side of the mouth and hence saliva is seen drooling from left side of the mouth.
TreatmentTreatment Large primary tumour can be given Large primary tumour can be given
preoperative radiotherapy,later definitive preoperative radiotherapy,later definitive procedureprocedure
Prophylactic block dissectionProphylactic block dissection
Multi- Disciplinary ApproachMulti- Disciplinary Approach
RadiotherapyRadiotherapy In small primary tumour- curative In small primary tumour- curative
radiotherapyradiotherapy Large primary tumour- initial Large primary tumour- initial
radiotherapy to reduce tumour size for radiotherapy to reduce tumour size for better resection laterbetter resection later
Advanced primary and secondaries in Advanced primary and secondaries in neck- Palliative external radiotherapyneck- Palliative external radiotherapy
Post operative radiotherapy-in large Post operative radiotherapy-in large tumours to reduce the chance of relapsetumours to reduce the chance of relapse
Growths in posterior third of tongue- Growths in posterior third of tongue- curative/palliativecurative/palliative
RadiotherapyRadiotherapy ComplicationsComplications loss of sensation like tasteloss of sensation like taste trismus and ankyloglossiatrismus and ankyloglossia infectioninfection pharyngeal and laryngeal oedemapharyngeal and laryngeal oedema dermatitis and skin infectiondermatitis and skin infection
CHEMOTHERAPYCHEMOTHERAPY Given in postoperative period and Given in postoperative period and
also for palliationalso for palliation Prince –Hill regimen is commonly Prince –Hill regimen is commonly
used used
Drugs are Drugs are methotrexate,vincristine,adriamycin,methotrexate,vincristine,adriamycin,
bleomycin and mercaptopurinebleomycin and mercaptopurine
PrognosisPrognosis Size of tumour> 4cm carries poor prognosisSize of tumour> 4cm carries poor prognosis Posterior third has poor prognosisPosterior third has poor prognosis Tumour crossing the midline/ bone Tumour crossing the midline/ bone
involvementinvolvement Positive histology in nodes reduces survivalPositive histology in nodes reduces survival Level III & IV has poor prognosisLevel III & IV has poor prognosis Bilateral/contralateral nodes Bilateral/contralateral nodes Extracapsular spread/size > 3cm Extracapsular spread/size > 3cm > 3 in number of nodes involved has poor > 3 in number of nodes involved has poor
signsign
Terminal eventsTerminal events Inhalational bronchopneumoniaInhalational bronchopneumonia Haemorrhage from erosion of lingual Haemorrhage from erosion of lingual
arteryartery Posterior third- erosion of internal Posterior third- erosion of internal
carotid artery can occurcarotid artery can occur Cancer cachexiaCancer cachexia Asphyxia due to pressure on air Asphyxia due to pressure on air
passagepassage
FLAPS FOR FLAPS FOR RECONSTRUCTIONRECONSTRUCTION
Reconstructive OptionsReconstructive Options Follows the reconstructive ladderFollows the reconstructive ladder Use simplest option that will achieve Use simplest option that will achieve
desirable outcomedesirable outcome– No closureNo closure– Primary closurePrimary closure– Skin graftingSkin grafting– Local pedicled flapsLocal pedicled flaps– Regional flapsRegional flaps– Microvascular flapsMicrovascular flaps
Small defectsSmall defects Defects up to 1/3 volume of the Defects up to 1/3 volume of the
tongue basetongue base Closed primarilyClosed primarily Split-thickness skin graftSplit-thickness skin graft GranulationGranulation Minimal functional defecitMinimal functional defecit
Large defectsLarge defects Larger than 1/3 volume of base of Larger than 1/3 volume of base of
tonguetongue Require reconstructionRequire reconstruction Primary closure/skin grafting causes Primary closure/skin grafting causes
functional deficitfunctional deficit– Tongue tetheringTongue tethering– Pharyngeal stenosisPharyngeal stenosis
Local flapsLocal flaps Have fallen out of favorHave fallen out of favor Limited amount of tissueLimited amount of tissue Inferior functional resultsInferior functional results Not very useful for tongue defectsNot very useful for tongue defects
– Tongue flaps, divide tongue anteriorly Tongue flaps, divide tongue anteriorly and rotate posteriorlyand rotate posteriorly
– Limited tongue motionLimited tongue motion
Regional flapsRegional flaps AdvantagesAdvantages
– Abundant, well-vascularized tissueAbundant, well-vascularized tissue– Single stage reconstructionSingle stage reconstruction– Easy to harvestEasy to harvest
DisadvantagesDisadvantages– Limited superior reachLimited superior reach– BulkBulk– Tip necrosisTip necrosis
ReconstructionReconstruction
Platysma Flap ReconstructionPlatysma Flap Reconstruction
ReconstructionReconstruction
Regional flapsRegional flaps Pectoralis majorPectoralis major Latissimus dorsiLatissimus dorsi TrapeziusTrapezius PlatysmaPlatysma SternocleidomastoidSternocleidomastoid
ReconstructionReconstruction Deltopectoral FlapDeltopectoral Flap
– Axial distant flapAxial distant flap– First four perforators First four perforators
of internal mammaryof internal mammary– Deltoid portion is Deltoid portion is
randomrandom– Preliminary delay Preliminary delay
procedureprocedure– Creates dependent Creates dependent
orocutaneous fistulaorocutaneous fistula
Microvascular flapsMicrovascular flaps Overcome the deficiencies of Overcome the deficiencies of
regional flapsregional flaps Ability to provide sensory or motor Ability to provide sensory or motor
innervationinnervation
Microvascular flapsMicrovascular flaps FasciocutaneousFasciocutaneous
– ForearmForearm– Lateral thighLateral thigh– Lateral armLateral arm
Latissimus dorsiLatissimus dorsi Rectus abdominisRectus abdominis
Carcinoma floor of the Carcinoma floor of the mouth mouth It is aggressive tumourIt is aggressive tumour
It invades hyoglossus ,mylohyoid,genioglossus It invades hyoglossus ,mylohyoid,genioglossus anterior mandible earlyanterior mandible early
Bilateral neck nodes are commonly involved.Bilateral neck nodes are commonly involved. Rim resection of mandible with wide excision Rim resection of mandible with wide excision
of tumour with muscle and soft tissue + of tumour with muscle and soft tissue + bilateral neck dissection.bilateral neck dissection.
Post op radio therapy and later chemotherapyPost op radio therapy and later chemotherapy
Prognosis is poor with poor cosmetic result.Prognosis is poor with poor cosmetic result.
Carcinoma alveolusCarcinoma alveolus It is squamous cell carcinoma arising from It is squamous cell carcinoma arising from
gums.gums.
Common in malesCommon in males
There will be invariable bone involvement by There will be invariable bone involvement by direct extension.direct extension.
Nodal spread is also common.Nodal spread is also common.
Wide excision with mandibulectomy and block Wide excision with mandibulectomy and block dissection of neck is the treatment.dissection of neck is the treatment.
Carcinoma Hard PalateCarcinoma Hard Palate Minor salivary gland tumours are more Minor salivary gland tumours are more
common in palate.common in palate. In males-in reverse smokers- due to In males-in reverse smokers- due to
repeated thermal injury.repeated thermal injury. Malignant tumours may spread to Malignant tumours may spread to
periosteum,bone,maxilla,sinus or nose.periosteum,bone,maxilla,sinus or nose. Squamous cell carcinoma is ulcerative with Squamous cell carcinoma is ulcerative with
raised and everted edge.raised and everted edge. Upper deep cervical nodes involved in 25 %Upper deep cervical nodes involved in 25 % Rx- wide excision with removal of underlying Rx- wide excision with removal of underlying
palatal bone.Maxillectomy may be required.palatal bone.Maxillectomy may be required.
Cancer of Palate after habit of smoking
CANCER OF MAXILA AFTER SMOKING HABIT
Diagnostic SurgeryDiagnostic Surgery
What happens after What happens after Treatment?Treatment?
Speech and Swallowing Therapy Speech and Swallowing Therapy Follow-up tests Follow-up tests Chemoprevention Chemoprevention Watch for new symptoms Watch for new symptoms General health considerations General health considerations
PALLIATIVE CAREPALLIATIVE CARE
Relapse caseHe was operated for cancer of lower jaw in oct ‘00
Feeding/FluidsFeeding/Fluids GastrostomyGastrostomy IV fluidsIV fluids Parenteral Parenteral
feeding ?feeding ?
BreathingBreathing OxygenOxygen CorticosteroidsCorticosteroids Tracheostomy? Tracheostomy? Excessive secretionsExcessive secretions
SocialSocial DisfigurementDisfigurement Odour Odour Eating Eating SocialisingSocialising
OdourOdour DressingsDressings PeppermintPeppermint Metronidazole locallyMetronidazole locally Metronidazole 500mg TIDMetronidazole 500mg TID
PsychologicalPsychological DisfigurementDisfigurement GuiltGuilt Slow decline Slow decline Invasive Invasive
proceduresprocedures Suicidal Suicidal
thoughtsthoughts
RECENT ADVANCESRECENT ADVANCES
Moh’s Surgery - PrinciplesMoh’s Surgery - Principles Refined over the decades first to use Refined over the decades first to use
a fresh tissue staining technique, a fresh tissue staining technique, then frozen section.then frozen section.
Allows examination of 100% of the Allows examination of 100% of the tumor margin, unlike convention tumor margin, unlike convention surgery (<1%)surgery (<1%)
Mohs Surgery - IndicationsMohs Surgery - Indications Large Skin TumorsLarge Skin Tumors
– Higher cure rates with Higher cure rates with Mohs (93% 5yr disease Mohs (93% 5yr disease free for tumors > 3cm)free for tumors > 3cm)
Clinically Ill-Defined Clinically Ill-Defined MarginsMargins
Irradiated SkinIrradiated Skin– More histologically More histologically
aggressive tumors, aggressive tumors, more SCCAmore SCCA
Cheek ReconstructionCheek Reconstruction reconstruction aided by laxity of skin reconstruction aided by laxity of skin
and relative abundanceand relative abundance small to moderate defects closed small to moderate defects closed
primarilyprimarily anvancement, transposition, rotation anvancement, transposition, rotation
flaps flaps caution given to level of facial nervecaution given to level of facial nerve
Cheek ReconstructionCheek Reconstruction
Cheek ReconstructionCheek Reconstruction
What's new in oral cavity and What's new in oral cavity and oropharyngeal cancer research oropharyngeal cancer research
and treatment?and treatment? DNA changes:DNA changes:
One of the changes often found in DNA of oral One of the changes often found in DNA of oral cancer cells is a mutation of the p53 gene. cancer cells is a mutation of the p53 gene.
Recent studies suggest that tests to detect Recent studies suggest that tests to detect these p53 gene alterations may allow very early these p53 gene alterations may allow very early detection of oral and oropharyngeal tumors. detection of oral and oropharyngeal tumors.
These tests may also be used to better define These tests may also be used to better define surgical margins surgical margins
What’s New…What’s New… Tumor growth factors:Tumor growth factors:
Oral and oropharyngeal cancers with too Oral and oropharyngeal cancers with too many EGF receptors tend to be especially many EGF receptors tend to be especially aggressive. New drugs that specifically aggressive. New drugs that specifically recognize cells with too many EGF recognize cells with too many EGF receptors are now being tested in clinical receptors are now being tested in clinical trials. These drugs work by preventing EGF trials. These drugs work by preventing EGF from promoting reproduction of cancer from promoting reproduction of cancer cells, and may also help the patient's cells, and may also help the patient's immune system recognize and attack the immune system recognize and attack the cancercancer
What’s New…What’s New… New chemotherapyNew chemotherapy
New radiotherapy methodsNew radiotherapy methods
Vaccines:Vaccines: Some oral and oropharyngeal Some oral and oropharyngeal cancers contain DNA from human cancers contain DNA from human papillomaviruses, vaccines against these papillomaviruses, vaccines against these viruses are being studied as a treatment for viruses are being studied as a treatment for these cancers .these cancers .
Gene therapy: Gene therapy: Another type of gene therapy Another type of gene therapy adds new genes to the cancer cells to make adds new genes to the cancer cells to make them more susceptible to being killed by them more susceptible to being killed by certain drugs certain drugs
The FutureThe FutureRadiotherapyRadiotherapy – tissue sparing – tissue sparing ChemotherapyChemotherapy – more targeted therapies – more targeted therapiesMechanismMechanism – basic science and animal data – basic science and animal dataPreventionPrevention – novel clinical studies – novel clinical studiesPain controlPain control – Blocks – BlocksMicrobiologyMicrobiology – further studies needed – further studies neededEmergence of new challengesEmergence of new challenges – –
Bisphosphonates...Bisphosphonates...
Take Home Message Take Home Message stage I & II has got 80 % 5 years survivalstage I & II has got 80 % 5 years survival stage III & IV has got less than 20 % 5 year stage III & IV has got less than 20 % 5 year
survival rate.survival rate. Carcinoma lip has got best prognosis.Carcinoma lip has got best prognosis. Carcinoma posterior one third has worst Carcinoma posterior one third has worst
prognosis.prognosis. Perineural invasion and angioinvasion carries Perineural invasion and angioinvasion carries
poor prognosis.poor prognosis. Histologically positive nodes decrease the Histologically positive nodes decrease the
survival rate by 50 %survival rate by 50 % Tumour thickness > 6mm has poor prognosisTumour thickness > 6mm has poor prognosis Exophytic tumour is better than infiltrating type.Exophytic tumour is better than infiltrating type.
REFERENCESREFERENCES BAILEY AND LOVEBAILEY AND LOVE SCHWARTZSCHWARTZ SABISTONSABISTON RUTHERFORD BOOK OF HEAD & NECK RUTHERFORD BOOK OF HEAD & NECK
OncoOnco INDIAN JOURNAL OF SURGERYINDIAN JOURNAL OF SURGERY AMERICAN JOURNAL OF SURGERYAMERICAN JOURNAL OF SURGERY RECENT ADVANCES BY – TAYLORRECENT ADVANCES BY – TAYLOR RECENT ADVANCES BY- RL GUPTARECENT ADVANCES BY- RL GUPTA SURGICAL ANATOMY ATLASSURGICAL ANATOMY ATLAS
HELLO– ANY QUESTIONSHELLO– ANY QUESTIONS
Oral cancerOral cancerRisk among smokers
Relative risk in FORMER smoker
27.5
8.8
Drop of 33% in risk if you will quit smoking.
Mortality attributed to smoking: 92%
20 minutes after quitting: 20 minutes after quitting: Your blood pressure drops to a Your blood pressure drops to a level close to that before the level close to that before the
last cigarette. The temperature last cigarette. The temperature of your hands and feet of your hands and feet increases to normal. increases to normal.
((
24 hours after quitting: 24 hours after quitting: Your chance of a heart attack Your chance of a heart attack
decreases. decreases. ((
2 weeks to 3 months after 2 weeks to 3 months after quitting: quitting:
Your circulation improves and Your circulation improves and your lung function increases up your lung function increases up
to 30%. to 30%. (US Surgeon General's Report, 1990, pp.193,194,196,285,323)(US Surgeon General's Report, 1990, pp.193,194,196,285,323)
1 year after quitting: 1 year after quitting: The excess risk of coronary The excess risk of coronary
heart disease is half that of a heart disease is half that of a smoker's. smoker's.
((
5 years after quitting: 5 years after quitting: Your stroke risk is reduced to Your stroke risk is reduced to
that of a nonsmoker. that of a nonsmoker.
Still not convinced?Still not convinced?
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