- Email: [email protected]
K-7 Premalignant lesions
Keynote Orations
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Premalignant lesions
C. Scully. UK Oral cancer appears to be Increasing an Incidence, and mortality has scarcely improved over the past 25 years. Better us:derstanding o f the aetiopathogenesis should lead to more accurate and earlier diagnosis and more effective treatments with fewer adverse effects, prov:dmg the best chance of a cure. Cancer as the result of DNA mutations arising spontaneously and from the action of various mutagens, especially In tobacco and alcohol. Cancer is a consequence of an Interaction of many factors. A sequence o f genetic changes leads eventually to loss of growth control and autonomy, but countering these changes are mechanisms to metabolise carcinogens, repair DNA damage, control growth, and defend against cancer. Potentaally malignant (premahgnant or precancerous) lesions whach precede some neoplasms Include erythroplasia (erythroplakaa) - the most hkely lesion to progress to severe dysplasia or carcinoma, and leukoplal~a. Clinical features winch suggest a potentially malignant lesion is hkely to transform, or has transformed, to carcinoma Include: the presence o f red lesions (erythroplama); a verrucous, speckled or granular appearance or an ulcer with fissuring or raised exophytic margins; induration; fixation of the lesion to deeper tissues or to overlymg skin or mucosa; cervical lymph node enlargement. Clmicians should be aware that single ulcers, lumps, red patches, or white patches - particularly if any of these are persisting for more than three weeks, may be mamfestations of frank mahgnancy. There should be a tngh index of suspicion, especially of a solitary lesion present for over 3 weeks: biopsy is invariably Indicated. The whole oral mucosa should be examined as there may be widespread dysplastic mucosa ("field change") or even a second neoplasm and the cervical lymph nodes must be examined. Laboratory diagnostic aids increasingly look to detection of cellular and now molecular changes. Molecular tectmNues are being introduced for prognost:cat:on m potentially mahgnant lesions. DNA content as a prognostic marker and can predict the development of carcinomas m non-dysplastlc lesions. Treatment as controversial, and there is little t~ard evidence that removal of the lesions affects the prognosis. Indeed, recent evidence suggests that removal of aneuploidal lesions has no effect on mortahty. Treatment is Increasingly looking towards chemotherapy and now gene therapy, but currently, there is no doubt that prevention is still the most important aspect, particularly patient education and the reduction of risk habits and env:ro:~lental factors.
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]
Rehabilitation - the key to quality of life
S. Rogers. UK Following the diagnosis of oral cancer, patients and their carers are usually most concerned about cure and survival. However after treatment there tends to be a stnft towards 'quality of hfe' issues. 'Quality of hfe' is strongly Influence by fan:fly and social re-integration and appropriate rehabthtatlon as paramount. Optin~al rehabilitation begins before treatment and as ongoing afterwards. From an oral perspective speech, chewing and swallowmg are major patient priorities. There are varaous factors to consider but the platform for effective rehabilitation is often best achieved during the initial treatment phase. Multi-disciplinary team working is essential. Rehabthtat:on Includes: • Psychological (anxiety, mood, fear of recurrence), • Self-awareness (sp:nlual, purpose), • Socaal (interaction with others),
29
• Physical (mobility, recreation), • Head and neck specific function (e.g. shoulder, swallowing, chewing) Rehabilitation should be viewed from the patients point of view hence pat:ent-derived data is essential in order to facilitate the process. The key steps are (i) Involvement, (ii) nfformation, (iii) mteraction, and (iv) Intervent:on. This presentation will not only look at issue of oral rehabilitation but also explore rehabilitation in a holistic, patientcentered, multi-disciplinary team env:ro:iment.
Neck dissections - what have we learned/ where are we going? G.L. Clayman. USA Disseclaon o f the cervical lymphatics has been a component o f head and neck oncologic survey for over one hundred years. For decades, the standard of thas management was the radical neck dissection. Over the past four decades, modificat:ons o f these neck dissect:ons have become popularized throughout the world in the management of a variety of mahgnancies affecting the head and neck. The oncologic objective has always been to maintain or improve survival and regional control as well as mlnumze morbidity of the cervical lymphatic resection. Contemporary treatment approaches, which have focused upon organ preservation approaches, have further comphcated the elective or salvage neck dissection. Discussion of these :ssues as well as the contemporary role of neck dissection m head and neck oncologlc surgery will be discussed.
I•O]
New developments in reconstruction of the midface and maxilla: a classification system and reconstructive algorithm
RG. Corde:ro. USA M~xillectomy defects become much more complex when critical structures such as tile orNt, globe, and cranial base are resected and reconstmction with distant tissues becomes essential. This talk will cover a wide range of oncologic maxillectomy defects reconstructed mm:edlately using pedicled and free flaps. A classification system consisting o f type I, lim:ted m~xillectomy; type II, subtotal maxillectomy, type IIIA, total m~xillectomy with perforation o f the orbital contents, type IIIB, total maxlllectomy with orbital exenteratlon; and type IV, orbital ma_xillectomy will be described. A n algorithm for reconstruction o f these complex defects and outcomes analysis including chewing and speech furlction, cliet, and aesthetic results will also be presented. The above presentat:on wall demonstrate that free tissue transfer provides the most effect:ve and reliable form of ln~nediate reconstruction for complex maxlllectomy defects. The rectus abdommus and radial forearm flaps m combination with mmlediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional results.
I•]
Molecular progression of head and neck cancer: an update
J. Cahfano. USA The molecular understanding of the progression o f normal mucosa to invasive sqttamous cell carcinoma provides practical insights into cancer development in the upper aerodigestive tract. Recent Investigat:ons have provided a more precise us:derstandmg of early molecular events and the:r :mpact on b:ologic behavior m tile development of head and neck squamous cell carcinoma. This understanding has already led to advances
•
G
]
Premalignant lesions
C. Scully. UK Oral cancer appears to be Increasing an Incidence, and mortality has scarcely improved over the past 25 years. Better us:derstanding o f the aetiopathogenesis should lead to more accurate and earlier diagnosis and more effective treatments with fewer adverse effects, prov:dmg the best chance of a cure. Cancer as the result of DNA mutations arising spontaneously and from the action of various mutagens, especially In tobacco and alcohol. Cancer is a consequence of an Interaction of many factors. A sequence o f genetic changes leads eventually to loss of growth control and autonomy, but countering these changes are mechanisms to metabolise carcinogens, repair DNA damage, control growth, and defend against cancer. Potentaally malignant (premahgnant or precancerous) lesions whach precede some neoplasms Include erythroplasia (erythroplakaa) - the most hkely lesion to progress to severe dysplasia or carcinoma, and leukoplal~a. Clinical features winch suggest a potentially malignant lesion is hkely to transform, or has transformed, to carcinoma Include: the presence o f red lesions (erythroplama); a verrucous, speckled or granular appearance or an ulcer with fissuring or raised exophytic margins; induration; fixation of the lesion to deeper tissues or to overlymg skin or mucosa; cervical lymph node enlargement. Clmicians should be aware that single ulcers, lumps, red patches, or white patches - particularly if any of these are persisting for more than three weeks, may be mamfestations of frank mahgnancy. There should be a tngh index of suspicion, especially of a solitary lesion present for over 3 weeks: biopsy is invariably Indicated. The whole oral mucosa should be examined as there may be widespread dysplastic mucosa ("field change") or even a second neoplasm and the cervical lymph nodes must be examined. Laboratory diagnostic aids increasingly look to detection of cellular and now molecular changes. Molecular tectmNues are being introduced for prognost:cat:on m potentially mahgnant lesions. DNA content as a prognostic marker and can predict the development of carcinomas m non-dysplastlc lesions. Treatment as controversial, and there is little t~ard evidence that removal of the lesions affects the prognosis. Indeed, recent evidence suggests that removal of aneuploidal lesions has no effect on mortahty. Treatment is Increasingly looking towards chemotherapy and now gene therapy, but currently, there is no doubt that prevention is still the most important aspect, particularly patient education and the reduction of risk habits and env:ro:~lental factors.
•
]
Rehabilitation - the key to quality of life
S. Rogers. UK Following the diagnosis of oral cancer, patients and their carers are usually most concerned about cure and survival. However after treatment there tends to be a stnft towards 'quality of hfe' issues. 'Quality of hfe' is strongly Influence by fan:fly and social re-integration and appropriate rehabthtatlon as paramount. Optin~al rehabilitation begins before treatment and as ongoing afterwards. From an oral perspective speech, chewing and swallowmg are major patient priorities. There are varaous factors to consider but the platform for effective rehabilitation is often best achieved during the initial treatment phase. Multi-disciplinary team working is essential. Rehabthtat:on Includes: • Psychological (anxiety, mood, fear of recurrence), • Self-awareness (sp:nlual, purpose), • Socaal (interaction with others),
29
• Physical (mobility, recreation), • Head and neck specific function (e.g. shoulder, swallowing, chewing) Rehabilitation should be viewed from the patients point of view hence pat:ent-derived data is essential in order to facilitate the process. The key steps are (i) Involvement, (ii) nfformation, (iii) mteraction, and (iv) Intervent:on. This presentation will not only look at issue of oral rehabilitation but also explore rehabilitation in a holistic, patientcentered, multi-disciplinary team env:ro:iment.
Neck dissections - what have we learned/ where are we going? G.L. Clayman. USA Disseclaon o f the cervical lymphatics has been a component o f head and neck oncologic survey for over one hundred years. For decades, the standard of thas management was the radical neck dissection. Over the past four decades, modificat:ons o f these neck dissect:ons have become popularized throughout the world in the management of a variety of mahgnancies affecting the head and neck. The oncologic objective has always been to maintain or improve survival and regional control as well as mlnumze morbidity of the cervical lymphatic resection. Contemporary treatment approaches, which have focused upon organ preservation approaches, have further comphcated the elective or salvage neck dissection. Discussion of these :ssues as well as the contemporary role of neck dissection m head and neck oncologlc surgery will be discussed.
I•O]
New developments in reconstruction of the midface and maxilla: a classification system and reconstructive algorithm
RG. Corde:ro. USA M~xillectomy defects become much more complex when critical structures such as tile orNt, globe, and cranial base are resected and reconstmction with distant tissues becomes essential. This talk will cover a wide range of oncologic maxillectomy defects reconstructed mm:edlately using pedicled and free flaps. A classification system consisting o f type I, lim:ted m~xillectomy; type II, subtotal maxillectomy, type IIIA, total m~xillectomy with perforation o f the orbital contents, type IIIB, total maxlllectomy with orbital exenteratlon; and type IV, orbital ma_xillectomy will be described. A n algorithm for reconstruction o f these complex defects and outcomes analysis including chewing and speech furlction, cliet, and aesthetic results will also be presented. The above presentat:on wall demonstrate that free tissue transfer provides the most effect:ve and reliable form of ln~nediate reconstruction for complex maxlllectomy defects. The rectus abdommus and radial forearm flaps m combination with mmlediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional results.
I•]
Molecular progression of head and neck cancer: an update
J. Cahfano. USA The molecular understanding of the progression o f normal mucosa to invasive sqttamous cell carcinoma provides practical insights into cancer development in the upper aerodigestive tract. Recent Investigat:ons have provided a more precise us:derstandmg of early molecular events and the:r :mpact on b:ologic behavior m tile development of head and neck squamous cell carcinoma. This understanding has already led to advances