- Email: [email protected]
S34 The Brazilian experience on tobacco control
122 progressed into high-grade lesions (11 FVL), and 7 progressed into SCC (6 FVL). Of the 62 clinically unremarkable prior lesion sites with FVL, appearance of clinical lesions followed in 21 (12 biopsied: 6 high-grade, 3 low-grade and 3 nondysplastic), and 41 remained clinically lesion free. Of these, FVL in 22 decreased in size or disappeared. The remaining 19 were biopsied: 6 cancer, 6 high-grade, 5 low-grade and 2 nondysplastic). Conclusion: The data support the use of VELscope as an adjunct tool to identify high-risk oral lesions. Keywords: autofluorescence, oral premalignant and malignant lesions, visualization tool, early detection
Keynote address K6 Reconstruction of the oral cavity: old problems, new challenges and the future R. Gilbert *. Canada Reconstruction of the oral cavity continues to challenge head and neck surgeons. This presentation will review the current state of oral reconstruction and discuss the specific challenges of restoring oral function. The presentation will review the current state of reconstruction of the oral mucosal structures, mandible and maxilla. The author’s views regarding the principles, approaches and problems associated with the variety of available reconstructive techniques will be critically appraised. The new challenges of treating patients following concomitant chemoradiation will be discussed and some potential approaches to this complex group of patients will be discussed. The current interest in reconstruction of the maxilla will be highlighted with a discussion of classification of defects and some new approaches utilizing the tip of scapula will be presented. The future challenges for head and neck reconstruction surgeons including the role of tissue transplantation will be discussed.
Symposium Brazilian Society of Head and Neck Surgery
Primary prevention and screening of oral cancer S33 Chemoprevention of head and neck cancer: present status and future directions F. Chiesa *. European Institute of Oncology, Italy Over the last two decades the loco-regional control of head and neck cancers has improved, but mortality remains high mainly due to the development of second primaries in relation to continuing exposure of the epithelial surface of the oral cavity, oropharynx and larynx to carcinogens (mainly tobacco and alcohol). Primary prevention (stopping exposure to carcinogens) would seem to be the best approach to such cancers, however once started the multistep carcinogenic process seems to continue in the absence of continued exposure to known carcinogens, or perhaps because of continuing exposure to unrecognized endogenous and exogenous carcinogenic agents. Oral leukoplakia is a precancerous mucosal condition: the probability of transforming into oral carcinoma is estimated to be about 10% over 20 years. Furthermore patients whose leukoplakias are removed surgically frequently develop local relapses or new leukoplakias; they are also at increased risk of developing or oral carcinoma. Such patients are excellent candidates for trials on chemopreventive agents particularly since the accessibility of the oral cavity allows convenient histological and photographic evaluation to assess intervention efficacy. Clinical experiences: Retinoids are promising chemopreventive agents. They exert a beneficial effect on epithelial differenti-
Oral and Symposium abstracts, Sunday 20 May ation, and can inhibit malignant transformation and suppress tumor promotion. Since the 1970s many clinical studies have sought to determine whether natural and synthetic retinoids have a primary cancer-preventive action. Some studies found that these substances may have such an action by promoting the disappearance of oral leukoplakias. In other studies, retinoids had an adjuvant chemopreventive effect in reducing the incidence of new head and neck carcinomas. Results of these trials are not satisfactory, so new drugs are going to be tested. The future: The activation of EGFr has been identified as a key initiating event that starts the cascade of intracellular signalling events that regulate the proliferation, differentiation, survival, angiogenesis, and metastasis of tumours. The inhibition of EGFr tyrosine kinase (EGFr-TK) is a very promising and important approach to reduce HNSCC incidence. A strong link between nonsteroidal anti-inflammatory drugs (NSAIDs) and the reduction of cancer incidence at a variety of organ sites is evident from epidemiological studies in humans and carcinogenesis studies in rodent. In the case of Upper Aerodigestive tract carcinogenesis, the presence of chronic inflammation and prostaglandins in the local milieu is well documented. COX-2 has been shown to be upregulated up to 150-fold in HNSCC and up to 50-fold in the normal appearing tissue of patients with HNSCC compared with normal subjects. NSAIDs family inhibit the cyclooxygenase family of enzimes. Thus there is a strong rationale for the testing of NSAIDs for prevention of Head and Neck carcinogenesis. S34 The Brazilian experience on tobacco control J. Kligerman *. Brazil The overall purpose of the National Tobacco-Control Program, coordinated by the Ministry of Health through INCA (Brazilian Cancer Institute) is to reduce the prevalence of smokers, and therefore tobacco-related morbidity and mortality in Brazil. The Program’s specific objectives are: • Reduce smoking initiation, particularly among the youths • Enhance smoking cessation. Guidelines: • A social and political scenario favorable to tobacco control • Equity, comprehensiveness, and inter-sectors development of actions • Fostering of partnerships to face tobacco-control resistances • Decrease social acceptance of smoking • Decrease encouragement for smoking initiation • Reduce access to tobacco products • Protection against the risks of environmental tobacco smoke • Reduction of social barriers that hamper smoking cessation • Increase of access and affordability to smoking-cessation treatments • Control and monitoring of tobacco product marketed in the country, from their contents and emissions to their marketing and promotion strategies. • Monitoring and surveillance of consumption trends, and their effects on health, economy and environment. Working in consonance with Brazilian Tobacco Control Program, Rio de Janeiro’s City Hall through Municipal Health Secretariat is improving a local program to reduce tobacco consumption. The program resulted in a threefold set of activities: • More than 50 cost free centers supporting smokers wishing to quit smoking have been established with free distribution of nicotine replacement medicines • Students of around 1000 schools in Rio are receiving educational information of the consequences of tobacco and encouraged to talk about it in their family environment
Oral and Symposium abstracts, Sunday 20 May
S35 The Brazilian experience on mass screening M.P. Curado *. Brazil The head and neck cancer is the sixth major prevalent neoplasm over the world being responsible for 5% of all neoplasm in men and 2.5% in women. Mortality caused by oral cavity cancer represented 4% of all death in men and 1% in women. In Brasil, INCA, estimates 10.060 new oral cancers, for male and 3410 new cases for female in 2006. It have been more incident in Southeast, South and West-Center regions for both genders. The cities of Salvador and S˜ ao Paulo had the biggest mortality rates. There has been observed in S˜ ao Paulo the biggest percentage rate of death by oral cavity lip, for both genders. Most of the oral cancer was advanced disease stage III and IV. The mortality rates are high for most of these patients. With aim to reduce these high death rates of oral cancer in Brasil it was created an early detection program. It was in the city of Vitoria, in southwest part of Brasil. Most of oral cancer cases discovery by this program in initial years were stage III and IV. With the establishment of this early detection group the percentage of advanced cases are decreasing gradually every year. Now after more than 10 years it looks stable with around 25% of early oral cancer detected. This is an example of early detection for oral cancer to be implemented in any country. S36 Causes of diagnostic delay of oral cancer L.P. Kowalski *. Brazil Cancer of the oral cavity ranks among the most common neoplasms in developing countries. The survival expectation for patients with oral cancers living in these geographic areas is generally lower than for those living in developed countries. The most significant feature of oral cancer prognosis in developing countries is that most patients will present at advanced stage of disease. Clinical stage at presentation can be influenced by several demographic, clinical and sociodemographic variables, including patient and professional delays. Patient delay in the diagnosis of oral cancer has been attributed to two major factors: patient delay in recognizing the signs or symptoms of cancer, and difficulties in accessing professional care. Professional delay can be attributed to failure in recognizing the signs and symptoms suspicious of cancer. Several studies showed that gender, dental status, alcohol consumption, and socio-economic status are the main variables associated with clinical stage at diagnosis. Another important determinant of advanced stage is tumour location on the less visible surfaces of the oral cavity and oropharynx. The delay to start the oncologic treatment also change the prognosis of oral cancer patients, mainly if this delay results in a clinical upstaging of the tumour. Treatment of cancer should be quickly initiated after diagnosis, however, for some reasons this not always happens. The adoption of continued educational programs for the population and professionals regarding primary prevention and the identification of early symptoms of oral cancer as well as health-care access for prompt treatment are warranted as the best ways of improving prognosis. Unfortunately the majority of the health promotion programs have been unsuccessful in developing countries mainly because the emphasis is only focused the control of environmental risks factors tobacco and alcohol. Other possible explanation is that the knowledge about the image of cancer in the community has not been applied to the prediction of change in behaviour. An analysis of the social representations of patients and companions about cancer and its prevention,
was recently conduced with the aim of granting data for educational and health programs. The results revealed that the social representations of cancer were centred on ideas of seriousness, scare, suffering and death. Although most people considered tobacco and alcoholic beverages as risk factors, however few adopted preventive attitudes. For some people, it was impossible to prevent cancer, since they did not know the causes, which seems to predispose them to self-medical prescription and alternative treatments. The establishment of public health policies that privileges public and health professional education are required as a fundamental measure for cancer prevention, and to provide equal conditions to health services access.
Oral abstracts Surgery II O180 Pathological patterns of cervical lymph node metastasis at presentation in T1 2 oral tongue cancer in Pakistan A. Jamshed *, R. Hussain, A. Ali Syed, S. Ahmad, K. ur Rehman, R. Azhar, S. Hameed, M. Ali Shah, Z. Faruqui. Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan Purpose: South East Asia has a high incidence of oral cancer with a predilection for tongue. Twenty to thirty percent of the patients with oral tongue cancer have occult neck nodal metastasis at presentation. Treatment of neck in early T stage tongue cancer is controversial. The study was conducted to determine the histological distribution of neck node metastasis in early squamous cell carcinoma (SCC) oral tongue and improve the rationale for optimum treatment. Patients and Methods: Between November 2003 and June 2006, 30 patients with oral tongue SCC (pT1 and pT2) treated with curative surgery at Shaukat Khanum Memorial Cancer Hospital and Research Centre between were analyzed retrospectively. There were 18 males and 12 female patients. The median age for the group was 48 years (range 15 74 years). All the patients underwent partial glossectomy with neck dissection. Neck dissection was ipsilateral in 28 patients (93%) and bilateral in 2 patients (7%). Sixteen patients (47%) had pT1 and 14 patients (53%) had pT2 tumours. A total of 1056 cervical lymph nodes were analysed. The number of nodes in level I, II, III, IV and V was 261, 295, 230, 250 and 20 respectively. Results: 53% (16/30) of the patients had positive cervical nodal disease. 61% (11/18) of males and 41% (5/12) of females had pN+ disease. Fifty five percent of patients 40 (5/9) years of age had pN+ in comparison with 52% (11/21) of patients >40 years of age. The distribution of positive nodes in neck was 40%, 40%, 20%, 10% and 0% in level I, II, III, IV and V respectively. Skip metastasis in level III and IV were seen in 10% (3/30) of the patients. No patient had isolated level IV involvement. In pT1 disease 44% (7/16) and in pT2 64% had neck node metastasis; patterns of neck nodal involvement in level I, II, III, IV and V for pT1 was 25%, 31%, 19%, 12% and 0% and for pT2 was 57%, 50%, 21%, 7% and 0% respectively. Conclusion: Risk of cervical nodal metastasis at presentation in early tongue cancer is high (> 50%). Level I and II are the most frequently involved nodal sites in the neck. Treatment of upper neck should be considered mandatory in these patients. Keywords: carcinoma tongue, neck dissection, pN
Oral abstracts
• Intensive campaign on tobacco free environment is being directed to shoppings centers, restaurants and stores, in general. The goal is to decrease evidence of oral cancer and tobacco diseases related.
123
Keynote address K6 Reconstruction of the oral cavity: old problems, new challenges and the future R. Gilbert *. Canada Reconstruction of the oral cavity continues to challenge head and neck surgeons. This presentation will review the current state of oral reconstruction and discuss the specific challenges of restoring oral function. The presentation will review the current state of reconstruction of the oral mucosal structures, mandible and maxilla. The author’s views regarding the principles, approaches and problems associated with the variety of available reconstructive techniques will be critically appraised. The new challenges of treating patients following concomitant chemoradiation will be discussed and some potential approaches to this complex group of patients will be discussed. The current interest in reconstruction of the maxilla will be highlighted with a discussion of classification of defects and some new approaches utilizing the tip of scapula will be presented. The future challenges for head and neck reconstruction surgeons including the role of tissue transplantation will be discussed.
Symposium Brazilian Society of Head and Neck Surgery
Primary prevention and screening of oral cancer S33 Chemoprevention of head and neck cancer: present status and future directions F. Chiesa *. European Institute of Oncology, Italy Over the last two decades the loco-regional control of head and neck cancers has improved, but mortality remains high mainly due to the development of second primaries in relation to continuing exposure of the epithelial surface of the oral cavity, oropharynx and larynx to carcinogens (mainly tobacco and alcohol). Primary prevention (stopping exposure to carcinogens) would seem to be the best approach to such cancers, however once started the multistep carcinogenic process seems to continue in the absence of continued exposure to known carcinogens, or perhaps because of continuing exposure to unrecognized endogenous and exogenous carcinogenic agents. Oral leukoplakia is a precancerous mucosal condition: the probability of transforming into oral carcinoma is estimated to be about 10% over 20 years. Furthermore patients whose leukoplakias are removed surgically frequently develop local relapses or new leukoplakias; they are also at increased risk of developing or oral carcinoma. Such patients are excellent candidates for trials on chemopreventive agents particularly since the accessibility of the oral cavity allows convenient histological and photographic evaluation to assess intervention efficacy. Clinical experiences: Retinoids are promising chemopreventive agents. They exert a beneficial effect on epithelial differenti-
Oral and Symposium abstracts, Sunday 20 May ation, and can inhibit malignant transformation and suppress tumor promotion. Since the 1970s many clinical studies have sought to determine whether natural and synthetic retinoids have a primary cancer-preventive action. Some studies found that these substances may have such an action by promoting the disappearance of oral leukoplakias. In other studies, retinoids had an adjuvant chemopreventive effect in reducing the incidence of new head and neck carcinomas. Results of these trials are not satisfactory, so new drugs are going to be tested. The future: The activation of EGFr has been identified as a key initiating event that starts the cascade of intracellular signalling events that regulate the proliferation, differentiation, survival, angiogenesis, and metastasis of tumours. The inhibition of EGFr tyrosine kinase (EGFr-TK) is a very promising and important approach to reduce HNSCC incidence. A strong link between nonsteroidal anti-inflammatory drugs (NSAIDs) and the reduction of cancer incidence at a variety of organ sites is evident from epidemiological studies in humans and carcinogenesis studies in rodent. In the case of Upper Aerodigestive tract carcinogenesis, the presence of chronic inflammation and prostaglandins in the local milieu is well documented. COX-2 has been shown to be upregulated up to 150-fold in HNSCC and up to 50-fold in the normal appearing tissue of patients with HNSCC compared with normal subjects. NSAIDs family inhibit the cyclooxygenase family of enzimes. Thus there is a strong rationale for the testing of NSAIDs for prevention of Head and Neck carcinogenesis. S34 The Brazilian experience on tobacco control J. Kligerman *. Brazil The overall purpose of the National Tobacco-Control Program, coordinated by the Ministry of Health through INCA (Brazilian Cancer Institute) is to reduce the prevalence of smokers, and therefore tobacco-related morbidity and mortality in Brazil. The Program’s specific objectives are: • Reduce smoking initiation, particularly among the youths • Enhance smoking cessation. Guidelines: • A social and political scenario favorable to tobacco control • Equity, comprehensiveness, and inter-sectors development of actions • Fostering of partnerships to face tobacco-control resistances • Decrease social acceptance of smoking • Decrease encouragement for smoking initiation • Reduce access to tobacco products • Protection against the risks of environmental tobacco smoke • Reduction of social barriers that hamper smoking cessation • Increase of access and affordability to smoking-cessation treatments • Control and monitoring of tobacco product marketed in the country, from their contents and emissions to their marketing and promotion strategies. • Monitoring and surveillance of consumption trends, and their effects on health, economy and environment. Working in consonance with Brazilian Tobacco Control Program, Rio de Janeiro’s City Hall through Municipal Health Secretariat is improving a local program to reduce tobacco consumption. The program resulted in a threefold set of activities: • More than 50 cost free centers supporting smokers wishing to quit smoking have been established with free distribution of nicotine replacement medicines • Students of around 1000 schools in Rio are receiving educational information of the consequences of tobacco and encouraged to talk about it in their family environment
Oral and Symposium abstracts, Sunday 20 May
S35 The Brazilian experience on mass screening M.P. Curado *. Brazil The head and neck cancer is the sixth major prevalent neoplasm over the world being responsible for 5% of all neoplasm in men and 2.5% in women. Mortality caused by oral cavity cancer represented 4% of all death in men and 1% in women. In Brasil, INCA, estimates 10.060 new oral cancers, for male and 3410 new cases for female in 2006. It have been more incident in Southeast, South and West-Center regions for both genders. The cities of Salvador and S˜ ao Paulo had the biggest mortality rates. There has been observed in S˜ ao Paulo the biggest percentage rate of death by oral cavity lip, for both genders. Most of the oral cancer was advanced disease stage III and IV. The mortality rates are high for most of these patients. With aim to reduce these high death rates of oral cancer in Brasil it was created an early detection program. It was in the city of Vitoria, in southwest part of Brasil. Most of oral cancer cases discovery by this program in initial years were stage III and IV. With the establishment of this early detection group the percentage of advanced cases are decreasing gradually every year. Now after more than 10 years it looks stable with around 25% of early oral cancer detected. This is an example of early detection for oral cancer to be implemented in any country. S36 Causes of diagnostic delay of oral cancer L.P. Kowalski *. Brazil Cancer of the oral cavity ranks among the most common neoplasms in developing countries. The survival expectation for patients with oral cancers living in these geographic areas is generally lower than for those living in developed countries. The most significant feature of oral cancer prognosis in developing countries is that most patients will present at advanced stage of disease. Clinical stage at presentation can be influenced by several demographic, clinical and sociodemographic variables, including patient and professional delays. Patient delay in the diagnosis of oral cancer has been attributed to two major factors: patient delay in recognizing the signs or symptoms of cancer, and difficulties in accessing professional care. Professional delay can be attributed to failure in recognizing the signs and symptoms suspicious of cancer. Several studies showed that gender, dental status, alcohol consumption, and socio-economic status are the main variables associated with clinical stage at diagnosis. Another important determinant of advanced stage is tumour location on the less visible surfaces of the oral cavity and oropharynx. The delay to start the oncologic treatment also change the prognosis of oral cancer patients, mainly if this delay results in a clinical upstaging of the tumour. Treatment of cancer should be quickly initiated after diagnosis, however, for some reasons this not always happens. The adoption of continued educational programs for the population and professionals regarding primary prevention and the identification of early symptoms of oral cancer as well as health-care access for prompt treatment are warranted as the best ways of improving prognosis. Unfortunately the majority of the health promotion programs have been unsuccessful in developing countries mainly because the emphasis is only focused the control of environmental risks factors tobacco and alcohol. Other possible explanation is that the knowledge about the image of cancer in the community has not been applied to the prediction of change in behaviour. An analysis of the social representations of patients and companions about cancer and its prevention,
was recently conduced with the aim of granting data for educational and health programs. The results revealed that the social representations of cancer were centred on ideas of seriousness, scare, suffering and death. Although most people considered tobacco and alcoholic beverages as risk factors, however few adopted preventive attitudes. For some people, it was impossible to prevent cancer, since they did not know the causes, which seems to predispose them to self-medical prescription and alternative treatments. The establishment of public health policies that privileges public and health professional education are required as a fundamental measure for cancer prevention, and to provide equal conditions to health services access.
Oral abstracts Surgery II O180 Pathological patterns of cervical lymph node metastasis at presentation in T1 2 oral tongue cancer in Pakistan A. Jamshed *, R. Hussain, A. Ali Syed, S. Ahmad, K. ur Rehman, R. Azhar, S. Hameed, M. Ali Shah, Z. Faruqui. Shaukat Khanum Memorial Cancer Hospital and Research Centre, Pakistan Purpose: South East Asia has a high incidence of oral cancer with a predilection for tongue. Twenty to thirty percent of the patients with oral tongue cancer have occult neck nodal metastasis at presentation. Treatment of neck in early T stage tongue cancer is controversial. The study was conducted to determine the histological distribution of neck node metastasis in early squamous cell carcinoma (SCC) oral tongue and improve the rationale for optimum treatment. Patients and Methods: Between November 2003 and June 2006, 30 patients with oral tongue SCC (pT1 and pT2) treated with curative surgery at Shaukat Khanum Memorial Cancer Hospital and Research Centre between were analyzed retrospectively. There were 18 males and 12 female patients. The median age for the group was 48 years (range 15 74 years). All the patients underwent partial glossectomy with neck dissection. Neck dissection was ipsilateral in 28 patients (93%) and bilateral in 2 patients (7%). Sixteen patients (47%) had pT1 and 14 patients (53%) had pT2 tumours. A total of 1056 cervical lymph nodes were analysed. The number of nodes in level I, II, III, IV and V was 261, 295, 230, 250 and 20 respectively. Results: 53% (16/30) of the patients had positive cervical nodal disease. 61% (11/18) of males and 41% (5/12) of females had pN+ disease. Fifty five percent of patients 40 (5/9) years of age had pN+ in comparison with 52% (11/21) of patients >40 years of age. The distribution of positive nodes in neck was 40%, 40%, 20%, 10% and 0% in level I, II, III, IV and V respectively. Skip metastasis in level III and IV were seen in 10% (3/30) of the patients. No patient had isolated level IV involvement. In pT1 disease 44% (7/16) and in pT2 64% had neck node metastasis; patterns of neck nodal involvement in level I, II, III, IV and V for pT1 was 25%, 31%, 19%, 12% and 0% and for pT2 was 57%, 50%, 21%, 7% and 0% respectively. Conclusion: Risk of cervical nodal metastasis at presentation in early tongue cancer is high (> 50%). Level I and II are the most frequently involved nodal sites in the neck. Treatment of upper neck should be considered mandatory in these patients. Keywords: carcinoma tongue, neck dissection, pN
Oral abstracts
• Intensive campaign on tobacco free environment is being directed to shoppings centers, restaurants and stores, in general. The goal is to decrease evidence of oral cancer and tobacco diseases related.
123