The Farber Center: For Radiation Oncology

What is the oral cavity? It is made up of several areas including:

• Lips
• Oral tongue
• Floor of mouth
• Buccal mucosa
• Upper/Lower Gingivae (“Alveolar ridge”)
• Retromolar trigone
• Hard Palate

Although cancers of the head and neck region only account for five percent of all cancers reported yearly in the human body, 30 percent of these cancers occur in the oral cavity. That is roughly 22,000 new cases per year if cancers of the lip are not included. Between 6000 and 7000 deaths per year occur because of oral cavity cancer.

• Enlarged neck lymph nodes
• Sore throat
• Ear pain
• Difficulty swallowing
• Painful swallowing
• Foul breath
• Voice changes
• Bleeding
• Difficulty opening your jaw/pain in opening your jaw
• Pain

Risk Factors:

• Tobacco and alcohol use are the major risk factors for most cancers of the head and neck including the oral cavity. Although the most common use of tobacco in the United States a cigarette smoking, the use of smokeless tobacco, or chew, is associated with oral cavity cancers.
• Beetle nut chewing: In countries such as India, where the use of a specific type of smokeless tobacco and a substance called beetle nut is common, the inner cheek area of the oral cavity is most commonly affected.
• Alcohol: Drinking alcohol increases the risk of developing oral cavity and oropharyngeal cancers. The risk goes up even more for people who use both tobacco and alcohol. About 7 out of 10 patients with oral cancer are heavy drinkers
• Immunodeficiency: People taking drugs that suppress the immune system to prevent rejection of transplanted organs or to treat certain immune system diseases may be at increased risk for cancers of the oral cavity and oropharynx.
• Sun: Cancer of the lip can be caused by exposure to the sun. Using a lotion or lip balm that has a sunscreen can reduce the risk. Wearing a hat with a brim can also block the sun's harmful rays. The risk of cancer of the lip increases if the person also smokes.

Complete history and physical examination including: a thorough history will be taken asking for some of the symptoms. There are many symptoms that raise concern for the possibility of the oral cavity cancer being present. The most common of these is a nonhealing wound on the tongue, in the floor of mouth or along the inner cheek. These can be painful, but in some cases do not cause significant discomfort.

Physical exam of the lips and oral cavity: An exam to check the lips and oral cavity for abnormal areas. The doctor or dentist will feel the entire inside of the mouth with a gloved finger and examine the oral cavity with a small long-handled mirror and lights. This will include checking the insides of the cheeks and lips; the gums; the roof and floor of the mouth; and the top, bottom, and sides of the tongue. The neck will be felt for swollen lymph nodes. A history of the patient’s health habits and past illnesses and medical and dental treatments will also be taken.

Biopsy a small piece of tissue taken from the suspected tumor - is often advised. This tissue is sent to a pathologist to define which types of cells are making up the tumor.

Tumor HPV testing

MRI and/or CT scans of head and neck One or both of these can may be necessary at each can provide very specific information concerning the extent of disease. The physician may also order an X-ray or CT scan of the chest to see if there is any spread of disease to the lungs, the most common site of spread outside of the neck.

Consider PET/CT scan A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.

Dental evaluation

Nutrition, speech and swallowing evaluation as indicated

Examination under anesthesia with endoscopy

T indicates the size of the main (primary) tumor and which, if any, tissues of the oral cavity has spread to.

Tis: carcinoma in situ. This means the cancer is still within the epithelium (the top layer of cells lining the oral cavity) and has not yet grown into deeper layers of oral tissue

T1: tumor is 2 cm (about ¾ inch) across or smaller

T2: tumor is larger than 2 cm across, but smaller than 4 cm (about 1 ½ inch)

T3: tumor is larger than 4 cm across

T4a: The tumor is growing into nearby structures. This is known as moderately advanced local disease.
For oral cavity cancers: the tumor is growing into nearby structures, such as the bones of the jaw or face, deep muscle of the tongue, skin of the face, or the maxillary sinus.
For lip cancers: the tumor is growing into nearby bone, the inferior alveolar nerve (the nerve to the jawbone), the floor of the mouth, or the skin of the chin or nose.

T4b: The tumor has grown through nearby structures and into deeper areas or tissues. This is known as very advanced local disease. Any of the following may be true:

The tumor is growing into other bones, such as the pterygoid plates and/or the skull base
The tumor surrounds the internal carotid artery
For lip and oral cavity cancers: the tumor is growing into an area called the masticator space.

N stands for spread to nearby lymph nodes in the neck

N0: There is no evidence of cancer in the regional nodes.

N1: Cancer has spread to a single node on the same side as the primary tumor and the cancer found in the node is 3 cm or smaller.

N2: Describes any of the following conditions:

N2a: Cancer has spread to a single lymph node on the same side as the primary tumor, and is larger than 3 cm, but not larger than 6 cm.
N2b: Cancer has spread to more than one lymph node on the same side as the primary tumor, and none measure larger than 6 cm.
N2c: Cancer has spread to more than one lymph node on either side of the body, and none measure larger than 6 cm.

N3: Cancer found in the lymph nodes is larger than 6 cm.

M is for metastasis (spread to distant organs).

M0: The cancer has not spread to distant sites.

M1: The cancer has spread to distant sites.

Stage Grouping

Stage 0
Tis, N0, M0

Stage I
T1, N0, M0

Stage II
T2, N0, M0

Stage III
T3, N0, M0, OR T1 to T3, N1, M0

Stage IVA
T4a, N0 or N1, M0, OR T1 to T4a, N2, M0

Stage IVB
T4b, Any N, M0, OR Any T, N3, M0

Stage IVC
Any T, Any N, M1

SURGERY
Surgery (removing the cancer in an operation) is a common treatment for all stages of lip and oral cavity cancer. Wide local excision: Removal of the cancer and some of the healthy tissue around it. If cancer has spread into bone, surgery may include removal of the involved bone tissue. Neck dissection: Removal of lymph nodes and other tissues in the neck. This is done when cancer may have spread from the lip and oral cavity Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

RADIATION
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

CHEMOTHERAPY
is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

HYPERTHERMIA THERAPY
is a treatment in which body tissue is heated above normal temperature to damage and kill cancer cells or to make cancer cells more sensitive to the effects of radiation and certain anticancer drugs.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.