Laskaris Treatment of Oral Diseases

A Concise Textbook
1. Auflage 2004
ISBN: 978-3-13-257820-3
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 220 Seiten, ePub

George Laskaris is renowned for his excellent , one of Thieme's all-time bestsellers. This new title by Laskaris represents the ideal companion to the atlas, providing a logical extension from the diagnostic atlases toward treatment of the diseases described here.

Each disease is described in capsule form, with epidemiology, etiology, the main clinical features, and the appropriate diagnostic tests. After this, a section follows on general therapeutic guidelines, which involve topical or systemic treatment, environmental factors and alternative or experimental treatments. Finally, each report includes a section of the most important references on that condition.

This efficiently conceived therapeutic guide to oral diseases will be an invaluable aid for all residents and physicians who may be called upon to evaluate oral diseases.

Zielgruppe

Ärzte

Autoren/Hrsg.

Laskaris, George

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Zahnmedizin

Inhaltsverzeichnis

Part I: Diseases
Part II: Drugs
Part III: Laser Therapy

Leseproben

Squamous cell carcinoma

Definition

Oral squamous cell carcinoma is by far the most common malignant neoplasm. It accounts for more than 90% of all oral malignancies.

Etiology

The etiology is unknown. However, several predisposing factors have been implicated. The most important are tobacco use, alcohol consumption, human papillomavirus (types 16, 18, and 33) and chronic sun exposure (for lip carcinoma only).

Main Clinical Features

Clinically, oral squamous cell carcinoma has a broad spectrum of features and may mimic a variety of diseases.

Early Stage

•Asymptomatic red or white plaque or both

•Erosion or superficial small ulcer

•Small exophytic mass

•Erosion with crust formation, as in lip carcinoma

Advanced Stage

•Painful deep ulcer with irregular vegetating surface, elevated border, and hard base

•Large exophytic mass with or without ulceration

•Infiltrating hardness of the oral tissues

•Periodontal destruction and tooth mobility

•Regional lymph nodes enlargement

•Longstanding indurated lesions are always suspect for malignancy

•The posterior lateral border and the ventral surface of the tongue, the floor of the mouth, and the gingiva are the most commonly affected sites

•The prognosis depends on the stage at diagnosis and the histologic pattern

Diagnosis

The clinical diagnosis should be confirmed by a biopsy and histopathologic examination.

Differential Diagnosis

•Traumatic ulcer

•Aphthous ulcer

•Tuberculous ulcer

•Syphilitic ulcer

•Eosinophilic ulcer

•Leukoplakia

•Erythroplakia

•Pyogenic granuloma

•Necrotizing sialadenometaplasia

•Wegener granulomatosis

•Malignant granuloma

•Non-Hodgkin lymphoma

•Benign and malignant tumors of minor salivary glands

Treatment

Basic Guidelines

•The diagnosis must be made as soon as possible and treatment initiated promptly.

•The prognosis depends mainly on the clinical stage at diagnosis and the choice of treatment modalities.

•Before treatment decision, close collaboration between the stomatologist, radiologist, and oncologist is necessary.

•After treatment a follow-up program is important as the risk for recurrence is relatively high.

•Cessation of smoking and alcohol is essential.

Suggested Therapies

Treatment of oral squamous cell carcinoma consists of surgical excision, radiation therapy, or combination of both. Chemotherapy is also been used in combination with surgery and radiation. The decision for monotherapy or combination of therapies depend on the clinical stage of the disease, and the age and general health of the patient.

Surgical Treatment

The main aim of surgical treatment is total excision of the tumor with a wide 1.5-2.5 cm margin of surrounding healthy tissues in all three dimensions.

In cases of bony involvement a peripheral, partial and finally hemi-mandibulectomy or hemi-maxillectomy should be performed.

Several surgical methods allow complete removal and immediate reconstruction of the missing soft and hard tissues to achieve a better functional and cosmetic result for the patient. According to the nature of the defect, skin or bony grafts are used for reconstructive purposes as well as the several types of cutaneous, myocutaneous, or osseomyocutaneous flaps. These flaps can be either local or regional or can be applied as free microvascular flaps from the iliac crest, fibula, radius, and scapula as well as the serratus and latissimus dorsi muscles.

Besides elimination of the primary site of the tumor, surgical management includes several types of surgical neck dissections to remove all possible regional lymph node metastases.

Despite recent improvement in surgical techniques and diagnostic tools, the overall postoperative 5-year survival rate of squamous cell carcinoma is still poor. Consequently, prevention and early diagnosis of oral squamous cell carcinoma is of great importance.

Radiotherapy

Modern era radiotherapy plays an important role in the radical treatment of patients with oral squamous cell carcinomas and has improved local control and their quality of life. It can be combined with surgery, pre- or postoperatively, and/ or chemotherapy or can be used as the sole method of curative treatment. Radiotherapy combined with chemotherapy has the extra advantage of organ preservation. The introduction of multileaf linear accelerators and new software making use of computerized tomography (CT), magnetic resonance (MR), and, recently, positron emission tomography (PET) images, resulted in the development of three-dimensional conformal radiotherapy (3DCRT) and, even most recently, in what is called intensity modulated radiotherapy (IMRT).

Radiotherapy has been used in combination with chemotherapy in nonresectable oral squamous cell carcinoma in preparation for surgery, or the two together in organ preserving, radical curative attempts. A meta-analysis published in 2003 concluded that cisplatin, carboplatin, mitomycin-C and 5-fluorouracil (FU) single drug or combinations of 5-FU with one of other drugs, combined with simultaneous radiotherapy leads to a profound survival benefit in unresectable head and neck cancer patients irrespective of the fractionation schedule.

Radiotherapy can also be used as brachytherapy with interstitial radioactive isotopes, either in the form of temporary implants of radioactive iridium or after loading machines, thus achieving excellent conformity of radiation dose to the gross tumor volume.

Hyperthermia is another type of treatment that can be combined with radiotherapy with additive cancer killing effect and nonadditive side effects.

While modern era radiotherapy in combination with other modalities has improved life expectancy and organ preservation of patients with oral cavity squamous cell carcinomas, prophylactic reduction of alcohol and cigarette consumption is the best way to reduce morbidity and mortality.

Chemotherapy

Chemotherapy was used in the past in advanced disease or for recurrence after surgery and/or radiotherapy. During the last few years chemotherapy has been used more in a better and effective way. The term induction chemotherapy has gained ground and several investigators have studied ways to improve the final outcome of the disease. To be able to start treatment with chemotherapy before any radiation or surgery produced hope and has shown a higher efficacy and response rate of the tumors to the cytotoxic agents.

Chemotherapy was initiated in the treatment of head and neck cancers, including the oral carcinomas, by the introduction of the cytotoxic drug cisplatin. Cisplatin in combination with other agents started producing reasonably effective results in advanced stage. Cisplatin combined with 5-FU is one of the most effective combination and one of the standard treatments. Other cytotoxic agents that have been used in combinations are methotrexate, bleomycin, hydroxyurea, and vinca alkaloids. Taxanes, e.g., paclitaxel combined with a cisplatin analogue carboplatin, has also been shown to be highly effective and can be considered a first-line treatment. Response rates of 24-39% in advanced disease have been recorded. Chemotherapy for recurrent or advanced metastatic disease may not produce sufficient cure rates but there is a degree of response and prolongation of survival.

Two other chemotherapeutical strategies have been used over the past 10 years to improve the treatment efficacy on the whole: a) chemotherapy before any other treatment (induction chemotherapy) and b) combination of chemotherapy with radiotherapy (concurrent treatment). The rationale behind induction chemotherapy is based on better drug delivery to the tumor when the vascular bed is intact, and the possible eradication of micrometastatic disease. The last may allow the drug dose to be more efficient and thus improve compliance. Response can result in less extensive surgery or tumors possibly become operable. The response rate of patients after induction chemotherapy has been highly increased. Concurrent treatment is gaining ground.

References

Al-Sarraf M, Pajak TF, Byhardt RW, et al. Postoperative radiotherapy with concurrent cisplatin appears to improve locoregional control of advanced, resectable bend and neck cancer, 1997;37:777–782.

Bernier J, Domenge C, Eschwege F. Chemo-radiotherapy, as compared to radiotherapy alone, significantly increases disease-free and overall survival in head and neck cancer patients after surgery: Results of EORTC phase III trial 22931 [abstract]. 2001;51(suppll):l.

Budach W, Hehr T, Beika C, Dietz K. Radiotherapy combined with cisplatin/carboplatin, mitomycin C and 5FU, single drug or two drug chemotherapy compared to radiotherapy alone in unresectable head and neck cancer: A meta analysis [abstract]. No. 684, 2003;l(suppl):5206.

Cawson RA, Binnie WH, Barrett AW, Wright JM....

Über Autor(innen)

George Laskaris