Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Otol Rhinol Vol: 4 Issue: 3

Dilemmas in Managing Oral Cavity Carcinoma: A Single Institution Experience with Illustration of Four Cases

Norhafiza Mat Lazim* and Baharudin Abdullah
ORL-HNS Surgeon, ORL-HNS Dept, School of Medical Sciences, Universiti Sains Malaysia
Corresponding author : Dr. Norhafiza Mat Lazim
ORL-HNS Surgeon, ORL-HNS Dept, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150 Kota Bharu, Kelantan, Malaysia
Tel: +60199442664
E-mail: [email protected]
Received: October 07, 2014 Accepted: November 29, 2014 Published: April 27, 2015
Citation: Mat Lazim N, Abdullah B (2015) Dilemmas in Managing Oral Cavity www.scitechnol.com/head-neck-surgery/head-and-neck-cancer-research.phpCarcinoma – A Single Institution Experience with Illustration of Four Cases. J Otol Rhinol 4:3. doi:10.4172/10.4172/2324-8785.1000223

Abstract

Dilemmas in Managing Oral Cavity Carcinoma – A Single Institution Experience with Illustration of Four Cases

Introduction: Oral cavity carcinoma is a common tumor of head and neck with tongue carcinoma is the main site of involvement in South East Asia region. Majority of patients present late and prognosis is dismal despite optimal treatment.

Methodology: A retrospective study of oral cavity malignancy at Hospital Universiti Sains Malaysia located in East Coast of Peninsular Malaysia was carried out from January 2011 to October 2013. Only four cases of oral cavity carcinoma were identified. Details of clinical presentation, imaging finding, histopathological diagnosis and treatment outcomes were reviewed.

Clinical presentation and Result: The age of patients ranges from 35 to 43 years old with a Chinese and three Malays. Two patients were male and two were female. All cases are oral tongue carcinoma subsites. Three patients had glossectomy and neck dissections with adjuvant chemoradiation. The other male patient adamantly refused any form of surge and went for complementary and alternative medicines. All patients had minimal response to chemoradiation and two patients succumbed to diseases.

Discussion: The survival of oral cavity carcinoma patient is reducing in South East Asia in contrast to an increasing survival trend seen in Western World. Multiple factors contribute to this phenomenon and numerous local issues are taken into consideration in highlighting the true spectrum of this diseases and its progression locally. Most patients deteriorate despite multimodality treatment.

Conclusion: OCSCC is an important entity in the armamentarium of head and neck cancer management. Despite multimodality treatment, the outcome remains poor. Thus it is imperative to refine treatment strategies and expertise locally in order to ensure a finesse cancer patients care in near future.

Keywords: Oral cavity carcinoma; Treatment; Neck dissection; Glossectomy; Chemoradiation

Keywords

Oral cavity carcinoma; Treatment; Neck dissection; Glossectomy; Chemoradiation

Introduction

Oral cavity cancer is one of the commonest head and neck cancers. It comprises of 30% of head and neck malignancy and majority are squamous cell carcinoma [1]. It is the eighth common cancer globally. Its incidence is declining in the Western World however in South East Asia, the disease continues to rise and contributes significantly to health economic locally. The primary treatment for oral cavity squamous cell carcinoma (OCSCC) is surgical excision especially for early tumors with good outcomes. Multidisciplinary treatment is commonly practiced for a more advanced disease with use of chemoradiation as part of the treatment strategy. Despite adjuvant chemoradiation, loco regional recurrence for oral cavity carcinoma remains high.
In Malaysia, the first national cancer registry report was published in 2003 under Public Health Department of Ministry of Health. There were 200 multidisciplinary centers which participate in this registry and involve in data collection throughout Malaysia. According to this registry, in the year of 2003 to 2005, there were a total of 68,762 new cancer cases diagnosed and among these 29,956 are males and 38,196 are females [2]. The most frequent cancer was breast cancer followed by large bowel cancer and lung cancer. Tongue cancer is ranked seventeenth and twenty-first most common cancers among males and females respectively in Peninsular Malaysia and the incidence is highest among ethnics Indians followed by Malay and Chinese. The most common histopathology diagnosis is squamous cell carcinoma which contributes to 92.6 % of reported cases.
The evolving trend in OCSCC management has resulted in better patient survival in majority of patients in the Western World countries. Despite an increasing trend seen in the survival rates of OSCCC patients in developed countries, our center still experiences a poor treatment outcome for this category of patients. There are many factors that contribute to this poor outcome and it includes patient factor, surgeon factor, facilities factor and importantly hospital economic factor. The fact that very few patients present with an early diseases at our local practices makes the better treatment outcome for this group of patients is unreachable. The other factor that should be taken into consideration in relation to this issue is for instance time taken for a final confirmatory histopathology diagnosis. Repeated aspirations and biopsies sometimes have to be carried out before the final diagnosis can be made which subsequently caused delay in initiating optimal treatment to these patients. In addition not all patients that seek treatment will be agreeable for surgical excision as part of their treatment. Some of them especially the patients in our local community is a strong believer in traditional medicine and majority of them opt for a complementary and alternative medicine as part of their cancer treatment.
This study is a retrospective study of oral cavity malignancy at Hospital Universiti Sains Malaysia (HUSM) which is located in the East Coast of Peninsular Malaysia. From January 2011 to October 2013 only four cases of oral cavity carcinoma were identified. Details clinical presentation, imaging finding, histopathology diagnosis and treatment outcomes were reviewed. Pertinent issues to these four patients are further discussed in bringing together the multifaceted treatment issues faced locally in order to highlight the challenges that were encountered in managing this malignancy.

Case History

Mr. LKC is a 41 year old Chinese male who presented in April 2002 with history of painful area at anterior tongue especially while eating spicy food. Clinical examination on later follow up revealed a small, non-ulcerative lesion in midline of anterior two third of tongue with no evidence of contact bleeding. Initial biopsy showed a dysplastic epithelial lesion with no evidence of malignancy. Repeated incisional biopsy performed because of persistent mass at central tongue which revealed as pseudo-epitheliomatous hyperplasia superimposed with fungal infection. He was started on oral Fluconazole at 400 mg as a loading dose plus 200 mg daily dose for 2 weeks duration. The central tongue mass however persists despite antifungal treatment and measured 3.0×3.0×4.0 cm in diameter. Subsequently, the patient underwent excision biopsy on August 2012 with postoperative histopathology result showed as a well differentiated squamous cell carcinoma. He underwent subtotal glossectomy with bilateral selective supraomohyoid neck dissection with anterolateral thigh free flap in October 2012. Post-operative histopathology examination revealed a well differentiated SCC with floor of mouth involvement. He was referred to oncology unit where he received adjuvant radiotherapy followed by brachytherapy which he completed in March 2013. He however represented with a residual lesion on follow up and repeated biopsy and PET scan confirmed it was a recurrence. Subsequently he received platinum based chemotherapy and during his last follow up in April 2014 he was doing fairly well with complaint of trismus.
Second patient, Mr. KA presented with history of persistent right tongue ulcer associated with loss of appetite and loss of weight. Clinical examination revealed a lesion measuring 2.0×2.0×3.0 cm on his right lateral oral tongue. The lesion however did not cross the lingual septum. There was an enlarged right submandibular node on CT scan imaging but there was no floor of mouth or masticator space involvement and the mandible was intact. Patient was advised for right hemiglossectomy with right selective supraomohyoid neck dissection however patient refused surgery and went for traditional medications for his treatment. On later follow up, he developed bilateral neck nodes and had significant weight loss of 20 kg. He was referred to Oncology team and after a lengthy counselling he agreed for concurrent chemoradiotherapytreatment. During chemoradiation, his disease however progressed with the neck nodes getting bigger and becomes ulcerated. He was emaciated and was admitted for several times for symptomatic and palliative pain management. He eventually passed away after two cycles of chemotherapy.
Third case, Mrs. NA presented with history of non-healing ulcer on her right lateral tongue with right neck swelling for 3 months duration. On oral cavity examination, there was an extensive growth on her right lateral tongue which crossed midline and extend to the right floor of mouth. The tongue mobility was good and tongue base was normal on palpation. There was neck node palpable at right submandibular region which measures 4.0×5.0×2.0 cm in diameter. CT scan performed on August 2012 documented it as a carcinoma of tongue with bilateral cervical nodes metastasis and radiologically staged as T3N2aM0 tumor. She underwent subtotal glossectomy, left modified radical neck dissection and right radical neck dissection with anterolateral thigh free flap reconstruction in September 2012. Postoperative histopathology examination confirmed it as a moderately differentiated SCC. She completed adjuvant radiotherapy in February 2013. Unfortunately, she represented with a level II neck nodes and tissue biopsy confirmed it was a recurrent squamous cell carcinoma. She was admitted to ward several times for symptomatic treatment and palliative chemotherapy. She subsequently developed upper gastrointestinal bleeding while on chemotherapy and passed away due to episode of neutropenic sepsis.
Fourth case, Mrs. JH also presented with a non-healing ulcer of her left tongue for 2 weeks duration in April 2012. The biopsy taken confirmed as poorly differentiated squamous cell carcinoma. Initially she was staged as T2N1M0 tumor and underwent left hemiglossectomy, left marginal mandibulectomy, left supraomohyoid neck dissection and tongue reconstruction with left radial forearm free flap on 18th April 2012. Post opt HPE revealed an aggressive high grade epithelioid sarcoma with surgical margin involvement. Follow up CT scan showed her disease had progressed significantly. She was started on palliative chemotherapy but she also experienced complications with episodes of neutropenic sepsis and was dead due to her disease on 30th August 2012.

Discussion

Oral cavity squamous cell carcinoma (OCSCC) is an important entity in the armamentarium of head and neck cancer as increase number of patients has been diagnosed annually worldwide. Despite refinement in investigation tools and surgical approaches, the prognosis of this cancer remains suboptimal. A proportion of patients with treated early tumours had an outstanding treatment outcomes, the late stage tumour however continues to present as a therapeutic challenge especially at our local centre in East Coast of Peninsular Malaysia. The main treatment of this type of cancer remains a complete surgical excision of the primary tumour together with a neck dissection and concomitant use of chemoradiation in clinically indicated cases.There are numerous factors that should be taken into serious consideration when planning for an optimum treatment strategy for patients with an oral cavity carcinoma. These factors include size and stage of the tumor, patient medical status, and availability of surgeon with better expertise, postoperative histopathology details, presenceof a good reconstruction team, a well dedicated clinical oncologist and radiotherapist as well as a competent physical and psychosocial rehabilitation team. Recent update on the virology of the OCSCC also has a significant impact on the patient treatment. Patient with HPV positive has been known to have better outcome than the negative HPV patient. This HPV status is being extensively investigated in the upper aerodigestive tract and head and neck tumors and this brings the multitude treatment issues of this disease to a more complex and challenging level.
In this study only four cases of OCSCC were identified and treated at our Otorhinolaryngology-Head and Neck Surgery, HUSM. This is due to the fact that the patients with OCSCC will also be referred to the oral maxillofacial unit for subsequent management. In addition, in state of Kelantan there are few other hospitals which are under the umbrella of Ministry of Health where the cost of treatment is much lower. This attracts patients to seek treatment at these local hospitals. Apart from that some of the patients also presented at the district health clinics and eventually did not wish to be referred to the major hospital. There are myriad other local and personal factors that contributes to this preference of hospital such as the travel distance to the nearest hospital, transportation cost, availability of immediate family members to look after the patient when they are hospitalized and also presence of friends that work in the hospital that can help with the admission process which sometimes can be very troublesome.
Three of the patients had neck dissections as part of their treatment regimen which ideally should be optimal for their cancer treatment. However from the literature review even with incorporation of neck dissection as part of the treatment regimen, locoregional failure remains high for OCSCC patients. A study by Iqbal et al. highlighted that a failure in selective neck dissection not only occurred in N plus neck but also in N0 neck of patients with oral cavity squamous cell carcinoma [3]. This could represent subset of patients with aggressive nature of OCSCC which warrants in depth investigations either on molecular biology or genetic aspect of this tumor. At present, there are numerous surgical approaches and techniques that have been introduced and utilized in the armamentarium of OCSCC management in order to arrive to a better patient treatment outcome and quality of life. Nevertheless majority of patients present at late stage of diseases and require multidisciplinary treatment approach with combination of chemoradiation as part of their initial therapy. According to Arya et al., approximately 40-60 % of patients with OCSCC present with advanced stage diseases [4]. And to our understanding, these subsets of patients will ultimately have higher tendency for locoregional recurrence despite treatment in comparison to those patients who present with an early stage diseases. The morbidity of the treatment will also be far greater among this subset of patients with more comprehensive neck dissections performed and more requirement for free flap reconstructions.
In Western World, there has been an increasing trend in the survival of patient with OCSCC which attributes to better perioperative imaging, wider surgical resection, presence of better free flap reconstruction team, a multidisciplinary treatment approach and application of more precise imaging modalities during patients follow up [5]. The use of combination imaging modalities such as PET-CT or CT-MRI fusion and the application of sentinel lymph node biopsy have made the cancer care in Western World even more appealing. This is supported by a large multicenter study which collaborates seven large head and neck cancer centers worldwide in comparing the oral cavity carcinoma treated in 1990 to 2000 to those patients treated in 2001 to 2011 [5]. They revealed that the later group of patient present with more late stages of disease but they had better overall 5 year survival outcome of 70% compare to 59 % of patients treated in 1990 to 2000. This group of patients also had less extensive neck dissection and received more adjuvant radiotherapy as part of the treatment. Despite this new exciting evidence, the treatment outcome of patient with OCSCC at our local center remains substandard. This is due to an array of factors namely patient late presentations, strong refusal for surgery in local community, twisted belief in complementary and alternative medicine, lack of excellent multidisciplinary team and expertise and devoid of facilities much needed for optimum head and neck cancer patients management.
The management of OCSCC should also emphasized on factors that reflects the true spectrum of this diseases. This brings to the pertinent issues of a factor of delay. This factor of delay attributes to either patients delay or professional delay. Patient delay is the time taken from the first appearance of symptom to the time of presentation at hospital for treatment. Professional delay comprises of delay in getting the final confirmatory diagnosis and delays in initiating treatment for a given tumor. According to Wildt et al., patients delay is not significant, however professional delay correlate significantly with tumor size and age of patients [6]. With regards to professional delay, the longest professional delay was seen in patients with small tumors. The smaller the tumor, the greater the delay encountered in detecting the cancer. As seen in the case histories, we encountered both i.e. the patient delay and professional delay. Lesson to be learnt is to judiciously examine patients with persistent non healing ulcer with a good biopsy specimen and utilization of good imaging techniquesif available to detect clinically unapparent disease at earliest. OCSCC in its initial stage shows an erythroleukoplastic area without symptoms but in advanced stages there are ulcers and lumps with irregular margins which are rigid to touch [7]. Thus it is imperative and a responsibility of a treating physician or surgeon to anticipates the disease process and actively involves in early recognition and detection of this malignancy.
The other important issue encountered at our center is dilemmas in getting the final confirmatory histopathology diagnosis due to inadequate expertise, inadequate equipment and inadequate resources. This phenomenon occurred mainly in the third world countries with economic instability with increased burden of head and neck malignancy. There is a dire need for a stringent protocol in getting a finesse pathological specimen and a finesse of reporting pathologists to ensure optimum treatment for the benefit of OCSCC patients. This means more funds and cooperation are needed in clinical research, knowledge and expertise transfer between multi institutionsglobally that can be an impetus for a finesse cancer care in near future. Needless to say the role of imaging in the treatment of OCSCC with the advent of combined modality such as CT-PET, CT-MRI fusion and functional MRI, the disease localization and staging becomes much more accurate. Early detection of disease whether locally or at the neck has resulted in a substantial improvement of patients overall survival. The availability of versatile radiotherapy machines and competent staffs also is a major determinant for the success of OCSCC patient treatment. The limited number of machines and staffs that are available for treatment of head and neck cancer patients at our local center add to the treatment dilemmas in this population of patients. This mean that we cannot cope with an increasing burden of OCSCC patients treated daily at our center in order to ensure optimum treatment delivery. The machines also frequently break down which causes further interference of patient treatment schedules and this ultimately added more to failures of treatment of these patients.
Notably in contrast to laryngeal carcinoma, OCSCC has a poorer prognosis and survival outcome. This is partly due to the fact that OCSCC has a rich lymphatic supplies as well as lack of barriers of tumour spread. This factor augments the natural aggressive biology of this type of tumour [8]. Patients with recurrent OCSCC have an approximately 30-45% overall 5 year survival following a salvage surgery. The issues of refusal of surgery is not new entity and it is experienced by many head and neck surgeons globally but more commonly in our local patients population. It should be keep in mind that the surgery is the primary treatment modality for OCSCC and chemoradiation has a limited role and is still under investigations. Bossi et al., highlights that there has been a mixed result with the use of chemotherapy in treating OCSCC with majority fails to show significant improvement in disease survival [9]. These patients should be strongly counseled for a primary surgical excision of the tumor and neck dissection whenever indicated at the very first presentation when the diagnosis is made. The role of chemoradiation is limited in OCSCC and this need to be emphasized to the patients as well as to their immediate family members. A study by Chinn et al. comparing the induction chemotherapy versus primary surgical extirpation for advanced OCSCC demonstrated that primary surgical extirpation group had better overall survival, disease specific survival and less locoregional recurrence than the induction chemotherapy group [10]. Furthermore, the induction chemotherapy also tends to cause multiple side effects and treatment related complications which impairs patient quality of life.
Complementary and Alternative Medicine (CAM) not only widely practice in low and middle income countries but also in developed countries such as Australia, USA, France and Canada. More than 50% of people in Canada and France used CAM as part of their diseases treatment [11]. CAM is also strongly practiced among local people all over Malaysia. Some of this treatment did not show any promising or positive results but instead causes more harmful effects. The worrisome is that in certain group of people, this practice has been exploited either for personal advantage or because of financial reason. This holds true especially in a marginalized local community with a poor socioeconomic status and health awareness. The lack of health education in most of underdeveloped areas and remote villages augmented to the stigma of getting professional health treatment in a well establish and affiliated hospitals. Many locals believe in the idea that the use of surgical instruments over their physical body parts will cause more harm to them and will accelerates the cancer. In addition to this false notion, the wrong advice and inaccurate information from the closed local community further stray these patients away from the professional treatment at the hospitals. Many patients refused surgery and went for traditional herbal medications and traditional massage or holy water applications. This is endemic and is occurring at large in our local community. This many taboos and beliefs need to be eradicated with a mass educational program by local agency and government authority by collaborating effective leaders in every closed local community. The right way of practicing CAM should be established and promoted to the local community at large in order to eradicate this mishaps practice that culminates disease progression and complications.

Conclusion

OCSCC is an important entity in the armamentarium of head and neck cancer management. The survival and outcome of this subset of patients remains poor despite multimodality treatment. Multitude of local issues added to the treatment dilemmas in treating this malignancy at our local center in Peninsular Malaysia. Thus it is prudent to refine treatment strategies and local expertise in order to ensure a finesse cancer patients care in near future.

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