Download - Cancer Planseu
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CARCINOMUL CARCINOMUL PLANSEULUI PLANSEULUI
ORALORAL
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FRECVENTA si ETIOLOGIEFRECVENTA si ETIOLOGIE
Locul al treilea intre cancerele cavitatii oraleLocul al treilea intre cancerele cavitatii orale Sex masculin (5:1)Sex masculin (5:1) Dupa 45 de aniDupa 45 de ani Factori favorizanti: alcool concentratFactori favorizanti: alcool concentrat
tutun tutun
igiena orala precaraigiena orala precara
CancerCancer : : primar/ secundarprimar/ secundar
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Riscul relativ de dezvoltare a cancerului oral Riscul relativ de dezvoltare a cancerului oral la consumatorii de alcool si tutunla consumatorii de alcool si tutun
Marginile limbii si planseul Marginile limbii si planseul adiacentadiacent
Zona in forma de “U” Zona in forma de “U” adaposteste 70% din adaposteste 70% din cancerele oralecancerele orale
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Anatomie patologicaAnatomie patologica sediu : planseul anteriorsediu : planseul anterior posteriorposterior punct de plecare: punct de plecare: mucoasa epiteliom (-spinocelular)mucoasa epiteliom (-spinocelular) gl.salivare mici carc. adenoid chisticgl.salivare mici carc. adenoid chistic gl. sublinguala carc.muco-epidermoidgl. sublinguala carc.muco-epidermoid
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Epiteliom al planseului oralEpiteliom al planseului oral
Forma ulcerativ distructiva
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Carcinom mucoepidermoidCarcinom mucoepidermoid
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Carcinom adenoid chisticCarcinom adenoid chistic
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StadializareaStadializareaStadiul 0Stadiul 0 TISTIS N0N0 M0M0
Stadiul IStadiul I T1T1 N0N0 M0M0
Stadiul IIStadiul II T2T2 N0N0 M0M0
Stadiul IIIStadiul III T3T3
T1,T2,T3T1,T2,T3N0N0
NINIM0M0
M0M0
Stadiul IVStadiul IV T4T4
Orice TOrice T
Orice TOrice T
N0, N1N0, N1
N2, N3N2, N3
Orice NOrice N
M0M0
M0M0
M1M1
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Clinica boliiClinica bolii
SubiectivSubiectiv
Zona anterioara a planseului - zona frenului Zona anterioara a planseului - zona frenului
- durere moderata durere - durere moderata durere accentuataaccentuata
Zona laterala /posterioaraZona laterala /posterioara
- silentioase - silentioase
- pierderea stabilitatii protezei- pierderea stabilitatii protezei
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ObiectivObiectiv
• Forma Forma ulcerativa: debutulcerativa: debut
cea mai frecventacea mai frecventa
de la mucoasa –leziuni premalignede la mucoasa –leziuni premaligne
nu obligatoriu pe fond diskeratozicnu obligatoriu pe fond diskeratozic
aspect: leziune traumatica odontogenaaspect: leziune traumatica odontogena leziune de decubitleziune de decubit aftaafta
Malignizare! - indurarea bazei ulcerate Malignizare! - indurarea bazei ulcerate - ridicarea marginilor- ridicarea marginilor
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Leucoplazie proliferativ-verucoasa
Ulceratie maligna
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• Forma ulcerativă: perioada de stareForma ulcerativă: perioada de stare
ulceraţia se adânceşteulceraţia se adânceşte
marginile devin anfractuoasemarginile devin anfractuoase
prezintă ţesut de granulaţie sângerandprezintă ţesut de granulaţie sângerand
evolueaza spre una din cele doua evolueaza spre una din cele doua forme: forme:
- - ulcerativ distructivaulcerativ distructiva - ulcero - vegetanta- ulcero - vegetanta
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Forma ulcerativ distructiva:Forma ulcerativ distructiva:
contine detritusuri celulare necrozatecontine detritusuri celulare necrozateaspect gri-murdaraspect gri-murdarfetiditatefetiditate
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Forma ulcero-vegetanta:Forma ulcero-vegetanta:
ulceratie acoperita de muguri carnosiulceratie acoperita de muguri carnosi necroza—infectare—detritusurinecroza—infectare—detritusuri secretie fetidasecretie fetida
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• Forma nodularaForma nodulara
nodul micnodul mic nedurerosnedureros initial : - mobil pe planuriinitial : - mobil pe planuri ulterior : - se fixeazaulterior : - se fixeaza
- infiltreaza- infiltreaza
- se superficializeaza- se superficializeaza
- ulcereaza mucoasa- ulcereaza mucoasa
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Semne functionaleSemne functionale
InitialInitialulceratie nedureroasa spontanulceratie nedureroasa spontandurere la: alimente iritantedurere la: alimente iritante masticatiemasticatie vorbirevorbireIn evolutieIn evolutie:: durere spontana -- devine insuportabiladurere spontana -- devine insuportabila localizare: -limbalocalizare: -limba -arcada dent inferioara -arcada dent inferioara -ureche-ureche afectarea nervilor lingual si glosofaringian afectarea nervilor lingual si glosofaringian secretie salivara abundenta,fetidasecretie salivara abundenta,fetida masticatia si deglutitia dificile (fixarea limbii si masticatia si deglutitia dificile (fixarea limbii si
planseului)planseului) vorbirea grav alteratavorbirea grav alterata
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Semne generaleSemne generale
Apar odata cu - durerile spontaneApar odata cu - durerile spontane
- infectia locala- infectia locala
- fixarea tesuturilor de catre - fixarea tesuturilor de catre tumoratumora
Anemia- consecutiva hemoragiilor repetateAnemia- consecutiva hemoragiilor repetate
Inanitia- dificultati de alimentareInanitia- dificultati de alimentare
Alterarea starii generaleAlterarea starii generale
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AdenopatiaAdenopatia
afectarea limfonodulilor este precoceafectarea limfonodulilor este precoce
ganglioni submandibulari si jugulo-carotidieniganglioni submandibulari si jugulo-carotidieni
carcinom pl.anterior—diseminare bilateralacarcinom pl.anterior—diseminare bilaterala fen. de compensare a drenajului—metastaze fen. de compensare a drenajului—metastaze
contralateralecontralaterale
stadii avansate – mase tumorale metastaticestadii avansate – mase tumorale metastatice
-fixate -fixate
-ulcerate-ulcerate
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Masa tumorala ganglionara Masa tumorala ganglionara metastaticametastatica
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Traseul tipic de diseminare limfatica in Traseul tipic de diseminare limfatica in carcinomul oralcarcinomul oral
• Biopsierea Biopsierea limfonodulilorlimfonodulilor
santinela-santinela-
se evita indepartarea se evita indepartarea
chirurgicala a chirurgicala a ganglionilorganglionilor
sanatosi sanatosi
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DiagnosticDiagnostic examinarea clinica examinarea clinica riguroasariguroasa a a zonelor de risczonelor de risc
- caractere de adenopatie maligna-leziunea - caractere de adenopatie maligna-leziunea primara e primara e
greu observabilagreu observabila depistarea si evaluarea leziunilor cu potential depistarea si evaluarea leziunilor cu potential
dede
malignizaremalignizare
diagnostic precoce- semne :- induratia bazeidiagnostic precoce- semne :- induratia bazei
- extensia rapida- extensia rapida
- fixarea nodulului- fixarea nodulului
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Diagnostic precoce:Diagnostic precoce:
- albastru de toluidina - albastru de toluidina
- solutie de iod- solutie de iod
Metode de investigare:Metode de investigare:
-CT-CT
-RMN-RMN
-Ecografie-Ecografie
-Scintigrafie-Scintigrafie
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Diagnostic diferentialDiagnostic diferential
Leziuni ulcerative traumaticeLeziuni ulcerative traumatice Leziuni inflamatorii specifice (sifilis – Leziuni inflamatorii specifice (sifilis –
tuberculoza)tuberculoza) Litiaza salivara a canalului Wharton-coliciLitiaza salivara a canalului Wharton-colici Chiste dermoide-ocupa zona medianaChiste dermoide-ocupa zona mediana Ranula –continut chistic si perete subtireRanula –continut chistic si perete subtire Mucocel-fluctuent si albastruiMucocel-fluctuent si albastrui
!!! Biopsie!!! Biopsie
Examen histopatologicExamen histopatologic
Examen radiologicExamen radiologic
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Mucocel Ranula
Chist dermoid Calcul salivar
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Diagnostic diferentialDiagnostic diferential
• Leziuni aftoaseLeziuni aftoase• VaricelaVaricela• Whartonita nelitiazica-la presiune pe glanda-se elimina Whartonita nelitiazica-la presiune pe glanda-se elimina
saliva vascoasa, puroisaliva vascoasa, puroi
• Abces de loja sublinguala-fen.septice ,semne inflamatoriiAbces de loja sublinguala-fen.septice ,semne inflamatorii• Abces de loja submandibulara-semne exoorale,semne Abces de loja submandibulara-semne exoorale,semne inflamatorii inflamatorii
• Flegmon al planseului-adenopatiile metastatice Flegmon al planseului-adenopatiile metastatice --evolutie indelungata--evolutie indelungata --starea nu e toxicoseptica--starea nu e toxicoseptica
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Afta, varicela, leziune Afta, varicela, leziune proliferativaproliferativa
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Evolutie si ComplicatiiEvolutie si Complicatii
• Tumorile mici se apropie de gingie/limbaTumorile mici se apropie de gingie/limba
• Tumorile mari pot implica gingia +/- limbaTumorile mari pot implica gingia +/- limba
• Carc. verucosCarc. verucos - evolutie relativ lenta - evolutie relativ lenta
• Carc. epidermoid-Carc. epidermoid- extindere extindere multidirectional multidirectional
• Carc. adenoid chisticCarc. adenoid chistic – extindere plurifocala – extindere plurifocala
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Carcinom mucoepidermoid
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CARCINOM EPIDERMOID ExtindereMEDIAN/MEDIAN/
PARAMEDIANPARAMEDIANLATERALLATERAL POSTERIORPOSTERIOR
bilateralbilateral nervi,vasenervi,vasegl.sublingualgl.sublingualaac.Whartonc.WhartonM.milohioidiaM.milohioidiann
limbalimba mucoasa mucoasa gingivalagingivala os os mandibularmandibular
baza limbiibaza limbii pilierii pilierii amigdalieniamigdalieni perete lat.perete lat.
faringianfaringianloja loja amigdalianaamigdaliana
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• Carc. adenoid chisticCarc. adenoid chistic 40-50% dintre cancerele cu punct de plecare 40-50% dintre cancerele cu punct de plecare
gl.salivare gl.salivare Crestere lenta ,exofitic sau polipoidalCrestere lenta ,exofitic sau polipoidal Tendinta crescuta de recidiva localaTendinta crescuta de recidiva locala Potential crescut de invazie a spatiului Potential crescut de invazie a spatiului
perineural:trigemen,glosofaring.,hipoglosperineural:trigemen,glosofaring.,hipoglos Evolutie spre SNCEvolutie spre SNC Extindere plurifocalaExtindere plurifocala Rare metastaze ganglionareRare metastaze ganglionare
Posibile metastaze pulmonare si osoasePosibile metastaze pulmonare si osoase
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Factori care afecteaza negativ Factori care afecteaza negativ supravietuireasupravietuirea in cancerul oral in cancerul oral
--amanarea tratamentuluiamanarea tratamentului-varsta avansata-varsta avansata-sexul masculin-sexul masculin-marimea tumorii-marimea tumorii-localizarea posterioara-localizarea posterioara-slaba diferentiere histologica-slaba diferentiere histologica-diseminarea ganglionara-diseminarea ganglionara
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Tratamentul carcinomului deTratamentul carcinomului de planseu oral planseu oral
tratament -profilactic tratament -profilactic
-curativ-curativ
tratament multimodal—chirurgicaltratament multimodal—chirurgical
--radioterapia--radioterapia
--chimioterapia --chimioterapia
--imunoterapia--imunoterapia
--terapia genetica--terapia genetica
-psihoterapia-psihoterapia
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• probleme - refacerea morfologicaprobleme - refacerea morfologica
- refacerea functionala- refacerea functionala
• cai de abord - oralacai de abord - orala
-mixta (orala si cutanata)-mixta (orala si cutanata)
-submandibulara-submandibulara
-transmandibulara-transmandibulara
• se pot efectua --pelvectomii se pot efectua --pelvectomii
--pelviglosectomii--pelviglosectomii
--pelvigingivectomii--pelvigingivectomii
--pelvi-gloso-mandibulectomii--pelvi-gloso-mandibulectomii
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Evolutia post-operatorie a unui Evolutia post-operatorie a unui carcinom de planseu carcinom de planseu
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Radioterapia-efecte nedoriteRadioterapia-efecte nedorite
In timpul tratamentului –xerostomieIn timpul tratamentului –xerostomie
-mucozita,epitelita-mucozita,epitelita
-candidoza-candidoza
-eritem-eritem
Pe termen lung -atrofia mucoasei si tegumentuluiPe termen lung -atrofia mucoasei si tegumentului
-risc de osteoradionecroza-risc de osteoradionecroza
-inducerea malignitatii-inducerea malignitatii
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Epitelita UlceratieEpitelita Ulceratie
-dupa iradiere in cancer de planseu-dupa iradiere in cancer de planseu
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Alte tumori maligne Alte tumori maligne ale planseului oral ale planseului oral• AdenocarcinomAdenocarcinom
• Tumori de origine conjuctivaTumori de origine conjuctiva
-angiosarcom -angiosarcom
-rabdomiosarcom-rabdomiosarcom
-liposarcom-liposarcom
-limfosarcom -limfosarcom CHIMIOTERAPIECHIMIOTERAPIE
-reticulosarcom-ex.histopatologic-reticulosarcom-ex.histopatologic
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AdenocarcinomAdenocarcinom
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NoutatiNoutati
• FLUOROSILICATUL DE SODIUFLUOROSILICATUL DE SODIU
-inducerea apoptozei in celulele cancerului oral-inducerea apoptozei in celulele cancerului oral
-fragmentarea A-fragmentarea ADNDN nucleosomal-electroforeza-agaroza nucleosomal-electroforeza-agaroza gelgel
-corpi apoptotici----analiza citometrica-corpi apoptotici----analiza citometrica
-sc-scăăderea Bcl2derea Bcl2
-eliberare de citocrom c in citosol-eliberare de citocrom c in citosol
-activarea caspazei-3-activarea caspazei-3