11/12: DX and TX of Oral Cancer and Precancerous Lesions

Transcribed by Anam Khalid Friday, June 18
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[Diagnosis and Treatment of Oral Diseases[ [Lecture #11 and 12] [Dx and Tx
of Oral Cancer and Precancerous Lesions] by [Dr. Kerr]

[1] [D2 Diagnosis and Management of Oral Cancer]
[Dr. Kerr] Good afternoon. Did you guys get the posting? Fantastic. Is this it? The
class? Seems like a smaller group than usual but anyway. Okay. Lets just turn some
of the lights down. Thats better, right? Okay. Okay, so in the second year, you
obviously learn a little bit more than we gave you in this area than last year but
youve still got a lot to come in third year. In the famous OMPR course which Im
sure youve all heard is the most enjoyable course in the college which I think it is.
So, but I hope youre enjoying this course and I know youve had some good lectures
with Dr. Shah

[2] [N/A]
[Dr. Kerr] I cant remember whether I showed you this case but its sort of a nice
case to get this lecture going. So here was approximately 40 year old Hispanic male
who presented to the College of Dentistry, can you imagine what his chief complaint
was? Right. So hes got a toothache. And thats what brought him in unfortunately.
And so, you know, this is an opportunistic examination. In other words, you take the
opportunity and when we took the opportunity, the student, who was actually a D3
student, spotted something in the floor of the mouth. It didnt look quite right and so
if you compare one side to the other, it looks different. So can anyone see or
comment on what they see?

[3] [N/A]
[Dr. Kerr] so what you see is a little white change and that white change has a
little bit of a redness around it and when you look at that white change and you can
see a little bit of granularity. Maybe a couple of little fissures on the surface. And
thats not supposed to be there, is it? I mean, the normal epithelium doesnt look like
that. And so then you ask yourself the question, at least you should be asking
yourself the question, well, you know, what is this? You know? Its not normal. You
can sort of wipe it, and it doesnt wipe off. And youre asking yourself well how
would someone traumatize the underside of their tongue? And of course you take a
history and this gentleman is a heavy smoker, hes a heavy alcohol user. He has
some medical issues and so you put all that into the equation and you cant quite
work out still why its there, hes not sticking an aspirin on the surface there because
of his toothache. Some people do that, they can cause aspirin burns in their mouth.
And theres nothing else really going on other than, of course, hes a smoker and a
heavy alcohol user so that tips it off and you go through that sort of algorithm, that
thought process that we went over when I lectured to you last year. And then youre
left sort of in your own mind, scratching the top of your head thinking well what do I
do now? And as you may recall, if you come across an epithelial lesion that you cant
explain why its there, you start thinking about some sort of pathology and you start
thinking well, is this potentially malignant oral disorder? And so the right thing to be
thinking is its abnormal, we have to rule out that it isnt malignant or doesnt have
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the potential to become malignant and so the next step would be to what? Take a
sample. Yeah. Procure a tissue sample. So we did that.

[4] [N/A]
[Dr. Kerr] And this is what the histopathology shows. Now, you know, you havent
really gone into, you know, histopathology in a big way yet but this is a superficially
infiltrating squamous cell carcinoma. So this is actually a cancer. And I think this is
probably the earliest cancer, well, one of the earliest handful of cancers that Ive
seen that are that small. That, first of all, you have to ask yourself the question, well
would I have actually detected that? Would I have visualized that? Of course when
its projected about a thousand times the size on the screen or more, you know, its
pretty obvious. But believe me, if you were to, you know, have a hundred dentists
come in and examine the patient and none of them, you know, were biased to what
the other ones were seeing, I guarantee you wouldnt have all 100 of those, you
know, looking for it or seeing that little lesion. Particularly if theyre coming in to the
emergency clinic because most dentists when someone comes in for an emergency,
just really focuses in on that emergency. But when youre looking at that tooth right
next to it you see this little area. So, the question is, how many people would really
be looking for it? And even if they were looking in the area, how many would sort of
go, hang on, theres a lesion there? So, if you can do that part, youre doing really
well. And then, the decision is well what do I do with it? And thats another decision-
making sort of process. So by the time you graduate, hopefully youll have a good
solid decision strategy, you know, for these types of things. But its all contingent
upon being able to detect this in the first place.

[5] [N/A]
[Dr. Kerr] So what happens to a patient like this? Well this is quite a few years ago
and here is the patient in the operating room. The small circle circles the area that
we biopsied. We actually removed most of it just taking a little punch biopsy. And
then around that is another circle and thats the margin. So generally when you have
a malignancy, an oral malignancy, you take the malignant tissue and the margin just
to be safe. And that margin depends on whos doing the surgery but its usually
anywhere from a centimeter to a centimeter and a half. And so thats what
happened.

[6] [N/A]
[Dr. Kerr] And so it was surgically removed. These little probes or lacrimal probes
to reposition the submandibular, sublingual ducts, the Whartons duct. Because the
lesion was right in that area.

[7] [D2 Diagnosis and Management of Oral Cancer]
[Dr. Kerr] And then he had a split thickness skin graft taken from his lateral thigh
with a little dermatome and then its sutured into place. And Ive been following this
guy for the last six or seven years now and Im happy to report hes had no
recurrence of this disease. Hes had some issues related to tobacco use. We got him
to quit, then he started smoking again, we got him to quit, and then he started
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smoking again and so hes been back and forth trying to deal with his tobacco habit.
But he didnt develop any further disease.

[8] [N/A]
[Dr. Kerr] So, compare and contrast that patient to a patient that presents, and by
the way when that first patient presented, he had no idea he had this little lesion in
the floor of the mouth. It didnt cause him any discomfort. He was just in for that
toothache. On the other hand, this gentleman who is in his 60s, and African
American male, also very long history of over a pack a day of smoking for at least,
you know, 40 years. Heavy alcohol intake, you know, in the range of greater than 10
units a day. Poor nutrition. He presents with a severe pain in his mouth. And his pain
is from the problem that you see here. So this is at the other end of the spectrum.
Youve seen the very very early squamous cell carcinoma. Well, here, were seeing
an advanced carcinoma. And when you look in his mouth, you know, it just doesnt
look right. And it doesnt take a lot of experience to be able to go, wow. I mean,
youre looking at something that is, you know, a hundred times the size of the first
one you saw. So its impossible to overlook this. Absolutely impossible. So he opens
his mouth and you have to restrain yourself from going, OH MY GOD. And, obviously,
when you palpate the area, you put your finger into the floor of mouth, thats his
tongue and its all into the floor of mouth. Stretching over onto that edentulous
alveolar ridge, pushing back posteriorly and infiltrating deeply into the floor of the
mouth, such that when you do a bimanual palpation and you compare the normal
side to the affected side, its indurated. That tissue is rock hard. Its infiltrated into
all of the normal floor of mouth tissue which is normally soft and spongy. You are
feeling that induration. So thats a malignancy that has spread deep into the tissues
and is exquisitely tender to push on it. And the patient is having difficulty
swallowing because every time he moves his tongue, it bothers him. And hes really
in a lot of pain. when you examine his neck, hes already got a rock hard lymph node
in his anterior neck and you can see this lump in his neck and you put your finger on
it and hes got this hard, enlarged, fixed lymph node. And its totally different from
what you feel on the other side. So youre already thinking well, hes got a
malignancy and its already metastasized into his regional lymph nodes. So what are
you going to do now? Well, obviously, youre going to refer him to the same person.

[9] [N/A]
[Dr. Kerr] And this is what the head and neck surgeon removed. So on top is the
better part of his mandible because the lesion stretched across the midline all the
way back into the oropharynx. And then on the bottom are all of the lymph nodes
that they dissected including the metastatic lymph node. And that was a massive
operation.

[10] [N/A]
[Dr. Kerr] And so here he is, having had the cancer removed. So, he doesnt have
much of his tongue left. He doesnt have much of his mandible left. And thats his
carotid sitting there with a little piece of string just above it with the carotid bulb.
And now you ask yourself well what do we do now?
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[11] [N/A]
[Dr. Kerr] Well, he has to have a grafting procedure done to replace all of that
missing tissue. So, nowadays the surgical reconstruction is very sophisticated. I
mean, for, you know, over at NYU theyre doing face transplants now. So, you know,
this is relatively an easy procedure in comparison. So theyre taking the fibula and
theyre using the fibula bone, which you can manage without. And they fracture it
into the shape of the mandible. It comes with a skin paddle. It comes with its own
blood supply. This is a free flap, a vascular free flap and they reanastamose that
blood vessel to the local blood vessels and sow him up.

[12] [N/A]
[Dr. Kerr] and so here is the free flap and its been shaped into the shape of his
mandible. Theyve already worked out what that shape needs to be, preoperatively.

[13] [N/A]
[Dr. Kerr] They bolt it all into place and sow that piece of skin. Thats going to be
the rest of his tongue and then the floor of his mouth.

[14] [N/A]
[Dr. Kerr] and then sow him up. And thats just the first step to his therapy. So, hes
going to have to wait for another six weeks and then hell need to undergo head and
neck radiation and chemotherapy because he has advanced disease that has already
metastasized into the regional lymph nodes. So, no matter how good a surgeon you
are, you cant be assured that youve removed all of that disease and quite often, the
pathology will show something at the margins. So he goes in and he has head and
neck radiation and chemotherapy. And unfortunately, he had some problems
tolerating he had a lot of side effects from the radiation and chemotherapy, had
very very . mucositis he wasnt able to do the full regimen. Had a couple of
breaks in treatment. And he ended up getting through and within six months he
developed a recurrence in his neck and he died. So he went through all of this and
the morbidity associated with all of this and really went through its an awful
thing to go through all of the treatment and then died. So this is the problem with
advanced disease versus early disease. So one guy is alive and well, 7 years later.
This fellow didnt make it that long. And you ask yourself the question well how is it
that we couldnt intercept him at that early stage? I mean, what happened? Did he
never go to the dentist? And it turns out; he had been going to the dentist. I mean,
maybe he wasnt completely reliable but there probably had been an opportunity to
intercept this disease. So the question of delay in diagnosis is something that a
number of researchers are investigating because, you know, there are a lot of
different reasons for delay in diagnosis.

[15] [N/A]
[Dr. Kerr] So this was an email that I received from Jerry Yu, one of your former
classmates from several years ago, class of 2009. I doubt youd remember me as I
was rather unremarkable student wise and I dont think we had much personal
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interaction. I hope you are well and thank you for taking the time to read my email.
So I entered private practice in 2010 after my residency, a very break-n-butter
dentistry practice and actually had a patient with a lesion on the right lateral border
of the tongue. I recommended a biopsy and of course he hemmed and hawed but
after a while, finally convinced to do so and it came back as a squamous cell
carcinoma. He ended up having that section of the tongue resected, and though his
speech is more difficult to understand, hes overall fine and in good spirits. I hadnt
really seen that many oral pathology cases and I really dont have much of an
interest. But I did have to say that I noticed it because of your repetitive insistence
from the school days. So both I and him owe you a personal gratitude. I was
wondering da ra da da da and you dont need to worry about the rest. So of
course, you know, I showed that around to Dr. Phelan, to Dr. Shah, to other people in
the department and we were all really, you know, thats we live for this because,
you know, were happy this may never happen to this dentist again, I mean, if you
think about what the incidence is of oral cancer, its a rare disease. But you want to
be there and you want to detect it because if nothing else, you can save one life,
potentially. And it feels very good to do the right thing. Did you have a question?

[Student]So with like the most recent example you gave, would you even biopsy it
or send straight to the surgeon?

[Dr. Kerr}Right. So, in a situation where you have something that is absolutely
obvious and are you talking from the perspective of a general dentist? Yeah. So if
you have something that you think is obviously a malignancy, dont touch it. Just
send them right off. Because youre not really helping them along unless because
youre basically delaying it by getting a biopsy. I mean, theyll get a biopsy anyway.
But, sometimes when you do get a biopsy, in certain situations, it can actually cause
some of the nodes to light up in an inflammatory way that when they get a CT scan,
it can, you know, suggest that theres more disease in the nceck than there probably
is. So thats one of the justifications for not getting a biopsy and probably sending
them for a scan and then getting a biopsy. Yeah?

[Student]-- How long does it take for the disease to get to that point, to such an
advanced stage?

[Dr. Kerr]Very good question. And Ill get to that in a minute. Generally speaking,
this disease, overall, is relatively slowly growing but there are always examples of
patients who have highly aggressive disease that literally, between one week to the
next, its growing visibly each time you see them. So, its a good question. And
unfortunately we dont always have, you know, when you see someone in a cross-
point in time you dont really get that sense, other than by asking them questions.
But many of these patients, theyve had this disease. I bet you anything that second
guy had had that disease for at least a year and it just got slowly slowly worse. Now,
it may have been in a precancerous state for quite a long time then suddenly
transformed and then it really took off in terms of sort of a growth spurt. But, you
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know, again its hard to say because were not always following these things over
time.

[16] [N/A]
[Dr. Kerr] So just some stats, I know youve had a bunch of this but this is the latest
data from American Cancer Society, about 40,000 8,000 will die in the U.S., 2014.

[17] [N/A]
[Dr. Kerr] Most of these are squamous cell carcinomas. Im not going to get into all
the other types. I might have a couple of slides later on but its mostly squamous cell
carcinoma when it comes to the oral cavity and pharynx.

[18] [N/A]
[Dr. Kerr] Its about a 2.7 ratio, men to women.

[19] [Demographics of Oral Cancer-Age]
[Dr. Kerr] it tends to be in an older age group and thats probably related to longer
exposure to potential risk factors, coupled with changes in the immune system, the
immune surveillance, things like that. But, median age is 62 in the U.S.

[20] [Race/Ethnicity in USA]
[Dr. Kerr] its mainly in white males. Thats the biggest incidence, about 16.7 in
white males. You know, it used to be that it was higher in, you know, in African
American males but thats not true now. But what we do know is that African
American males have a much higher mortality rate and thats probably related to
the size of the tumor at the time of diagnosis and access to care issues. And so, thats
probably whats going on.

[21] [N/a]
[Dr. Kerr] there are a lot of famous people whove developed oral or pharyngeal
malignancies. Youve probably recognized quite a few of them. Sigmund Freud, Babe
Ruth, Grover Cleveland who actually had his cancer removed in the East River on a
boat. Colleen Zenk Pinter is a soap opera star. Aldous Huxley, one of my favorite
authors. Sammy Davis, Jr. And most recently, of course, Michael Douglas. Ill get to
that in a moment

[22] [N/A]
[Dr. Kerr] Unfortunately, you know by the time these patients have presented to
us, theyve already got a lot of them have got spread in their cancer. So, over 50% of
oral cancers are diagnosed after theyve already metastasized into the regional
lymph nodes or to distant organs.

[23] [N/A]
[Dr. Kerr] Like this patient. And again, you ask yourself, you know, how is it that it
took so long for her to come in and this thing didnt grow overnight.

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[24] [N/A]
[Dr. Kerr] Sometimes they metastasize to the lungs or to other organ systems. So
we generally will take a chest x-ray of our patients at baseline just to be sure that
theres no cancer in the lungs.

[25] [N/A]
[Dr. Kerr] again, an overall 5-year survival rate, around 62%. So its a lot worse
than many of the other cancers that are plaguing our population. Certainly a lot
lower than breast cancer, colon cancer, prostate cancer. And its shocking really
when you think about it, this is an accessible part of the body. I mean all you have to
do is open your mouth. Its not like the pancreas. You can understand why
pancreatic cancer is detected so often in late stage because you know theres no way
of really screening for it. You cant look for it. You cant examine the pancreas very
easily. Whereas with the mouth and pharynx, these are accessible parts of the body.

[26] [N/A]
[Dr. Kerr] And Ive mentioned to you about the mortality between African
Americans and whites and its usually related to the staging at the time of
diagnosing they usually have more advanced disease.

[27] [N/A]
[Dr. Kerr] This is a little study that we did with Dr. Morse.

[28] [N/A]
[Dr. Kerr] Whats interesting and if you read the American Cancer Society cancer
facts and figures for 2014, were seeing an increase in tongue and tonsil cancers in
the United States. So, oral tongue, not quite sure whats going on there and tonsil.
Now what is tonsil? Well the tonsils, some of you may have had your tonsils
removed. I had mine removed when I was five years old. Not only did I have my
palatine tonsils removed, which are the ones at the back of the tongue or the ones at
the back of the mouth in the oropharynx but I also had my adenoids removed, which
are my nasopharyngeal tonsils. And then there are lingual tonsils, which are on the
base of the tongue, thats what Michael Douglas had, is a base of tongue or lingual
tonsil cancer. So, were seeing an increase in these oropharyngeal cancers and in
tongue cancers. Again, Im not sure whats going on with the tongue cancer but the
oropharyngeal cancers are on the rise. Does anyone know what the cause is for that?
Right, you guys had a lot of information about HPV. So weve seen this emerging
epidemic of HPV associated oropharyngeal cancers.

[29] [N/A]
[Dr. Kerr] So youve already been through the risk factors. You know, cigarette
smoking, any form of tobacco is risky.

[30] [Its not just about cigarettes ]
[Dr. Kerr] So its not just about cigarettes. But there are lots of other habits that
people use tobacco. And it depends; there are many sort of cultural factors. So in
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South Asia, theyre using tobacco with the areca nut. Thats an independent risk
factor. And there are various chew tobaccos. Im not going to get into too much
detail.

[31] [The Risk of Oral &Pharyngeal Cancer by Smoking & Drinking Status, USA,
Males]
[Dr. Kerr] and we know that tobacco added to alcohol, theres a multiplicative
effect such that it, you know, multiples the risk so in patients that are smoking and
drinking heavily, they really have a really high risk. Some patients are, you know,
between thirty to forty times the risk compared to the general population.

[32] [How any fruits and vegetables do you need?]
[Dr. Kerr] We also know that diet can play a protective role. A number of case
control studies have shown this and patients who have poor diets are potentially at
higher risk for developing cancer.

[33] [Human Papillomavirus 16]
[Dr. Kerr] And then weve got HPV 16. So I was rather shocked to see, it was
probably a year ago now, on the New York Post that Sex Gave Me Cancer. Im
actually going to be at the largest ever head and neck cancer meeting, 2,800
attendees here in New York in 10 days from now. And Michael Douglas is actually
giving the keynote address. So Im sort of quite interested to see what he has to say.
And so Ill be going to listen to him. Its principally HPV 16. There are other
oncogenic subtypes of HPV but thats the predominant one. And we know that
patients are more at risk for developing persistent HPV infection if they engage in
multiple sexual encounters, both oral sex and otherwise and so we know that is a
risk factor. We dont understand the natural history of this disease sufficiently to be
able to pinpoint whos going to be at risk but, you know, its one of those things
where we do know its the sexual habits. And it seems to be occurring in a more
affluent population and potentially these are the patients more likely to come to the
dentist so you may be encountering patients who present with the signs and
symptoms of oropharyngeal cancer, which is usually lymphadenopathy because it
tends to metastasize quite quickly from the oropharynx into the neck. The good
news is that they seem to be very amenable to treatment, particularly radiation
and/or chemotherapy. They seem to do pretty well. Having said that, you know,
receiving radiation treatment is no walk in the park, in the short term, nor the long
term. And these patients have a lot of problems for the rest of their lives as a result
of being exposed to such high levels of radiation.

[34] [N/A]
[Dr. Kerr] So patient comes in and, you know, you do your exam and at some point
youll see something. Were not quite sophisticated enough to be able to detect, you
know, the changes, the early genetic changes, so generally, its contingent upon us
performing an exam and visualizing something. And so if we visualize a lesion that
we cant work out why its there and we think that there may be the possibility that
this could be what we call a potentially malignant lesion or potentially malignant
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disorder, then we have to ask ourselves, well whats the nature of that? And is it
cancer now? Is it potentially going to turn into cancer? Is it never going to turn into
anything? What is going on? And so generally what we do is we take a biopsy and
then we look at it under the microscope and it could be depending on the
microscopic features, it could be a malignancy at that point or it could be a
precancerous lesion and histopathologically we call that epithelial dysplasia. There
are abnormal features that we see when we look at the cells of that epithelium that
is in that sample. But all of those abnormal changes are confined to that epithelium.
Its only when those abnormal cells break through the basement membrane into the
underlying connective tissue that we have an actual malignancy. So until then there
may be nasty cells. Those cells may harbor genetic mutations that are bad and it
could drive that lesion to undergo malignant transformation down the road. We
dont know because we dont have sophisticated tests to be able to assess those
genetic mutations, at least not yet. In the research domain, may be, but its very
expensive and its certainly isnt the standard of care. And so we rely on, you know,
histopathology to guide many of the decisions that we make as clinicians. If its a
malignancy, no question they need to be as per the standard of care. But if theyre a
precancerous lesion, dysplasia, theres a little debate about what we should do.

[35] [N/A]
[Dr. Kerr] So, it used to be thought that, you know, this whole process took quite a
long time and it would go through this sort of series of events, accumulation of
genetic mutations over time that would lead from an innocuous lesion into
something that looked a little more suspicious and that would be associated with a
commensurate change in histopathology that was worsening from a mild dysplasia
to a moderate dysplasia to a severe dysplasia to a carcinoma in situ, eventually to a
malignancy. What we know is that this is not always linear, this process,
carcinogenesis, and not always predictable. So sometimes Ive seen patients, they
just jump right into a cancer. They dont go through all of the precancerous stages.
And then Ive seen others who go through, you know, these precancerous stages and
then become a malignancy and sometimes it takes 10 years. And sometimes it goes
from a mild dysplasia and rapidly goes into a cancer. We dont know whats going to
happen. Its very difficult to predict. Every patient is a little bit different.

[36] [4 Major Driver Pathways]
[Dr. Kerr] and there are a number of different pathways but the cell biologists, the
experts on this have really whittled it down really to four major driver pathways.
And this is related to, you know, defects in the genes that control the cell cycle of the
keratinocytes as they start as a basal cell and they slowly divide and mature and
then they get to the surface. Theyre the grandparents. They fall off. And then the
other ones come through from the basal cells, which are the baby cells, ride their
way up and it keeps going through that process. Well that whole process, that cell
cycle, that differentiation of those cells from basal cells to the superficial cells, that
can go wrong. Its, you know, its controlled by various genes that produce various
proteins. And when you get genetic mutations in these different pathways, things go
wrong. Cells dont divide properly. They divide in a way that they shouldnt. So thats
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one thing. The ability to suppress a cell that has gone wrong, we have systems,
tumor suppressor genes that we produce in our cells that tell a cell, we dont like
you and we shut them down and then we put them into apoptosis. Thats our way
of dealing with it. But sometimes the ability to produce those normal tumor
suppressor proteins is lost because of mutations in that tumor suppressor gene.
And, you know, differentiation, you know, the way that the cell differentiates can
sometimes go wrong. And then there are various other pathways. Again, Im not
going to get into it but I want you to understand that there are lots of different ways
that this carcinogenesis can lead to an immortal, you know, cell line.

[37] [N/A]
[Dr. Kerr] And it can be that certain mutations and certain genes, we get increases
or losses in genetic material. We can get epigenetic changes where we get
methylation in the promoter regions, which has an impact on how those genes are
transcribed. So, lots of different things going on and these are some of the different
genes in the differentiation, proliferation, cell cycle pathways, where we can find
these genetic mutations and many of these cancers, you know, there are multiple
genetic defects. And the primary cancer can have a different blend of those
mutations than the metastatic cancer. So the cancers evolving constantly to be able
to kill the host.

[38] [Progression vs. Regression? Aggressive vs. indolent?]
[Dr. Kerr] So this is why early detection is very important. So the question is, does
this lesion that I see, that I encounter in clinic, will it progress? Will it regress? Will it
be aggressive and move quickly or will it be fairly indolent? We know some cancers,
breast cancers, prostate cancers can be youve all heard of patients whove had
fairly indolent cancers. And then you hear of these other patients who have an early
breast cancer and its very aggressive. And so, the same thing probably holds true
for squamous cell carcinomas.

[39] [N/A]
[Dr. Kerr] And to answer your question again, I mean, youre not the fly on the roof
of the mouth. I mean, if you were the fly on the roof of the mouth, looking down on
that, on, you know, all of the oral structures youd be able to see how that lesion
truly is evolving. But we dont have the luxury of being the fly on the roof of the
mouth, do we? So we detect patients opportunistically, whenever we can, when
patients come in for a new patient exam or a recall exam or an emergency exam.

[40] [Mild dysplasia: No progression]
[Dr. Kerr] So heres an example of a patient who has a white lesion involving the
right buccal mucosa. We cant explain why its there. Theyre not rubbing it in any
way. Theres nothing in the history that makes us, well thats the reason for that. So
because we dont have a reason for it, we biopsy it to work out whats going out at
baseline. It turns out to be a mild, precancerous change, a mild epithelial dysplasia.
Nothing has happened. Ive seen this patient in 2014, still nothing going on, really
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should update the slide because its just looking just the same. So heres someone in
five years, absolutely no change.

[41] [Moderate dysplasia: Progression to SCCA]
[Dr. Kerr] And yet we have patients who, you know, over a period of a year can go
from a moderate epithelial dysplasia through to a squamous cell carcinoma. And
that can happen quite quickly. The good news is we discovered it very early on and
it was treated and shes still coming to see me. Shes in good health.

[42] [Severe dysplasia: Progression to SCCA & 2 Recurrences]
[Dr. Kerr] and then we have patients who, at baseline, had a severe epithelial
dysplasia. They had an operation to remove it. They continued to smoke. They got a
recurrence. They go to new cancer. Then they were treated for that cancer and then
they got another recurrence. And then they got treated even more aggressively. This
guys still alive.

[43] [N/A]
[Dr. Kerr] we have a staging system. And generally speaking, the staging system,
the more advanced the stage, the more likely that patient is going to die. So if you
pick up someone with very early stage disease, stage I, stage II, you can see weve
got a T, N, M staging system. T is the size of the primary tumor. N is the nodal
metastasis, the lymph node metastasis in the regional area. And then M is distant
metastasis, below the clavicle. So, if you have someone whos stage I or stage II, you
can see that the five-year survival rate is pretty good. When you get into advanced
stage disease, the five-year survival rate is much poorer.

[44] [Other Non-Epithelial Oral Cancers]
[Dr. Kerr] And there are other types of cancers. Im not going to get into this.

[45] [N/A]
[Dr. Kerr] This was a Hodgkins lymphoma.

[46] [N/A]
[Dr. Kerr] Kaposis sarcoma

[48] [N/A]
[Dr. Kerr] This is a salivary gland malignancy.

[49] [An ideal screening test]
[Dr. Kerr] Well talk more about it next year. So, lets get back to what youre going
to do as dentists. So, how do you screen for cancer? Well, we dont actually have, you
know, a screening test per se, but if we did, we want it to be highly sensitive. In
other words, it captures every cancer that you would want it to test. Its non-
invasive, its fast, its easy to perform, its low cost. That would be the ideal screening
test.

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, 2014

12
[50] [N/A]
[Dr. Kerr] So what is the evidence for screening for cancer? Well this actually just
came out very recently back in November November 2013. And this is really
designed; this U.S. preventive task force is really looking at, you know, primary
health care providers. It doesnt really include dentists and people who are expert at
looking at the mouth. And it concludes the current evidence is insufficient to assess
the balance of benefits and harms of screening for oral cancer in asymptomatic
adults. Now when they first put it out, the results of this, they put it out for a test
period where you could send in a letter to comment. And I actually sent in a letter to
them because, initially, this is what they were putting out. But they didnt consider
what the dentist was doing and the way that the wording was that, you know, even
for dentists there was no reason for them to be doing that. And I thought that was
absolutely wrong and so, on behalf of the American Academy of Oral Medicine and a
couple of other organizations, we wrote some strong letters. And they actually
changed the wording as a result of our efforts, which was great.

[51] [N/A]
[Dr. Kerr] So, this recommendation applies to asymptomatic adults aged 18 years
or older who are seen by primary care providers. That wasnt in the wording before.
This recommendation focuses on screening (visual inspection and palpation) of the
oral cavity performed by primary care providers and not dental providers or
otolaryngologists. That was added in based on our commentary. This
recommendation is intended for primary care providers and does not pertain to
dental providers. Dental care providers and otolaryngologists may conduct a
comprehensive examination of the oral cavity and pharynx during the clinical
encounter. This is what we do! Right?! This is what we do. We look in the mouth.
Okay? You can understand that a physician isnt going to be spending the time
looking in the mouth. So for them to add that to what they do, you can understand
that that would add an extra bonus to what they do, given that there isnt any
evidence for or against doing it. Some of them will do that, but for us, we need to be
doing this.

[52] [N/A]
[Dr. Kerr] And then theres the Cochran Collaboration. This is a recent systematic
review that also just came out in 2013 and I was very fortunate to be on this.

[53] [N/A]
[Dr. Kerr] And we looked at all of the data to support whether or not we should be
performing screening using, you know, the conventional exam versus other
adjunctive techniques to help us screen. And so, the results were that index tests at a
prevalence reported in the population were better at correctly classifying the
absence of any lesions in disease-free individuals than classifying the presence in
diseased individuals. So were very good pretty good at looking at someone and if
they have nothing going on saying, youve got nothing going on. Were not so good at
finding the disease but when there isnt any disease, were pretty good at saying
there is no disease. Unfortunate, but thats the result. General dental practitioners
th
, 2014

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and dental care professionals should remain vigilant for signs of potentially
malignant disorders and oral cancer whilst performing routine oral exams in
practice. And if you want to look at that and read more about it, youve got the
citation.

[54] [N/A]
[Dr. Kerr] So the only really good study, and again, its questionable and theres a
lack of generalizability to the United States and to industrialized countries, really
comes from this big study in India, where they actually showed that oral visual
screening can reduce mortality in patients who are high-risk: smoking, drinking,
using tobacco products, and that in those individuals we really should be
performing a screening exam.

[55] [N/A]
[Dr. Kerr] So what do we do? Well? We look and we palpate. Okay? I dont think
thats swearing in any particular population. Youve got to watch out which finger
you stick up there but

[56] [N/A]
[Dr. Kerr] And we know that dental offices are much better at picking up early
disease. Because early disease is generally asymptomatic and when we do our
opportunistic screening, were more likely to pick it up. Physicians actually pick up
more cancer but thats because more cancer is advanced and so a patient comes in,
they go, hey, doc, Ive got this pain, Ive got this lump. You know, and then they go
stick out your tongue and well, there it is. Of course. Its standing there as obvious as
can be.

[57] [N/A]
[Dr. Kerr] So, our motto here at the college is if your dentist doesnt do an oral
cancer exam, change dentists. Very important. Youve got to promote what you do.
Yank. Were the tongue-yankers. We look at the tongue. We pull out the tongue. This
is what defines us.

[58] [N/A]
[Dr. Kerr] And Im not going to go through the exam today. Youve seen it before.

[59] [N/A]
[Dr. Kerr] But we do a careful head and neck extraoral and intraoral exam.

[60] [N/A]
[Dr. Kerr] And Ill post those videos if you want to have another look. So regardless
of your ability, the clinician has an obligation to inform the patient in terms they will
understand about the nature of something that they find thats abnormal. And what
the plan is to reach a definitive diagnosis and/or rule-out serious pathology. Well
any persistent and progressive epithelial lesion for which a clinican can determine
no clear cause should raise suspicion and must be evaluated to rule out
th
, 2014

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premalignant or malignant changes. Now, the issue is, what is persistent, what is
progressive? Say, if youre finding a patient at a time point, then youve got to decide,
well should I let it go on a little bit longer so that I can assess that progressiveness or
the persistence. So sometimes youll have the patient, youll go, okay, well lets just
send you off but youve got to come back in three weeks if its still there. Then that
really confirms that it is persistent. And it may be progressive in terms of it may
look a little bit worse. But at least its not going away so we need to do something.
Other times, you dont really need to prove that its persistent and progressive
because the patient will tell you its been there for a while. Thats good enough. Or it
just looks highly suspicious at baseline and therefore you know youve got to just get
going on that diagnostic testing.

[61] [N/A]
[Dr. Kerr] So, I call this an across-the-room diagnosis. Patient looks at you, sticks
their tongue out if they can and theyve got this nasty, deeply infiltrative cancer. You
dont need to win an award. I hope that your patient who youve been seeing for
twenty years doesnt come into your office showing you this. Youre not going to feel
too good, but it happens.

[62] [N/A]
[Dr. Kerr] And look at it. It has all these characteristic features. You put your finger
on it. Its rock hard. Its not spongy like a normal tongue. Its rock hard. And theres
ulceration. Its very, very painful.

[63] [N/A]
[Dr. Kerr] Some patients will present with a lump in the neck. And you palpate
their lymph nodes in the neck and theyre hard. And you know that theres probably
a primary, either in the oral cavity or the oropharynx. In this case it was the
oropharyngeal disease. This may be the only finding in that patient. You may
examine their oral cavity, their oropharynx and not detect anything.

[64] [N/A]
[Dr. Kerr] Heres another guy. You already saw this picture.

[65] [N/A]
[Dr. Kerr] These lesions are friable. These cells dont behave normally. They fall
apart. Theres a release of angiogenic factors that cause these lesions to bleed
profusely.

[66] [N/A]
[Dr. Kerr] Sometimes theyll get advanced. Theyll just railroad right through the
alveolus form the floor of the mouth. I had just pulled out this patients tooth. I was
worried they were going to aspirate it. Theyre in a nest of cancer coming through
the alveolar bone

[67] [N/A]
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, 2014

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[Dr. Kerr] Sometimes patients will present with a gingival lesion that isnt healing
and they have bone loss.

[68] [N/A]
[Dr. Kerr] And you go ahead and you think well maybe thats a periodontal
problem so you scale them and root planing. Nothings getting better. Its getting
worse. Well, what are you going to do? Youre going to biopsy and this was a patient
that had a delay in diagnosis because they went through three rounds of periodontal
treatment in this local area, nothing else going on elsewhere in the mouth until it
was biopsied.

[69] [N/A]
[Dr. Kerr] sometimes the cancers are deeply invasive and dont have much on the
surface. It may be just this rolled border that we see.

[70] [N/A]
[Dr. Kerr] Heres another one; an ulcer with a rolled border. Ulceration can
sometimes be the solitary sign of the malignancy.

[72] [N/A]
[Dr. Kerr] Heres another one. Very firm, patients in a lot of pain. Seeing a
periodontist for, you know, lots of periodontal therapy. But the periodontist never
put two and two together that this was a malignancy.

[74, 75, 76] [N/A]
[Dr. Kerr] These are all advanced cancers. Sometimes theyre very granular,
nodular, exophitic. And they can occur on any surface. Sometimes they are very
white, sometimes theyre red.

[77] [N/A]
[Dr. Kerr] And again, you can see. If you palpate the tongue, its firm. Theres a deep
ulceration in the centre.

[78] [N/A]
[Dr. Kerr] I know we have some Canadians in the room. And you guys
automatically get five points just for being Canadian.

[79] [N/A]
[Dr. Kerr] So, red and white. So these are all advanced cancers. You dont have to
see too many of them in your career. The ones that you may see that really pays off
is when you see the earlier lesions where the features arent always as ominous and
as obvious. Theres no lymphadenopathy associated with them. Theyre often not
causing any pain. They may cause pain. Early cancers can cause pain. But the red
and white feature is quite often something that we look for so thats why I call it the
Canadian-flag type lesion. So, we use terms like erythroleukoplakia or leukoplakia.
Erythroleukoplakia is a red and white lesion that you cant explain why its there.
th
, 2014

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And erythroleukoplakia is a term that we use when weve ruled out everything else.
Its a clinical diagnosis and it means that we have to rule out precancer or cancer. So
we have to take a biopsy. So its a clinical diagnosis, not a histopathologic diagnosis.
And so youll see here, the clinical diagnosis, and then next to it, the histopathologic
diagnosis. So this is an erythroleukoplakia and it turns out, when its biopsied, to be
a squamous cell carcinoma. And its very friable. You can see a little area where I just
rubbed it with my periodontal probe and it bled quite easily.

[80] [N/A]
[Dr. Kerr] So you can see the mixed red and white change.

[81] [N/A]
[Dr. Kerr] Heres another erythroleukoplakia with ulceration. Also, a squamous cell
carcinoma.

[82] [N/A]
[Dr. Kerr] But these are early. This was a patient who had a denture and the dentist
thought, well, you know, its a denture sore. And they kept whittling down the
denture and it just didnt go away. And finally, they referred it to have a biopsy and
it was a squamous cell carcinoma. But look at it! It has all of the high-risk features.
Its red and white and it has ulceration in it. But its not an advanced cancer; its an
early cancer.

[83] [N/A]
[Dr. Kerr] Heres another example where we just have ulceration but it is a
malignancy. So no red and white features but its ulcerated. It just has a slight rolled
border to it. Very easy to mix.

[84] [N/A]
[Dr. Kerr] And theres a little bit of bone loss in the area too.

[85] [N/A]
[Dr. Kerr] And there it is.

[86] [N/A]
[Dr. Kerr] Another example of an erythroleukoplakia. Turns out to be a
malignancy. It was thought to be a little cheek bite. But when you look at it carefully

[87] [N/A]
[Dr. Kerr] it has a heterogeneous surface topography. Its a little bit friable to
palpation. Its small but thats an early malignancy.

[88] [N/A]
[Dr. Kerr] Heres another one, seen by an EMT and two other physicians was
thought to be a candidiasis or something like that, put on antifungals. Eventually got
th
, 2014

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to me, I take one look at it; its an erythroleukoplakia with ulceration. Turned out to
be a squamous cell carcinoma.

[89] [N/A]
[Dr. Kerr] Look at it. Its quite bumpy and granular in appearance. The orange area
is ulceration. Non-homogenous lesions. Its got white and red changes and
ulcerations. Squamous cell carcinoma.

[90] [N/A]
[Dr. Kerr] Heres another one. Way posterior in the mouth. Little ulceration, slight
rolled border. Squamous cell carcinoma.

[91] [N/A]
[Dr. Kerr] Again, look at it. Its not obvious.

[92] [N/A]
[Dr. Kerr] Heres another one. Right on the gingival tissues. Erythroleukoplakia.
Squamous cell carcinoma.

[93] [N/A]
[Dr. Kerr] Look at it.

[94] [N/A]
[Dr. Kerr] Floor of mouth. You ask yourself well where is that? Its a little
erythroleukoplakia on the left floor of mouth.

[95] [N/A]
[Dr. Kerr] Look at it. Its got a little bit of a roll to it. Its a little bit firm. Squamous
cell carcinoma.

[96] [N/A]
[Dr. Kerr] This patient has a leukoplakia with ulceration. We dried it off.

[97] [N/A]
[Dr. Kerr] Got a really good look at it. Squamous cell carcinoma.

[98] [N/A]
[Dr. Kerr] Again, erythroleukoplakia. This time, a severe epithelial dysplasia. Look
at the surface topography.

[99] [N/A]
[Dr. Kerr] Very granular, and so when you get this abnormal surface topography,
thats quite often what it is.

[100] [N/A]
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, 2014

18
[Dr. Kerr] Again, another leukoplakia with abnormal surface topography. It has
grooves and bumps. It shouldnt be there.

[101] [N/A]
[Dr. Kerr] Severe dysplasia.

[102] [N/A]
[Dr. Kerr] Sometimes the lesions are quite heterogenous and it makes it quite
difficult because if you take a sample from one area of the lesion, its different
histopathological than in another area. So you can get variability of the
histopathology. So it means that if you are going to take a sample, you better make
sure you get the worst area. So where would you go, what area would you biopsy?
What dictates that thought process? Well I always go to an area where it feels a little
bit firm because that tells me that there may be some submucosal spread that could
be where the cancer is. Otherwise, a red area or an ulcerated area. Generally the
white areas arent as ominous as the red or the ulcerated areas.

[103] [N/A]
[Dr. Kerr] Yes?

[Student]So when you find severe dysplasia or moderate dysplasia, what do you
do? Do you just watch it and tell the patient to come back?

[Dr. Kerr]Well get to that in a minute, okay? So, thats a very, very good question.
And it really depends on the individual. So, you know, I have some patients who
have high-grade dysplasia and Im watching them. But you know, if you were to ask
ten experts what to do in those situations, theyll go well you must remove that. But
in some situations, theyve had them removed and many times it keeps coming back.
Ive had severe dysplasias that have regressed. Very rarely, but it occurs. So in
general, surgical excision is the treatment of choice for high-grade dysplasia. And, of
course, cancer. When you get below high-grade dysplasia, when youre in the
moderate to mild category, its a little debate about what to do and what should
guide your decision and I wish we had better evidence to support what we should
do. Some people feel we should still remove them, some people feel we shouldnt.
So, theres sometimes a little bit of creativity that goes into this. And the evidence
doesnt support removal of every time of lesion. Okay?

[104] [N/A]
[Dr. Kerr] So, again, this was thought to be a little canker sore on the soft palate, on
the oropharynx and you can see that ulceration when you look at it. Theres white
changes but the cancer is in that ulcerated area.

[105] [N/A]
[Dr. Kerr] Again, a little ulcer in the floor of mouth.

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, 2014

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[106] [N/A]
[Dr. Kerr] Little red area. Its only red. Squamous cell carcinoma.

[107] [N/A]
[Dr. Kerr] Slight rolled border posteriorly.

[108] [N/A]
[Dr. Kerr] Again, gingival lesion was just red. That was it. Turned out to be a
squamous cell carcinoma

[109] [N/A]
[Dr. Kerr] right in that gingivae. Very subtle.

[110] [N/A]
[Dr. Kerr] Youve got to know how to pick that up. Again, leukoplakia with a little
bit of ulceration, was carcinoma in situ.

[112] [N/A]
[Dr. Kerr] Moderate dysplasia and erythroleukoplakia with moderate dysplasia.

[114] [N/A]
[Dr. Kerr] Erythroplakia that was carcinoma in situ.

[115] [N/A]
[Dr. Kerr] Sometimes we have patients with multifocal disease. And these patients
we call this proliferative verruca leukoplakia. And these generally are older, female
individuals that have a high propensity for malignant transformation. So when you
see patients with multifocal precancerous changes or have a propensity for
malignancies and have had their first malignancy already, these patients, they
should be followed in a surveillance clinic by experts.

[116] [N/A]
[Dr. Kerr] Lip cancers.

[117] [Oral submucous fibrosis]
[Dr. Kerr] Oral submucous fibrosis which is a disease, a precancerous disease that
occurs in patients who chew the areca nut which is a nut that grows on palm trees in
South Asia. This will cause this fibrosis but it also puts the patient at a high risk for
developing malignancy.

[118] [Erythroleukoplakis in field of OSMF]
[Dr. Kerr] And here is an erythroleukoplakia in the field of oral submucous fibrosis
that turned out to be a malignancy.

[119] [Leukoplakia in field of oral lichen planus: severe epithelial dysplasia]
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[Dr. Kerr] Here is a leukoplakia in the field of oral lichen planus, turns out to be
severe epithelial dysplasia. So oral lichen planus also itself confers a slight increase
risk for developing the disease.

[120] [Leukoplakia: Mild dysplasia]
[Dr. Kerr] Now as you get earlier on in the disease or when you only have a white
component in the disease, it usually is not high-grade dysplasia or carcinoma.
Although, having said that, I have had patients with a leukoplakia, which is just a
white change, a white patch that doesnt wipe off. You cant explain why its there
and therefore you have to rule out precancer or cancer. Very rarely would it be
cancer. Very rarely. Its usually going to be a precancerous change.

[121] [Leukoplakis: Mild dysplasia]
[Dr. Kerr] And so all of these leukoplakia, mild dysplasia

[123] [N/A]
[Dr. Kerr] mild dysplasia.

[125] [N/A]
[Dr. Kerr] Mild dysplasia.

[127] [Leukoplakia: Mild dysplasia]
[Dr. Kerr] Mild dysplasia.

[128] [Leukoplakia: Moderate dysplasia with candid ]
[Dr. Kerr] Moderate dysplasia.

[130] [Leukoplakia: Epithelial]
[Dr. Kerr] Mild dysplasia. Actually this was epithelial hyperkeratosis. But we
couldnt explain why it was there.

[132] [Leukoplakia: Epithelial ]
[Dr. Kerr] Epithelial hyperkeratosis hyperplasia but still, couldnt explain why it
was there. There were no sharp or anything like that.

[137] [Leukoplakia: moderate epithelial dysplasia]
[Dr. Kerr] So these all tend to be low-grade epithelial dysplasias or benign
diagnosis.

[139] [Leukoplakia: mild epithelial dysplasia]
[Dr. Kerr] But we cant explain why theyre there. But these are the things that we
need to pick up on.

[141] [Leukoplakia: carcinoma in situ]
[Dr. Kerr] This one turned out to be a carcinoma in situ. It has a little bit of
pigmented changes. I was surprised about that.
th
, 2014

21

[142] [Leukoplakia: mild epithelial dysplasia actinic cheilitis]
[Dr. Kerr] And here is a mild epithelial dysplasia of the lip.

[143] [N/A]
[Dr. Kerr] So. In general, those higher risk features having ulceration, red and
white changes, theyre ususally commensary with higher-grade disease than just the
white changes on their own, but not always. So, youve all heard of these adjunctive
techniques. Theyre all in the marketplace being marketed to dentists left, right, and
center. And so the question is, can these add value in how you perform as a clinican?
So can you use any of these adjunctive techniques to help you decide and
differentiate out which of those lesions truly are the ominous ones? And so the
answer is that were also doing a very big Cochrane review on this at the moment.
Itll be published hopefully in the next three or four months. So I cant present that
data to you today but maybe next year. So there are a number of different devices
that are available in the marketplace and techniqes in the marketplace. And one of
the groups of devices is called visualization adjuncts. Theyre basically fancy lights
that you shine on a lesion and it gives you a little bit more information about whats
going on. And the ones that I like are the auto-fluorescence devices. These are the
devices that work on the premise that if you shine a certain wavelength of light on
the mucosa, there are naturally occurring molecules in the mucosa and submucosa
that differentially fluoresce and so you can then look at a lesion and go well, is that a
normal fluorescence pattern for epithelium or is there a loss of fluorescence or an
increase in fluorescence.

[144] [N/A]
[Dr. Kerr] the other group of adjuncts that we use are what are known as vital
stains or vital dyes. So we use a dye called toluidine blue and that can sometimes
help us determine areas of a lesion that are harboring the worst histopathology.
Because this works extremely well in cancers and high-grade dysplasias to stain
those particular areas.

[145] [N/A]
[Dr. Kerr] And then theres a commercially available kit that we use and this is the
toluidine blue stain. Youll learn more about this next year.

[146] [N/A]
[Dr. Kerr] So heres an example of a patient who develops an erythroleukoplakia in
the floor of the mouth and when we do the toluidine blue staining, it really shows
very nicely the area of the worst disease and thats all carcinoma in situ. So this
helps sometimes in where you should select your biopsy site and/or for a surgeon
working out, well where are the worst areas of disease, I need to get around all of
these areas. I dont want to miss that little tiny speck, you know, that I see right here
and here because those harbor bad disease and yet I might have missed that looking
at this area alone. Question from someone? No.

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, 2014

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[147] [N/A]
[Dr. Kerr] Heres an example of a cancer. The cancer stains beautifully with
toluidine blue but the normal tissue around it doesnt because its normal tissue. So
that shows how it can be very specific for high-grade disease.

[148] [N/A]
[Dr. Kerr] But yet none of these adjunctive techniques are perfect. They dont
always work. So not every case of dysplasia will show a positive toluidine blue
staining. Ive had cancers that dont stain with toluidine blue. Ive had a lot of other
lesions that are not precancerous that do stain with toluidine blue and the same is
true for the visualization adjuncts. So, these are not perfect but used collectively,
they add nuances to the entire examination that guides you in making decisions. So
when I say you, it could be you or me, it depends on the level of expertise how you
use these adjuncts.

[149] [N/A]
[Dr. Kerr] So here is the auto-fluorecense device that I use. Its known as Velscope.

[151] [N/A]
[Dr. Kerr] And you can see very clearly in this advanced cancer that it really helps
to delineate the margins of that cancer very nicely.

[152] [N/A]
[Dr. Kerr] and in this cancer in the floor of mouth, if you happen to be using it as a
dentist, you might have missed that little tiny lesion in the floor of the mouth on a
normal white-light exam but pick it up when you use the Velscope. Now, should you
be charging patients in using this? We dont have enough data. But there is an
example where you might, it might be of benefit.

[153] [N/A]
[Dr. Kerr] And heres another example of where we get a loss of fluorescence and
so the apple green color that you see on the lateral border of the tongue, thats the
normal fluorescence pattern of the tongue. But where you get this dark area and you
can see the real interface between the normal and the abnormal, you can see that
that area of loss of fluorescence which correlates with this actually is quite a bit
bigger than the lesion. So that suggests that that neoplasia thats going on actually is
quite a bit bigger than what you see visibly and there are some studies showing that
when you take these margins of tissue auto-fluorescence loss, youre more likely to
capture all of the bad cells that harbor those genetic mutations. But again, we need
more research in this area.

[154] [N/A]
[Dr. Kerr] And heres some other examples of loss of fluorescence.

[155] [N/A]
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23
[Dr. Kerr] Here are some confounding lesions. So, just like toluidine blue, this
tissue auto-fluorescence has a high degree of sensitivity but not great specificity in
the hands of front-line clinicians. So you may encounter a patient in the bottom who
has an erythematous candidiasis from an asthma inhaler. Theres a red patch on the
roof of the mouth but thats candidiasis. You put them on anti-fungals and it
completely goes away. Its not a precancerous change. Its not an erythroplakia. If
you take a careful history and you have a good education in mucosal diseases, youll
know whats going on there and yet you get this loss of fluorescence and so any red
lesion in the mouth, any inflammatory lesion will show a loss of fluorescence
because the blue light of that auto-fluorescence scope is absorbed by the
hemoglobin in that inflammatory lesion. So youve got to be able to tease out this
other one as a hematoma. So there are going to be false positives, we call them
confound lesions. So this is why using it in the hands of someone who doesnt have
the experience of diagnosing mucosal diseases can sometimes be problematic
because it means that more patients are going to be sent or a biopsy than should be.

[156] [N/A]
[Dr. Kerr] So, again we need to have more training in this area and well give you
lots of training next year.

[157] [Other single light autofluorescence devices]
[Dr. Kerr] Heres another system thats just come out in the marketplace, which is
just another auto-fluorescence device.

[158] [N/A]
[Dr. Kerr] There are cytopathologic devices where we can collect cells from a
lesion. So instead of performing a tissue biopsy, you as dentists may not feel
comfortable procuring a tissue biopsy. You may not want to give an injection to the
patient. You may not want to take a scalpel blade and remove a piece of tissue and
submit it for histopathology. Well, this system can help you because its based on a
sampling. Its rather like a pap smear for the oral cavity, although its different. A
pap smear is a screening test where we do a blind sweep of the cervix but when it
goes to the lab they look at those cells. This is when you encounter a lesion; you can
take a little brush, sample the cells from that lesion and then send it off for an
analysis. Now, if youve got a lesion that you have an index of suspicion that you
think this might be something concerning, then youre going do a scalpel biopsy.
Youre going to refer to a patient to do a scalpel biopsy because in the end of the day,
a scalpel biopsy will yield a piece of tissue where the histopathologist can see that
architecture, how those abnormal cells organize in the epithelium. They can
differentiate between the different levels of dysplasia or a carcinoma. This cant do
that. Youre just taking the cells. It cant tell whether those cells came from, you
know, a squamous cell or a mild epithelial dysplasia. So, we generally reserve these
cytopathologic techniques for lesions that we have a low index of suspicion that they
are something serious, where we dont feel the urgency to send that patient to the
expert right away. And this way, without doing an expensive and uncomfortable
procedure we can rule out with very good accuracy that there isnt a precancerous
th
, 2014

24
change in that lesion or even a cancerous change in that lesion. The problem is that
if you get a lesion and you do use one of these cytopathologic techniques, you want
to make sure that it is a small lesion, its very homogenous in its presentation.
Because if you sample one area of a lesion and theres another area over here, that
could be the area with the malignancy. So you dont want to use on a larger lesion
that is heterogeneous unless youre willing to map out the entire lesion with ten
different brushes and go this is brush number one from here, brush number 10 is
from down here. I dont think youre willing to do that. So, this is available but it has
to be used in the appropriate way.

[159] [N/A]
[Dr. Kerr] One of these techniques is looking at abnormal DNA content within the
nuclei of cells. This is known as ploidy or quantitative DNA cytology. This isnt here
in the US yet but its mainstream in Europe and Canada. And this will pick up cells
that have abnormal changes in their DNA content which you know to be true
because of those mutations, we can have increases, gains and losses in genetic
material. This will help you find that.

[160] [N/A]
[Dr. Kerr] And then the other one which is known as the brush biopsy and there
are other cytopathologic techniques and platforms out there but this is probably the
most common one. Its based on cytopathology on its own. It looks for abnormal
looking cells. And we know that the abnormal looking cells have properties like an
abnormal nuclear to cytoplasmic ratio, you know, thats a sort of a classic one. And
there are other things that they look for. Abnormitotic figures. Things like this.

[161] [N/A]
[Dr. Kerr] And so you can look at these cells and go wow or those cells dont look
like your healthy, keratinocyte which is a small, nucleus and a large cytoplasm. So,
the cytopathologist will give you this diagnosis.

[163] [N/A]
[Dr. Kerr] Again, the quandary related to getting a sample that represents the
worst disease within that field of lesions. Some lesions are large and heterogeneous.
Where would you take the biopsy? Anyone? Youd go with C, right? Because its the
red area. Youre more likely to get the high-grade disease in C and remember,
palpate. If you feel any firmness or induration, thats the area you go with.
Sometimes Ill take multiple biopsies and sometimes Ill use these adjuncts,
particularly the toluidine blue to guide me because when we stain with toluidine
blue, well get possibly, it will show where the high-grade disease is.

[164] [N/A]
[Dr. Kerr] We use these little dermatologic punches to sample our tissue.

[165] [N/A]
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, 2014

25
[Dr. Kerr] And here is a patient where Ive stained it with toluidine blue and Im
going with one of the areas

[166] [N/A]
[Dr. Kerr] And we just basically pick it up, pop it into the bottle and send it off to
the lab.

[168] [N/A]
[Dr. Kerr] No sutures, generally, are needed.

[169] [N/A]
[Dr. Kerr] And we get the histopathology, in this case, a severe epithelial dysplasia.

[170] [Molecular markers for early cancer]
[Dr. Kerr] While there are some molecular markers that people are looking for
now in these lesions, but again, its not mainstream. And weve talked a little bit
about this, Im not going to get into too much detail. But there are a number of
different molecular markers that we can look for but thats for next year.

[171] [N/A]
[Dr. Kerr] So if your patient had a lesion diagnosed as an oral cancer or precancer

[172] [1. Would you treat the oral lesion(s)?]
[Dr. Kerr] The questions you need to be asking are, what is the diagnosis? Do you
have a diagnosis? Do you need to know the definitive diagnosis? Given the
diagnosis, do you know how to treat the patient? Okay, you may not be the one
whos going to treat the patient but its very important to have a definitive diagnosis.

[173] [2. If you dont know how to treat the patient, what do you do?]
[Dr. Kerr] If you dont know how to treat the patient, what do you do? Well, you
know, either youve got to train yourself so that you can treat the patient, get an
advanced training, become an oral medicine expert, oral pathologist, oral surgeon,
whatever you want. Or would you prefer to refer to an expert? And if youve got an
expert, you know, down the hall, thats great. Sometimes that expert isnt always the
expert and, you know, academic centers, in general, you know, theyre the people
who have the greatest expertise. You know, comprehensive cancer centers, these
are the people that you should be referring to.

[174] [3. If you have a definitive or presumptive diagnosis, what are your
treatment goals?]
[Dr. Kerr] If you have a definitive or presumptive diagnosis, what are your
treatment goals? Do you treat with an intent to cure? Do you treat to palliate a
condition which would resolve on its own? Do you treat to reduce or prevent the
chances for recurrence? Do you counsel patients about risks for contagion? Well,
this is a general question for oral mucosal diseases. Obviously in the area of cancer,
th
, 2014

26
we treat with an intent in most cases to cure. Sometimes they have such advanced
disease that we dont. we treat to palliate these patients, to give them some quality
of life at the end of their lives. Certainly if theyve had a history of cancer, theyre at a
high risk for getting a recurrence and therefore, you know, we need to follow these
patients very closely.

[175] [4. What are your treatment options?]
[Dr. Kerr] And what are the different treatment options?

[176] [Whats the role of the dentist in the management of patients with oral
cancer or precancer?]
[Dr. Kerr] So whats the role of the dentist in the management of patients with oral
cancer or precancer?

[177] [N/A]
[Dr. Kerr] First of all, cessation of risk activites. Alcohol, rather tobacco, heavy
alcohol use, ultraviolet light for lip cancers, areca nut use. Promotion of good health,
diet, nutrition, good oral health, safe sexual practices, possibly the HPV vaccine for
the younger, nave patients.

[178] [Appropriate/timely referral]
[Dr. Kerr] Few dentists are qualified to actually treat oral cancer or precancer but
they can and should play a role in the multidisciplinary approach to treatment.
Timely referral. Other providers that you would work with in that multidisciplinary
team could be head and neck surgeons. Most of them are otolaryngologists but the
surgeons that I work closely with like Dr. Schmidt is not an otolaryngologist. He is a
head and neck cancer surgeon. He has had an advanced training in head and neck
cancer surgery but he came through the oral surgery track. There are very few
surgeons like him in the country and I think that they do a really top-notch job at
managing people with oral disease. He already knows the oral cavity. Its not to say
that there arent fantastic otolaryngologist head and neck surgeons, there are. I
work closely with them as well. Radiation oncologists. Medical oncologists to
provide the chemotherapy. We work with speech and swallowing therapists.
Nutritionists, psychiatrists, psychologists, social workers. So, we play a very
important role.

[179] [Management of Oral Dysplasia]
[Dr. Kerr] How do we manage, going back to your question, how do we manage
patients with oral precancerous changes or oral epithelial dysplasia? And so there
are lots of different its quite controversial how we would manage. In some cases,
we will do a surgical excision. And theres controversy over which type of surgical
procedure that would be warranted. And there are investigators in some parts of the
world that advocate the use of ablation with a CO2 or other type of laser. Others like
cold steel and stripping a lesion in the mouth and thats what I advocate and thats
what we do in our cancer center. So scalpel removal is the way that we usually will
remove. And it depends again on is it a lesion that is amenable to surgical excision.
th
, 2014

27
Sometimes we have patients with multifocal disease. You cant surgically remove all
of their mucosa. So, clearly, thats a group where we have to think of other options.
And so in some cases we dont even remove the lesions, we really wait until they
develop a malignancy. And then when they do we treat that malignancy and that
area very aggressively. Avoidable risk factor modification, you know, again, this is
very important and there are some studies that suggest that if you can get patients
to quit smoking and heavy alcohol use that they actually can get regression of some
of those precancerous changes. So, risk factor modification cannot be taken lightly.
And so, we strongly advocate getting patients to quit. Performing a self-examination,
very important. The mouth is amenable to self-examination. Nowadays, you know,
with all these smart cameras Im asking patients to do selfies of their I train them
how to take cellphone pictures of their lesions and they send them to me. Its great.
Why not? You know? So, a little selfie of your tongue lesion and off it goes. I train the
spouse to, you know, take the picture. And theyve got it down to a fine art. So self-
examination is important. Knowing what are the features of worsening disease, if
you decide not to excise. Sometimes you excise and these lesions come back. Very
close surveillance. I use adjunctive techniques to give me a sense of where the areas
are when we get a new area, particularly in patients who have had a history of
radiation treatment. Its often very difficult to tease out, is this radiation damage
versus a new lesion? Theres really very little data to support the use of
chemoprevention or chemopreventive or chemotherapeutic agents that reverse
precancer. And theres been a lot of study looking at things like vitamin A analogs,
beta keratin, vitamin E, you know, extracts of certain berries and other antioxidants.
None of these really seem to work. And the vitamin A studies suggest that when you
take them off the vitamin A analogs, if theyve had some type of remission, that it
tends to bounce right back. So we dont have anything good to say there. And how
the diet really plays a role here is largely unknown because when you pull out the
micronutrients that you think are protective, you know, its usually a collection of all
these micronutrients working in tandem thats probably doing it and thats why a
healthy diet is important.

[180] [Case A]
[Dr. Kerr] So well go through a couple of cases. Heres a patient who had an actinic
cheilitis.

[181] [N/A]
[Dr. Kerr] Youve already seen his picture. So, what would you do for him? How
would you manage this guy? Whwat would be your thought process? Lets talk
about diagnosis first. Hes got actinic cheilitis. So how did we arrive at that
diagnosis? Right, we took a biopsy and it showed that he had this sun damage. And
the other thing is we want to know whether theres any epithelial dysplasia in there
so in this patient, he had some mild epithelial dysplasia, some actinic, you know,
cheilitis, which is sun damage. This is a precancerous change, its not a malignancy
and the question is what are you going to do now? Any advice about health
promotion? What do you thinks causing this? Right, sun exposure. So what would
you tell him to do? Right. Apply sunscreen from now on. And so the question is
th
, 2014

28
would you surgically remove that? And generally in these situations, lip cancers,
because of sun damage tend not to be, they tend to be more likely basal cell
carcinomas. But they can also have squamous cell carcinomas and, you know, the
skin rather is more likely to be basal cell carcinoma. The lips are more likely to be
squamous cell carcinoma but they tend not to be aggressive diseases. So in this
situation, there are things that can be done. We can apply certain chemotherapy
agents to the lip but generally Im not going to do a lip shave for something that has
mild epithelial dysplasia.

[182] [Case B]
[Dr. Kerr] Case B. 35 year old female. Tends the bar. 40 pack year history. 5
servings of fruits and vegetables. Drinks approximately 10 drinks a week. Diagnosis
of a mild dysplasia.

[183] [Case B]
[Dr. Kerr] And here we have a mild dysplasia on the inside of the cheek. So what
would you do for her? Okay. So certainly you would discuss with her risk factor
modification, particularly the cigarette smoking. Now shes got a mild epithelial
dysplasia. The likelihood of mild epithelial dysplasia transforming into a malignancy
is probably in the order of 5 to 10% over a ten year period. Its not very common. So
what would you do? What would be your options here? Okay, so you could put her
into surveillance. Any other options potentially? You could present to her, look
youve got a precancerous lesion in your mouth and heres the data on this. Now we
can try first if youd like, you know, quitting smoking. Lets see what happens. And
you can offer her, well, we can follow this or what else could we offer her? We could
offer her surgical excision.

[185] [N/A]
[Dr. Kerr] And in this case, you know, she had surgical excision with a CO2 laser.
Now, this was before, you know, I sort of changed my mind about CO2 lasers but I
just want you to be aware that this is one of the modalities for removing a
precancerous lesion.

[186] [Case C]
[Dr. Kerr] Case C. Hairdresser. 20 pack year history of smoking. Quit a year ago.
Heavy alcohol use. Has a diagnosis of AIDS. Currently an undetectable load. Severe
epithelial dysplasia.

[187] [Case C]
[Dr. Kerr] What would you do in this situation? Again, you would really focus on
the risk factor modification and optimize that. But would you be more prone to refer
this patient for a surgical excision? Yes, in this situation we would. Now the difficulty
in this situation is mapping out the disease so what will happen is usually this will
be done in an operating room environment because in an operating room, we can
remove the lesion and we can sample the margins. And we can send those marginal
tissues samples for a frozen evaluation so we can flash freeze the tissue, send it off
th
, 2014

29
to the pathologist while youre sitting in the operating room with the patient asleep
and the pathologist can say, yea youve got disease at that margin so you can go a
little bit further. Now what was interesting about this patient is hes recurred a
couple of times with dysplasia. Hes never developed a malignancy. I still follow this
patient. And he had to go back and have a couple of revisions because they kept
finding more disease and he kept smoking or he kept, yes, he quit and then he
started smoking again. So occasionally hell get back into cigarettes.

[189] [N/A]
[Dr. Kerr] And so here was the initial surgical incision. Now, because its severe
epithelial dysplasia or carcinoma in situ, when you take those initial biopsies you
cant be sure that there isnt one little area where there might be an early carcinoma.
So its very important, once youve done that surgical excision, to submit that entire
sample oriented in such a way that the pathologist knows whats superior, inferior
anterior, posterior, orient that and then they can look at all of the margins and work
out whether theres any carcinoma in there. If they find an area of carcinoma then
theres a possibility you may have to go back and do a revision. But anyway, this is
the type of surgical procedure that would be done.

[190] [N/A]
[Dr. Kerr] And then sometimes theyll put, you know, an artificial graft on there or
a split thickness skin graft.

[191] [N/A]
[Dr. Kerr] And sometimes theyll bolster it, sometimes they wont.

[192] [Management of Oral Cancer]
[Dr. Kerr] So there are lots of different ways of doing this and we do a lot of
surgical excisions, you know, in the oral cancer center here on the second floor in
Bluestone. What about oral cancer? What are the, you know, the modalities that we
use to manage patients with a malignancy? Well surgery its still a surgical
disease, principally. Unless youve got a cancer in an area that is not amenable to
surgery. And so the tonsilar cancers are very difficult to surgically operate in that
location. So quite often, radiation will be the principal, the primary, modality. But in
most cases, surgery is the primary modality. Nowadays these oropharyngeal cancers
on the base of the tongue, theyre now looking at robotic surgery. And at this head
and neck meeting itll be interesting to see what the latest advances are on this
robotic surgery. So, in terms of radiotherapy there are different ways of delivering
the radiation treatment. Most patients undergo whats called external beam
radiation therapy where they go every single day except for the weekends for five to
six weeks and they get delivered the radiation and they have a special helmet that
they wear thats custom designed for them so that when they sit in the radiation
machine, theyre locked in and their head and neck is oriented at exactly the same
position every time. And then they get delivered packets of radiation from outside
so as the machine will move around anywhere around the head and neck and theyll
deliver a little packet there, a little packet from here, a little packet from there and
th
, 2014

30
that maximizes the dose to the tumor and minimizes the dose to all of the normal
vital structures that are around. Because as you can imagine, in the head and neck,
there are a lot of vital structures such as the eyes, the brain, the salivary glands,
other important nerves and other structures. So we want to minimize the damage
to those structures and maximize the damage to the tumor. Chemotherapy is
sometimes added as an adjunct. Its never used as a primary modality in head and
neck cancer. Not yet. One of these days we may be able to look at the genetics of that
particular cancer, do a genomic analysis of the cancer and then lo and behold put it
into a computer and work out a therapeutic, chemotherapy that is targeted just to
that patients cancer, taken into consideration all of the different mutations that are
driving that cancer. Thats sort of for the 21
st
century but were not there yet.
Obviously, risk factor modification, self-exam, very close surveillance after theyve
had their cancer treatment.

[193] [N/A]
[Dr. Kerr] And there is actually a more recent version than 2012 but you dont
need to worry about this but there are clinical practice guidelines for the
management for oral cavity cancers. So depending on, you know, the various
features, the staging, the location of that cancer, there are algorithms that help head
and neck oncologic surgeons and cancer experts how to manage these patients. So
we actually go to a tumor board every Wednesday morning at NYU Medical Center
where we sit down and we discuss each of these cancer patients and how theyre
going to be managed and then we have this whole multidisciplinary team that all
chime in their expertise to help work out whats the best way to manage this patient.

[194] [N/A]
[Dr. Kerr] And here is an example of, you know, how you would manage someone
with cancer of the oral cavity.

[195] [Case D]
[Dr. Kerr] So we have case D. Social drinker, 85 year old, rinses 3 times a day with
alcohol mouth rinse, stage II squamous cell carcinoma.

[196] [Case D: before]
[Dr. Kerr] And here we see this cancer on the lateral/ventral border of the tongue.
And this is stage II so how do you think we would manage this patient? Surgery
alone? Okay, so hes got lets say a pathologic staging of a T2, N0, M0 so its just in
the tongue. Hes probably had a CT scan of the neck or an MRI that shows no nodal
involvement. Hes probably had a chest x-ray that shows no chest disease so we
stage him as a primary cancer greater than 2 cm in diameter. Between 2 and 4 cm in
diameter. Surgical disease. So he will go in and they will do a margin thats about a
centimeter to a centimeter and a half around it. They will surgically excise that and

[197] [Case D: after]
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, 2014

31
[Dr. Kerr] Here he is, having had that part of his tongue removed. Now, do you thin
hes going to be able to speak normally? Not too bad, youd be amazed how much
tongue you can have removed and with speech therapy you can get back on track.
The secret is keeping your tip. So we always try and maintain the tip of the tongue.
And so this patient can do remarkably well, you know, and function and have a
pretty normal life after having had this tongue cancer removed.

[198] [Case E]
[Dr. Kerr] And then finally we have a patient with a much more advanced
cancerous stage, stage IV cancer. Weve already seen a similar type patient.

[199] [Case E: before]
[Dr. Kerr] This is before.

[200] [Case E: after]
[Dr. Kerr] and this is after. So hes had his tongue cancer removed and he needed
to have a free flap so he actually had a flap that replaced the piece of his tongue
thats missing. Sometimes they will take that flap. It can either be a free flap or they
can actually move in tissue from other areas like pectoralis major flap and theyll
stick it up there. Nowadays they pretty much do mostly free flaps. And so they may
take something from his wrist or if they need a little bit more bulk, theyll take it
from other parts of the body and theyll pop it in there. And then hell get head and
neck radiation treatment.

[201] [Role of the dentist]
[Dr. Kerr] And possibly chemotherapy. So the role of the dentist, pre-treatment,
early detection, prevention. Thats your role as a dentist. Oral assessment, routine
oral care, oral hygiene and dietary counseling before treatment. When these
patients are going in to have cancer treatment you want their oral cavity to be as in
good of health as is possible. So if patients have got existing caries, theyve got
existing periodontal disease and theyre going to be getting radiation therapy down
the road, we dont want them to have complications long term. So sometimes the
dentist role is to clean them up and get them ready for that cancer therapy ASAP. So
I have patients that are referred to me to have an oral evaluation beforehand and
then during treatment, some dentist play a role, we have a study at the moment
where were doing oral care on patients who are going through radiation treatment
and develop some of the key complications of radiation and chemotherapy. Thats
particularly radiation therapy and they get terrible mucositis and youll learn more
about that next year as well. And then after treatment, once theyre through and its
successful then we play a role because there are a lot of long term complications in
these patient populations. And there are about a quarter of a million cancer
survivors that need dental care and its not just for oral cavity cancer, it could be for
any head and neck radiation patients or whove had other operations for laryngeal
cancer or other sub sites of pharynx or nasopharynx or, you know, other types of
cancers that have received head and neck radiation. And so these long term
complications, dry mouth because of irreversible damage to the salivary glands,
th
, 2014

32
difficulty opening their mouths because of damage to the muscles. And as a result, a
propensity for lots of different complications, dental caries, periodontal disease,
taste problems, you name it. These patients have a lot of oral complications. And
theyre difficult to restore. We have maxillofacial prosthodontists who can restore
patients whove had parts of their jaw removed and they can do that with implants
and there are lots of really clever things. Imagine losing, you know, your maxilla and
having that opening. Well they can create obturators that will block off the opening
into the nasopharynx. Surveillance, again, very important. You, as a dentist, can play
that role.

[202] [N/A]
[Dr. Kerr] Alright. And then in the bigger picture, you know, how many of you came
out to the oral cancer walk this year? Fantastic, fantastic. Well, next year, we also
give you the opportunity. Some of the students feel like I mandate it and of course I
dont, you know, in our own MPR course we have a community service component.
And so one of it is coming out to the oral cancer walk. You can, there are other
alternatives. You can take an online course but you know, its more fun and easier to
come out to the oral cancer walks. We love that you can come and join in and as a
result of this, the funds that we raise go towards cancer research and so did you
know that the funds that have been raised by the last nine years of the oral cancer
walk are the funds that allowed professor MoreyGillison(?) to identify the
relationship between HPV and oropharyngeal cancer. Now youre all hearing about
it now but it isnt that old, this break through in the field. And the early money that
was given to the oral cancer foundation funded some of her earlier research. So now
youre hearing about it but its your fellow students that their devotion to the course
led to a ground breaking, you know, opening in the research that is now affecting,
you know, thousands of people in the United States. So I want you to see what can
happen when you have a dream and you start a walk. And its not me; its you guys
who started the walk. Im merely the glue to make sure that everything sort of
comes together. But its the dedication of the students whove made this walk a
success. So, feel good about it.

[203] [N/A]
[Dr. Kerr] Weve got an Oral Cancer Center at NYU. Many of you didnt know that.
The NYU Oral Cancer Center. Dr. Brian Schmidt is the director. Were in the
Bluestone Center and we conduct research. We see patients and any of you want to
come by on a Wednesday morning to see us, delighted to have you.

[204] [N/A]
[Dr. Kerr] The Oral Cancer Foundation, a wonderful organization, non-for-profit
organization that has changed the lives for many cancer survivors and also
contributed to groundbreaking research.

[205] [N/A]
[Dr. Kerr] And finally, a little pitch to the American Academy of Oral Medicine. Im
an oral medicine expert and there arent many of us in the United States but our
th
, 2014

33
dedication is to, you know, mucosal diseases. If any of you are interested in learning
more about what is an oral medicine specialist or oral medicine expert, please come
and speak to me. Im really interested in hearing from you. Its a great field and a
great group of individuals. Alright, cheers.

11/12: DX and TX of Oral Cancer and Precancerous Lesions

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11/12: DX and TX of Oral Cancer and Precancerous Lesions

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Transcribed by Anam Khalid Friday, June 18

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