99年口腔黏膜健檢品質提升計畫
轉介個案處置與管理
陳信銘
DDS, MS, PhD
口腔顎面外科專科醫師
台大醫院牙科部口腔顎面外科主治醫師
台大牙醫學院口腔生物科學研究所助理教授
轉介個案處置與管理
•
•
•
•
•
•
待確診個案轉介醫療網（依個別區域分別
介紹）
口腔癌及其癌前病變處理流程
轉介常見或容易混淆之口腔癌及其癌前病
變
口腔癌癌前病變治療共識與原則
口腔癌治療共識與原則
轉介個案之管理
待確診個案轉介醫療網
口腔癌確認診斷及治療醫院名單
http://www.bhp.doh.gov.tw/BHPnet/Portal/Them_Show.aspx?Subject=200712250030&Class=0&No=200712250204
• 確診醫院條件 : 口腔顎面外科或耳鼻喉科
專科醫師一名及專任口腔病理科或病理專科醫
師一名
• 治療醫院條件 : 口腔顎面外科或耳鼻喉科專科
醫師、口腔病理科或病理專科醫師、整形外科
專科醫師、放射腫瘤科專科醫師、及腫瘤內科
專科醫師至少各一名
註：完整名單可至國民健康局網站癌症防治組查詢
口腔癌確認診斷及治療醫院名單(99.04)
確診治療
財團法人恩主公醫院
區域醫院
02-26723456
台北縣三峽鎮復興路三九九號
確診治療
財團法人徐元智先生醫藥基
金會附設亞東紀念醫院
區域醫院
02-29546200
台北縣板橋市南雅南路二段二一號
確診治療
財團法人天主教會耕莘醫院
區域醫院
02-22199509
台北縣新店市中山路三六二號
確診治療
財團法人佛教慈濟綜合醫院
臺北分院
新制優等
乙類教學醫院
02-6628-9779
台北縣新店市建國路二八九號
台北縣
確診
台北縣立醫院
地區醫院
02-29829111
台北縣三重市中山路2號
確診
行政院衛生署台北醫院
區域醫院
02-29927575
台北縣新莊市思賢里思源一二七號
確診
國泰綜合醫院汐止分院
新制合格
02-26482121
台北縣汐止市建成路59巷2號
確診
天主教耕莘醫院永和分院
地區醫院
02-29286060
台北縣永和市中興街80號
口腔癌確認診斷及治療醫院名單(99.04)
台北市
確診治療
國立台灣大學附設醫院
醫學中心
確診治療
行政院國軍退除役官兵輔
導委員會台北榮民總醫院
醫學中心
02-28712121
台北市石牌路二段二０一號
確診治療
三軍總醫院
醫學中心
02-23659055
台北市汀州路三段八號
確診治療
財團法人基督教臨安息日
會台安醫院
區域醫院
02-27813394
台北市八德路2段424號
確診治療
財團法人馬偕紀念醫院及
其淡水分院
醫學中心
02-25433535
台北市中山北路二段九二號
確診治療
財團法人國泰綜合醫院
醫學中心
02-27082121
台北市仁愛路四段二八０號
確診治療
財團法人振興復健中心
區域醫院
02-28264400
台北市北投區振興街45號
確診治療
財團法人新光吳火獅紀念
醫院
醫學中心
02-28332211
台北市士林區文昌路九五號
確診治療
財團法人私立台北醫學大
學附設醫院
區域醫院
02-27372181
台北市吳興街252號
確診治療
台北市立聯合忠孝院區
區域醫院
02-27861288
台北市南港區同德路八七號
確診治療
台北市立聯合中興院區
區域醫院
02-25523234
台北市大同區鄭州路一四五號
確診治療
台北市立聯合仁愛院區
區域醫院
02-27093600
台北市大安區仁愛路四段一０號
確診
台北市立聯合陽明院區
區域醫院
02-28353465
台北市士林區雨聲街一０五號
確診
台北市立聯合醫院婦幼院
區
區域醫院
02-23960728
台北市中正區福州街12號
確診
台北市立聯合和平院區
區域醫院
02-23889595
台北市中正區中華路2段33號
確診
台北市立萬芳醫院
區域醫院
02-29307930
台北市文山區興隆路3段21號
確診
國軍松山醫院
區域醫院
02-27648851
台北市松山區健康路一三一號
財團法人辜公亮基金會和
信治癌中心醫院
區域醫院
02-28970011
台北市北投區立德路一二五號
確診治療
02-23123456
台北市常德街1號
口腔癌及其癌前病變處理流程
口腔癌篩檢流程圖
口腔癌及其癌前病變篩檢
ABC
是
否
有可疑症狀
疑口腔檳榔病變
非口腔檳榔病變
疑陽性個案
轉介確診醫院
需切片
口腔癌及其癌前病變
陽性個案
不需切片
其它疾病
正常
治療建議
非口腔癌及其癌前病變
衛教
陰性個案
部份切除
進一步治療或觀察追蹤
完全切除
定期追蹤
定期追蹤
轉介常見或容易混淆之口腔癌
及其癌前病變
Outcome Following a Population Screening Programme for Oral
Cancer and Precancer in Japan
All adults over the age of 40 years resident in Tokoname city
19 056 subjects (5885 male, 13 171 female: mean age 60.7±11.3 years)
Oral mucosal lesions in 783 (4.1%) subjects
200 (25.5%) were referred
137 (68.5%) attended for follow up examination in hospital departments by specialists
39 subjects were confirmed as having oral cancer or precancer
(2 squamous cell carcinomas, 37 leukoplakias)
40 with lichen planus
Oral Oncology 36 (2000) 340-6.
Oral Oncology 36 (2000) 340-6
Outcome Following a Population Screening Programme for Oral
Cancer and Precancer in Japan
Oral Oncology 36 (2000) 340-6
Outcome Following a Population Screening Programme for Oral
Cancer and Precancer in Japan
Oral Oncology 36 (2000) 340-6
Outcome Following a Population Screening Programme for Oral
Cancer and Precancer in Japan
Oral Oncology 36 (2000) 340-6
口腔癌癌前病變治療
共識與原則
原則
Management of PMD
Treatment of Oral Potentially
Malignant Disorders
•
•
•
•
Wide excision of the lesion
CO2 laser surgery
Photodynamic therapy
Cryotherapy
Treatment of OSF
• Non-surgical treatment
– Corticosteroid
– Hyaluronidase
– Interferon-g
• Surgical treatment
– Graft
•
•
•
•
Split thickness skin graft (STSG)
Bucaal fat pad graft
Placental membrane
Xenograft (TerudermisTM)
– Flap
•
•
•
•
Nasolabial flap
Palatal island flap
Superficial Temporal fascia flap
Fore arm flap
– Coronoidectomy and myotomy
Treatment of Lichen Planus
• Submucous injection of Kenacort A
• Cryotherapy (Lichenoid leukoplakia)
口腔癌治療共識與原則
Staging
Regional Lymph Nodes (N)
2002 American Joint Committee on Cancer (AJCC)
TNM Staging System for the Lip and Oral Cavity
Primary Tumor (T)
TX
Primary tumor cannot be assessed
T0
No evidence of primary tumor
Tis
Carcinoma in situ
T1
Tumor 2 cm or less in greatest dimension
T2
Tumor more than 2 cm but not more than 4 cm
in greatest dimension
T3
Tumor more than 4 cm in greatest dimension
T4(lip)
Tumor invades through cortical bone, inferior
alveolar nerve, floor of mouth, or skin of face
(ie, chin or nose)
T4a
(oral cavity) Tumor invades adjacent
structures (eg, through cortical bone, into deep
[extrinsic] muscle of tongue [genioglossus,
hyoglossus, palatoglossus, and
styloglossus], maxillary sinus, skin of face)
T4b
Tumor invades masticator space, pterygoid
plates, or skull base and/or encases internal
carotid artery
*Note: Superficial erosion alone of bone/tooth socket by
gingival primary is not sufficient to classify as T4.
ST-1
NX
N0
N1
N2
N2a
N2b
N2c
N3
Regional nodes cannot be assessed
No regional lymph node metastasis
Metastasis in a single ipsilateral lymph node, 3
cm or less in greatest dimension
Metastasis in a single ipsilateral lymph node,
more than 3 cm but not more than 6 cm in
greatest dimension; or in multiple ipsilateral
lymph nodes, none more than 6 cm in
greatest dimension; or in bilateral or
contralateral lymph nodes, none more than 6
cm in greatest dimension
Metastasis in single ipsilateral lymph node
more than 3cm but not more than 6 cm in
greatest dimension
Metastasis in multiple ipsilateral lymph nodes,
none more than 6 cm in greatest dimension
Metastasis in bilateral or contralateral lymph
nodes, none more than 6 cm in greatest
dimension
Metastasis in a lymph node more than 6 cm in
greatest dimension
Distant Metastasis (M)
MX
Distant metastasis cannot be assessed
M0
No distant metastasis
M1
Distant metastasis
Staging
Stage Grouping
Stage 0
Tis N0 M0
Stage I
T1
N0 M0
Stage II
T2
N0 M0
Stage III
T3
N0 M0
T1
N1 M0
T2
N1 M0
T3
N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1
N2 M0
T2
N2 M0
T3
N2 M0
T4a N2 M0
Stage IVB AnyT N3 M0
T4b AnyN M0
Stage IVC AnyT AnyN M1
ST-2
Histologic Grade (G)
GXGrade cannot be
assessed
G1 Well differentiated
G2 Moderately
differentiated
G3 Poorly differentiated
Used with the permission of the American Joint Committee
on Cancer (AJCC), Chicago, Illinois. The original and primary
source for this information is the AJCC Cancer Staging
Manual, Sixth Edition (2002) published by Springer-Verlag
New York. (For more information, visit
(www.cancerstaging.net) Any citation or quotation of this
material must be credited to the AJCC as its primary source.
The inclusion of this information herein does not authorize
any reuse or further distribution without the expressed,
written permission of Springer-Verlag New York, Inc., on
behalf of theAJCC.
口腔癌的治療模式
第一期
第二期
第三期
第四期
早期口腔癌
晚期口腔癌
手術治療
手術治療
放射線治療
放射線治療
化學治療
標靶治療
Radiotherapy
Adjuvant Chemoradiation for Resected
High-Risk Disease
Concurrent Chemoradiotherapy for Unresectable Head
& Neck Cancer
Target Therapy for Head & Neck Cancer
Erbitux is a chimaeric monoclonal antibody (MAb)
specific for the EGFR.
Adapted from Bonner JA, et al. Radiotherapy plus cetuximab for squamous-cell
carcinoma of the head and neck. N Engl J Med. 2006;354:567-578.
Cetuximab
The Follow-up Strategy of Oral Cancer
• Physical examination:
– Year 1, every 1-3 mo
– Year 2, every 2-4 mo
– Year 3-5, every 4-6 mo
– >5 yr, every 6-12 mo
• Chest imaging
– Annually
– Or earlier if clinically indicated
• TSH every 6-12 mo, if neck irradiated.
轉介個案之管理
Annual Screening for Oral Cancer Detection:
Japanese Experience
Cancer Detect Prev 2003;27:333-7.
Annual Screening for Oral Cancer Detection:
Japanese Experience
Cancer Detect Prev 2003;27:333-7.
Annual Screening for Oral Cancer Detection:
Japanese Experience
The number of new oral cancers detected in the
program was too low to determine the optimal
frequency for oral cancer screening but new oral
lerkoplkias were found in annual re-screening:
the data indicate that the interval between two
screens for this population should not be greater
than 12 months.
Cancer Detect Prev 2003;27:333-7.
Annual Screening for Oral Cancer
Detection: Japanese Experience
• Compliance rates to re-attend were lower in the
youngest and oldest age groups.
• Females were also more likely to re-attend compared
with males.
Cancer Detect Prev 2003;27:333-7.
The Rate and the Time to Transformation in Patients with
Potentially Malignant Oral Epithelial Lesions
• The 1458 patients with histological diagnoses of various
premalignant oral lesions were followed up between
1991 and 2001.
• Within the cohort of 1458 patients, 44 patients
progressed to oral cancer in the same site as the initial
lesions with an overall transformation rate of 3.02% and
a mean follow-up time of 42.64 months.
J Oral Pathol Med 2007;36:25–9.
不同口腔癌前病變的惡性轉變率
•
•
•
•
Hyperkeratosis/epithelial hyperplasia (29.01%)
Submucous fibrosis (27.57%)
Verrucous hyperplasia (22.22%).
Epithelial dysplasia with hyperkeratosis/epithelial hyperplasia
(8.85%)
• Lichen planus (9.80%)
• Epithelial dysplasia with submucous fibrosis (2.54%)
J Oral Pathol Med 2007;36:25–9.
個案管理原則
• 建立高危險群資料庫
• 確立癌前病變回診再檢查模式
• 選擇適當回診時間