Tobacco and alcohol use are the main etiologic agents associated with the development of buccal carcinoma.

In Asia, betel nut is a significant etiologic agent, in addition to tobacco and alcohol. In India, over 90% of patients with buccal carcinoma have a history of using betel nut. Other suspected but not confirmed etiologic agents include: human papilloma virus, poor oral hygiene, and chronic irritation.

 It occurs more often in men, male:female ratio of 3-4:1 most commonly in the 7th or 8th decade of life. incidence of buccal carcinoma is much higher in Asia. In Southeast Asia, the disease is the most common form of oral cavity cancer. In India, buccal carcinoma is the most common cancer in men and the third most common cancer in women. widespread practice of betel nut chewing.

Betel nut, composed mainly of the fruit of the Areca Palm and often mixed with tobacco, is placed along the buccal mucosa to induce a feeling of euphoria. Buccal carcinoma related to betel nut chewing tends to develop at an earlier age, with most cases occurring between the ages of 40-70.

No symptoms in the early stage White or red lump in the mouth that does not go away after two weeks (Leukoplakia) A red, raised patch in the mouth that bleeds easily A lump or thickening in the mouth Pain increases when eating or drinking Soreness or a feeling that something is caught in the throat Difficulty chewing or swallowing Severe ear pain Difficulty moving the jaw or tongue Hoarseness Numbness of the tongue or other areas of the mouth Dentures fit poorly or become uncomfortable because the jaw is swollen

Buccal carcinoma commonly presents as a slowgrowing mass on the buccal mucosa. Small lesions tend to be asymptomatic and are often noted incidentally on dental examination. Pain commonly occurs as the lesion enlarges and ulceration develops. Oral intake may worsen the pain and lead to malnutrition and dehydration. Associated symptoms include bleeding, poor denture fit, facial weakness or sensory changes, dysphagia, odynophagia, and trismus.

A doctor will examine the inside of the mouth and back of the throat to check the location and size of the tumor. Examination of the ears, nose and neck are needed to help determine if the tumor has spread. CBC count,electrolytes, BUN and creatinine Prothrombin time (PT), Partial thromboplatin time Liver function test: used to increased for alcoholic liver damage Blood typing and cross matching X-rays to determine if the tumor has spread to the lung. Fine Needle Aspiration Biopsy (FNAB) Computerized tomography (CT) scan. Magnetic resonance imaging (MRI). Positron emission tomography (PET) scan.

ANATOMY & PHYSIOLOGY

1.Mouth (oral cavity, buccal cavity)

Histology: stratified squamous epithelium, except on gums, hard palate, tongue dorsum (these are keratinized); bound by lips anteriorly, cheeks laterally, palate superiorly, tongue inferiorly functions: ingestion: intake of food mechanical digestion: chewing of food chemical digestion: enzymatic breakdown of food
2. Teeth (will be covered in lab) grinding of food incisors blade shaped; function in clipping and cutting cuspids (canines) conical with sharp ridgeline and pointed tip; function in tearing and slashing bicuspids (premolars) 1-2 roots with flattened crowns and prominent ridges; function to crush, mash, and grind molars flattened crowns with prominent ridges with 3+ roots; function in crushing and grinding

3. Tongue - functions to manipulate food while chewing & swallowing 4. Salivary glands
types: (will be studied further in lab) parotid glands anterior to ear; between masseter muscle and skin; contain only serous glands (water secretion with little mucus) submandibular glands along the mandibular body; equal numbers of serous and mucus gland cells sublingual glands anterior to submandibular gland and under tongue; equal numbers of serous and mucus gland cells Saliva contents and their functions: mucus and water coating and putting food into solution salivary amylase digests complex carbohydrates antibacterial proteins lysozymes and defensins; inhibit bacterial growth

The American Joint Commission on Cancer defines the buccal mucosa as the membrane lining of the inner surface of the cheeks from the line of contact of the opposing lips anteriorly to the line of the pterygomandibular raphe (lateral to retromolar trigone) posteriorly. The medial boundary is the line of attachment of the buccal mucosa to the upper and lower alveolar ridges.

The layers of the cheek from medial to lateral include the mucosa, pharyngobasilar fascia, buccinator muscle, buccinator fat pad, subcutaneous tissue and skin. Sensory innervation of the buccal mucosa and cheek skin is from the maxillary and mandibular branches of the trigeminal nerve. The buccinator muscle is innervated by the facial nerve. The parotid duct (Stenson duct) pierces the buccinator muscle and buccal mucosa opposite the maxillary second molar.

The buccal region lacks anatomic barriers beyond the buccinator muscle and its fascia to prevent the spread of cancer. Buccal cancer can spread laterally to extend through the skin of the cheek; medially to involve the alveoli, palate, tongue, and floor of the mouth; posteriorly to involve the retromolar trigone mucosa, the ascending ramus of the mandible, and the masseter and pterygoid muscles; and anteriorly to involve the oral commissure and lips.

The primary-echelon lymphatics of the buccal mucosa drain to the facial and submandibular lymph node basins prior to the upper jugular nodes. The lymphatics may occasionally drain to the upper jugular nodes via the parotid nodes.

PATHOPHYSIOLOGY
PREDISPOSING FACTORS -age -gender -race PRECIPATING FACTORS -Smoking, -Chewing betel nut, -Alcoholism, -poor oral health -HPV and chronic irritation

Radiation therapy Indications for radiation or chemoradiation therapy in the postoperative setting include large or deeply invasive tumors, close or positive margins, multiple lymph nodes with metastatic cancer, lymph node extracapsular spread, or perineural invasion.

Chemotherapy The role of induction chemotherapy in the treatment of advanced stage head and neck squamous cell carcinoma is controversial and is often recommended for clinical trials. Chemotherapy may also be indicated in the palliative setting for recurrent or distantly metastatic disease.

CHEMOTHERAPY PROCEDURE
Once IVF inserted, please give pre medications and may start chemotherapy.
PRE-MEDS:
Diphenhydramine 50 mg Ranitidine 50 mg Dexamethasone 5mg

Gravisetron (Sancuso) 1 amp IV push

 Run the following as side drips:

1. Carboplatin 450mg in 250cc D5W x 30mins. 2. Docetaxel 100 mg in 250cc D5W x 1hr. then discontinue. Once docetaxel drip is consumed please request MROD to corporate Nimotuzumab 50 mg, 4 vials in 60 cc PNSS in soluset. Run soluset content (100ml) Gravisetron patch (Sancuso) attached.

PRN drugs: Hydrocortisone 100mg for allergic reaction. Give Neulastyl(Pegfilgastrim) 1 pre filled syringe SQ 24 hours after the end of nimotuzumab infusion. -CBC with WBC and platelet count monitoring was ordered. -Continue Erythropoietin 10,000 U SQ 3x a wk

DRUG

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTIONS

NURSING RESPONSIBILITIES

CARBOPLATIN (Naproplat) 450 mg Cytotoxic Chemotherapy

Carboplatin is secondgeneration platinum compound that may be classified as a nonclassical alkylating agent and is cell-cycle nonspecific. It is cytotoxic platinum complex that reacts with nucleophilic sites of DNA. This causes interstrand and interstrand cross links and DNA protein cross links, which inhibit DNA, RNA and protein synthesis.

Treatment of advanced ovarian cancer, smallcell lung cancer, head and neck cancer and in genito-urinary cancer, particularly in testicular, bladder and cervical cancers. Antitumor activity of carboplatin has also been observed in pediatric brain tumor (meduloblastoma).

Patients with a history of severe allergic reaction to cisplatin or other platinum containing compounds and patients with severe bone marrow depression or significant bleeding.

Hematologic Toxicity: Bone marrow suppression is the doselimiting toxicity of carboplatin. Thrombocytopenia, neutropenia, leucopenia, a higher incident of severe leucopenia and thrombocytopenia. Anemia, Bone marrow depression. Gastrointestinal Toxicity: Vomiting, Nausea, diarrhea, constipation. Neurologic Toxicity: Peripheral neuropathies with mild paresthesias, visual disturbances and change in taste occur rarely. Nephrotoxicity: Development of abnormal renal function test results is uncommon with carboplatin. Hepatic Toxicity: Abnormal liver function tests in patients may be found with normal value. Electrolyte Changes: The abnormally decreased serum electrolyte values may be found in some patients. Allergic Reactions: rash, urticaria, erythema, pruritus and rarely, bronchospasm and hypotension. Others: Pain and asthenia occurs most frequently. Alopecia, cardiovascular, respiratory , genitorurinary.

Carboplatin should be administered under the supervision of a qualifies physician experienced in the used of cancer chemotherapeutic agents. Appropriate management of therapy and complications is possible only when adequate diagnostic and treatment facilities are readily available. Ensure patients safety. Watch of for adverse reaction. Refer patient's tolerance to chemotherapy accordigly to the physician. Secure accuracy of drug dose and infusion.

DRUG

Docetaxel (Hentaxel) 80mg Cytotoxic Chemotherapy

MECHANISM OF ACTION Docetaxel is an antineoplastic agent belonging to paclitaxel family. It acts by disrupting the microtubular network in cells. Such action is essential for mitotic and interphase cellular functions. Docetaxel binds to free tubulin thereby resulting in the formation of stable microtubules and subsequently into microtubule bundles without normal function. This leads to the inhibition of mitosis in cells. Docetaxel's binding to microtubules does not alter the number of protofilaments in the bound microtubules, a characteristic not found in most spindle poisons currently in clinical use.

NURSING RESPONSIBILITIES Treatment of lcoally Patients who have a Marrow Suppression: Docetaxel for injection advanced or history of severe Neutropenia should be metastatic breast hypersensitivity Hypersensitivity Reactions: administered under cancer & non-small reactions to Severe hypersensitivity the supervision of a cell lung cancer, after docetaxel or to other reactions characterized by qualified physician failure of prior drugs formulated hypotension and/or experienced in the use chemotherapy. with polysorbate 80. bronchospasm, flushing, of antineoplastic Patients with erythema with or without agents. Because severe leukocyte counts of pruritus, chest stuffiness, back hypersensitivity <1500 cells/mm3 and pain, dyspnea, drug fever or reactions may occur, patients with severe chills.Fluid retention includes relevant first aid liver function edema, pleural effusion, facilities should be impairment. ascites, pericardial effusion, available. Main capillary permeability function index should increase and body weight be closely monitored gain. during infusion. GI symptoms include nausea, Ensure patient safety. vomiting and diarrhea. monitor vital signs Neurotoxicity frequently. Cardiovascular adverse Watch out for adverse reactions including reactions. hypotension, sinus Give pre-meds such as tachycardia, cardio palmus, anti allergic drugs to pulmonary edema and reduce possible hypertension may occur. adverse reaction. Other adverse reactions monitor patient's include alopecia, asthenia, status and refer to catarrh, arthritis, myalgia, physician hypotension and injection site accordingly.Check liver reaction. function test result before starting the course. INDICATION CONTRAINDICATION ADVERSE REACTIONS

DRUG Gravisetron (Sancuso) Antiemetic

MECHANISM OF ACTION Granisetron is a selective 5hydroxytryptamine3 (5HT3) receptor antagonist with little or no affinity for other serotonin receptors including 5-HT1, 5HT1A, 5-HT1B/C, 5-HT2; for 1-, 2-, or adrenoreceptors; for dopamine-D2; or for histamine-H1; benzodiazepine; picrotoxin or opioid receptors. Serotonin receptors of the 5-HT3 type are located peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone of the area postrema. During chemotherapy that induces vomiting, mucosal enterochromaffin cells release serotonin, which stimulates 5-HT3 receptors. This evokes vagal afferent discharge, inducing vomiting.

INDICATION Prevention of nausea and vomiting in patients receiving moderately and/or highly emetogenic chemotherapy regimens of up to 5 consecutive days duration.

CONTRAINDICATION

Known hypersensitivity to granisetron or to any of the components of Sancuso.

NURSING RESPONSIBILITIES Constipation, abdominal pain, Ensure patchs location. diarrhea, headache, arrythmias. Assess skin status on elevation of ALT and AST levels, patchs location. nausea and vomiting. Monitor patients Cardiovascular: Hypertension, hydration and hypotension, angina pectoris, Gastrointestinal status. atrial fibrillation and syncope Watch out for adverse have been observed rarely. reactions and refer Central Nervous System: accordingly to physician. Dizziness, insomnia, headache, anxiety, somnolence and asthenia. Hypersensitivity: Rare cases of hypersensitivity reactions, sometimes severe (eg, anaphylaxis, shortness of breath, hypotension, urticaria) have been reported. ADVERSE REACTIONS

DRUG Pegfilgrastim (neulastyl) 1 ampule Hematopoietic agent

MECHANISM OF INDICATION ACTION Hematopoietic growth Reduction in the factor. duration of neutropenia and the incidence of febrile neutropenia in patients treated with cytotoxic chemotherapy for malignancy (with the exception of chronic myeloid leukemia and myelodysplastic syndromes).

CONTRAINDICATION

ADVERSE REACTIONS Allergic-type reactions, including anaphylaxis, skin rash, urticaria, angioedema, dyspnoea and hypotension, occurring on initial or subsequent treatment have been reported both with pegfilgrastim and with the parent compound of pegfilgrastim, filgrastim. Isolated cases of splenic rupture have been reported during treatment with pegfilgrastim. Reversible, mild to moderate elevations in uric acid, alkaline phosphatase and lactate dehydrogenase, with no associated clinical effect. Very common: Musculoskeletal: Skeletal pain. Common: Application Site: Injection site pain. Body as a Whole: Chest pain (noncardiac), pain. CNS/PNS: Headache. Musculoskeletal: Arthralgia, myalgia and pain in the back, limb, musculoskeletal and neck.

Hypersensitivity to pegfilgrastim, filgrastim, E. coliderived proteins or to any excipients of Neulastyl.

NURSING RESPONSIBILITIES Before administration, pegfilgrastim solution should be inspected for visible particles. Only a solution that is clear and colourless should be injected. Excessive shaking may aggregate pegfilgrastim, rendering it biologically inactive. Monitor CBC levels especially WBC. Watch out for adverse reactions. Refer to physician accordingly.

DRUG

MECHANISM OF ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTIONS

NURSING RESPONSIBILITIES

Nimotuzumab Targeted Cancer Therapy

Antiepidermal Treatment of growth factor (EGF) glioma in adults receptor. and children. Nimotuzumab binds with intermediate affinity and high specificity to the extracellular domain of epidermal growth factor receptor (EGFR, HER1, c-Erb1). Nimotuzumab blocks the binding of the EGF and other ligands Nimotuzumab has a potent antiangiogenic, antiproliferative and pro-apoptotic effects, and also decreases motility, cell invasion and metastasis in those tumors that overexpress the EGFR.

Contrindicated to hypersensitivity to the drug and its component

Common adverse events with recommended dose reported following administration of nimotuzumab include chills, fatigue, headache, nausea, pyrexia, tremors and vomiting.

Monitor patients status frequently. Watch out for adverse reactions. Refer to physician accordingly.

Surgical Therapy
Surgery is the preferred treatment for early and advanced buccal carcinoma. Patients with advanced disease should receive postoperative radiation or chemoradiation. Surgical approach depends on the size of the tumor Metastatic neck disease (N+ disease) requires either a modified radical neck dissection or radical neck dissection depending on the extent of disease.

NURSING INTERVENTIONS
Instruct the patient to avoid exposing themselves to sunlight because of the harmful rays. Instruct patient refrain from smoking and consuming moderate to alcohol. Encourage good oral hygiene. Instruct patient to have oral check-ups to help detect the early signs of cancer. Encourage to eat nutritious foods and must these dietary guidelines include these seven basic recommendations:
Eat a variety of foods. Control your weight. Eat a low-fat, low-cholesterol diet. Eat plenty of vegetables, fruits, and grains. Eat sugar in moderation. Use salt in moderation. If you drink alcohol, do so in moderation; no more than two drinks per day of wine, beer, or spirits.