Oral Cancer

Incidence:
Oral cancer represents 3% of all cancers in males and 2% of all cancers in female.

Oncogenes:
They are cancer producing genes. They stimulate certain proteins "Kinases" that
stimulate the process of mitosis and neoplastic growth.

Antioncogenes:
They are cancers suppressor genes. They stimulate certain proteins "Cyclins" that
inhibit mitosis.

Carcinogeneic Factors:
1. Tobacco:
a. Smoked tobacco (cigar, cigarette, pipe, goza)
b. Smokless tobacco (Quid, snuff, chewing tobacco)
2. Actinic radiation:
Light – skinned individuals who sustain prolonged occupational exposure to
direct sunlight are at a greater risk of developing squamous cell carcinoma of
the lower lip. The condition is proceeded by actinic chellitis in which there is
hyperkeratosis, epithelial atrophy and dysplasia. The exposesd mucosal
surface appears mottled "red due to atrophy and white due to hyperkeratosis".
3. Infections:
a. Bacterial: Treponema pallidum (syphilitic mucous patches)
b. Fungi: Candida Albicans.
c. Viruses: HPV (human papilloma virus) – EPV (Ebstein Bar
virus) – HIV (Human Immunodeficiency)
4. Immunosuppression:
AIDS:- Oral Kaposi sarcoma and lymphoma in AIDS having patients are
much more common than squamous cell carcinoma.
5. Nutritional deficiencies:
Plummer-Vinson syndrome: Patients with chronic iron deficiency anaemia are
at a higher risk of developing oral and oesophageal cancer.
 6. Preexisting oral diseases:
a. Oral Submucous fibrosis.
b. Oral lichen planus: is still being debated.
7. Cofactors:
a. Alchol consumption.
b. Chronic irritation "ill-fitting dentures"
c. Liver cirrhosis.

Clinical Picture:
 The most common early presentation of intraoral squamous cell carcinoma:
are leukoplakia and erythroplakia.
 The more advanced lesion may appear as:
o Malignant ulcer → has indurated base, raised nodular averted edge
and necrotic floor.
o Malignant mass → hard – fixed.
o Ankyloglossia i.e fixation of the tongue due to infiltration of the
muscles of the floor of the mouth.
o Profuse salivation.
o Halitosis "bad oral smell".
o Pain referred to the ear along the chorda tympani.
o Haemorrhage from eroded lingual blood vessels.
o Difficulty in swallowing and articulation.
o Loosening or loss of the teeth due to invasion of the underlying bone
of the mandible or maxilla.
o Paraesthesia of the lower lip and tongue due to the infiltration of the
inferior alveolar nerve.
o Nasal obstruction and epistaxis.
o Diplopia → if the tumor infiltrates the extraocular muscles.
o Lymphadenopathy "clinically +ve neck" → enlarged, firm, fixed.

N:B
Tongue cancer patients should be examined for tongue mobility. The tongue when
protruded is deviated to the affected side due to infiltration of the ipsilatreal
hypoglossal nerve.
 Histopathology:
 Squamous cell carcinoma:
Is the most common malignant neoplasm of the oral cavity
representing approximately 90% of all oral cancers.

 It may be:

o Well differentiated: contain significant

amount of keratin, and the tissue resembles
normal stratified squamous epithelium. It has
the best prognosis.

o Moderately differentiated: contain little

keratin. The tissue still could be recognized as
stratified squamous epithelium.

o Poorly differentiated: Ther is no keratin with

lack of normal architecture and marked atypia.
It has worst prognosis.

Sites and incidence:

Site Relative incidence

Lower lip 35 %
Lateral tongue 25 %
Floor of the mouth 20 %
Soft palate 15 %
Gingival / alveolar ridge 4%
Buccal mucosa 1%

N.B.:
 Squamous cell carcinoma of the lower lip tends to be well differentiated. Those
that occur on the lateral border of the tongue are often moderately differentiated.
Those that occur on the posterior third of the tongue and tonsillar region tend to be
poorly differentiated.

Spread

A. Direct:
Tongue cancer of the anterior two thirds may spread to the gums or to the
floor of the mouth. Those of the posterior third may spread to the soft palate
and pharynx.

B. Lymphatic:
a. Lip Carcinoma → submental, submandibular and upper deep cervical
lymph nodes.
b. Tongue cancer metastasis:

o Lesions of the tip → submental, submandibular and jugular on both

sides.
o Lesions of the anterior two thirds → submandibular and jugular on
one side.
o Lesions of the anterior two thirds extended to within 1 cm of the
midline → Bilateral lymph nodes metastasis.
 o Lesions of the posterior thirds → metastasis to both jugular chains.

C. Haematogenous Spread:
Often to the lungs.

Clinical staging of head and neck cancer (TNM):

(T) "Primary Tumor"

T1 → Tumor size is less than 2 cm.
T2 → Tumor size 2 – 4 cm.
T3 → Tumor size 4 – 6 cm.
T4 → Tumor size is more than 6 cm.

(N) "Regional lymph nodes"

N0 → No palpable lymph nodes.
N1 → Palpable ipsilateral L.N
N2 → Palpable contralateral L.N. or bilateral L.M.
N3 → Large fixed L.N. "more than 6 cm in its greatest dimension.

(M) "Distant metastasis"

M0 → No distant metastasis.
M1 → Clinically or radiologic evidence of metastasis.

Stage ( I ) → T1 N0 M0
Stage ( II ) → T2 N0 M0
Stage ( III ) → T3 N0 M0
→ T1 T2 T3 N1 M0
Stage ( IV ) → T4
→ N2 N3
→ M1
 INVESTIGATIONS
• Biopsy
- incisional
- excisional
- aspiration
- true cut needle
- Frozen section
• Plain X-ray chest
• Abdominal sonography
• CT scan( lesion-chest-spine) to dedect
the local and the systemic extension
including the associated lymph nodes
• MRI

Treatment of Oral Cancer:

 Surgical excision.
 Radiotherapy.
 Chemotherapy.
 Combination.

A. Lower Lip Cancer:

Usually it is well differentiated and often diagnosed at an early stage, and can
usually be cured by local excision.
B. Carcinoma of the lateral border of the tongue or floor of the mouth:
Are usually moderately or poorly differentiated, diagnosed at a later stage and
quicker to metastasize. So, they need combined surgery, radiotherapy and
chemotherapy.

(1) Surgery:
 Local excision:
o The aim is to excise the lesion with 2 cm safety margin all
around.
o This may entail partial, hemi or total glossectomy.
o Indicated in early cases.
 Radical neck dissection:
o On one or both sides.
o Done even if the glands are not palpable as 30% of the
clinically no neck are pathologically +ve neck.
 Commando operation (combined mandibulectomy and neck
dissection):
o The aim of the commando operation is to remove the lesion
in continuity with the lymphatic drainage area.
o Indicated for advanced cases involving the tongue, floor of
the mouth, mandibular or cheek.
(2) Radiotherapy:
 Postoperative indications:
o No safety margin.
o More than one pathologically positive lymph node.
o Perinodal infiltration.
o Postoperative recurrence
 Preoperative indications:
- Large primary T4
o Alternative to excision in early cases.
o Tumours of the posterior third of the tongue..
o Inoperable cases.
(3) Chemotherapy:
 Preoperative "New adjuvant" → Down size and not down stage of
the tumor.
 Postoperative "Adjuvant" → Chemotherapy.