Oral cavity malignancy

Year 4 course 1

Professor Dr. Mohanned Alshalah

Learning objectives

To understand:
• The relationship between oral (pre)malignancy and the use of
alcohol and tobacco
• The cardinal features of premalignant and malignant lesions of the
oral cavity
• The investigation and treatment of these patients
 ANATOMY
The oral cavity extends from the skin–vermilion
border of the lips anteriorly to the junction of
the hard and soft palate superiorly and the line
of the circumvallate papillae on the junction of
the posterior one-third third and anterior two-
thirds of the tongue posteriorly.

It is divided into seven subsites: lips, alveolar

ridges, oral tongue, retromolar trigone, floor of
mouth, buccal mucosa, and hard palate.

Risk factors associated with cancer of the head and neck

●● Tobacco
●● Alcohol
●● Areca nut/pan masala

Poor nutrition
●● Inherited conditions (inc. Fanconi anaemia, Li-Fraumeni syndrome)
●● Human papillomavirus

Oral cancer predominantly effects people over the age of 65.

Conditions associated with malignant
transformation
High-risk lesions
●● Erythroplakia (homogenous or speckled)

●● Proliferative verrucous leucoplakia

●● Chronic hyperplastic candidiasis

Medium-risk lesions
●● Oral submucous fibrosis

●● Syphilitic glossitis

Low-risk/equivocal-risk lesions
●● Oral lichen planus

●● Discoid lupus erythematosus

●● Discoid keratosis congenita

Management of premalignant conditions

Elimination of associated aetiological factors is the initial basis of the

management of premalignant oral mucosal lesions.

A photographic record of the lesion is useful, particularly for long-term

follow-up.
All erythroplakia and speckled leucoplakia should undergo urgent
incisional biopsy, as many will represent either in-situ or early oral
cancer at presentation.
Severe epithelial dysplasia and carcinoma in situ should be
ablated by surgical excision where feasible.

Laser vaporisation can be employed

CLASSIFICATION AND STAGING

Staging of head and neck cancer is defined by the American

Joint Committee on Cancer (AJCC) and follows the TNM
system.
 Patterns of lymph node metastasis

The cervical lymph nodes are divided into

five principal levels.

SCC in the oral cavity and lips tends to

metastasise to lymph nodes at levels I, II.

Tumours arising in the oropharynx commonly metastasise to lymph

node levels II, III and IV, as well as retropharyngeal and contralateral
nodal groups.

Clinical features of oral cancer that warrent investigation

✓ Persistent oral swelling for >3 weeks
✓ Mouth ulceration for >3 weeks
✓ Sore tongue
✓ Difficulty swallowing
✓ Jaw or facial swelling
✓ Painless neck lump
✓ Unexplained tooth mobility
✓ Trismus
Ultrasound for the evaluation of undiagnosed neck lumps or presumed cervical
metastasis.

Used alongside fine-needle aspiration cytology (FNAC), ultrasound is capable of

delineating and sampling cervical lymphadenopathy and both thyroid and salivary
gland lesions/masses.

A tissue diagnosis, typically by way of incisional biopsy, is essential.

CT and MRI are both viable alternatives;
however, MRI suffers less degredation by
metallic dental restorations and provides
excellent visualisation of soft-tissue
infiltration of the tumour

CT is much more widely available than MRI. It is useful when bony

invasion is suspected.

The management of head and neck cancer necessitates a

multidisciplinary approach, integrating the combined skills and
capabilities of surgeons, oncologists, radiologists, pathologists
and allied health professionals to deliver an optimal treatment
strategy.
 In the work up : perform biopsy for definitive diagnosis
(punch or fine-needle aspiration);
examine under anesthesia (with direct laryngoscopy,
nasopharyngoscopy, rigid esophagoscopy, and
bronchoscopy)

LIP CANCER
Surgery and external beam
radiotherapy are highly effective
methods of treatment for lip
cancer.

The cure rate approaches 90%

for either modality.
Extensive tumours of the lower lip, which
invade adjacent tissues (T4), have a high
incidence of neck node metastasis.
Patients with such advanced disease require
surgery, which may include unilateral or
bilateral selective neck dissection and total
excision of the lower lip and chin, with or
without adjacent mandibular resection.

TONGUE CANCER
When performing surgical excision of the primary tumour, a 1cm margin
in all planes should be attempted in seeking a complete excision with
pathologically clear (>5mm) margins.
Partial or hemiglossectomy can be performed.

Advanced tumours (T3 and T4) often encroach upon the floor of
the mouth and, occasionally, the mandible.
In these circumstances a resection of the tongue and floor of the
mouth and mandible is required.

Ipsilateral selective neck dissections or contralateral selective

neck dissection will be dictated by radiological and clinical
findings.
 POST-TREATMENT MANAGEMENT
For most patients, in particular those who have received combined
modality treatment (surgery and (chemo)radiotherapy) medium to
long-term sequelae can have a significant impact on quality of life.

Speech and swallowing alteration is frequently encountered, as is

the complication of osteoradionecrosis, in up to 10% of patients
receiving adjuvant radiotherapy.

Surveillance for recurrence and, to a lesser extent, second primary

tumours is necessary.

Recurrence reaches it peak within the first 12–24 months post

treatment and therefore monitoring is most intensive in this period

The end