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CH 42
CH 42
NEOPLASMS OF THE
ORAL CAVITY AND
OROPHARYNX
Dennis H. Kraus, MD
John K. Joe, MD
ANATOMY
The oral cavity is defined as the region from the skin–vermilion
junction of the lips to the junction of the hard and soft palate
above and to the line of the circumvallate papillae below. The
oral cavity includes the lips, buccal mucosa, upper and lower
alveolar ridges, retromolar trigone, hard palate, floor of the
mouth, and anterior two-thirds of the tongue (oral tongue).
Regional lymph node groups in the neck are grouped into
various levels for ease of description. The lateral neck is
divided into levels I through V. Metastasis to regional lymph
nodes occurs in a predictable fashion through sequential
spread. Regional lymph nodes at highest risk for metastases
from primary squamous cell carcinomas of the oral cavity
include those at levels I, II, and III, collectively known as the
supraomohyoid triangle.
496
Neoplasms of the Oral Cavity and Oropharynx 497
PATHOLOGY
The risk of second primary tumors for squamous cell carci-
noma of the head and neck is approximately 4% annually, up
to 25% at 10 years.
The development of malignant tumors appears to be the
result of multiple accumulated genetic alterations. Genetic
alterations in the progression to carcinogenesis include acti-
vation of proto-oncogenes and the inactivation of tumor sup-
pressor genes. P53 is a tumor suppressor gene that plays an
important role in arresting cell growth in the presence of
genetic damage to permit deoxyribonucleic acid (DNA)
repair or lead to apoptosis. Mutations in and subsequent inac-
tivation of the P53 tumor suppressor gene may result in accu-
mulation of DNA damage and uncontrolled cellular growth.
It has been shown that the incidence of P53 mutations
increases throughout the progression from premalignant
lesions to invasive carcinomas.
Akin to the progression of genetic events leading to
phenotypic evidence of malignancy, various precancerous
lesions affect the oral cavity and oropharynx, with the poten-
tial for malignant degeneration. Leukoplakia is a clinical
descriptive term for a white patch in the oral cavity or phar-
ynx that does not rub off. The prevalence of premalignant or
malignant transformation is variable but has been estimated
at approximately 3.1%.
Erythroplasia appears as a red, slightly raised, granular
lesion in the oral cavity and oropharynx. In contrast to the
variable incidence of cancer in patients with leukoplakia, ery-
throplasia has a much higher correlation with concurrent or
subsequent malignancy.
Neoplasms of the Oral Cavity and Oropharynx 499
EVALUATION
The first step when evaluating a patient with cancer of the
oral cavity or oropharynx is a thorough history and compre-
hensive examination of the head and neck. The patient should
be asked about symptoms of dysphagia, odynophagia,
dysarthria, globus sensation, difficulty breathing, hemoptysis,
otalgia (possibly referred), weight loss, or other constitutional
symptoms and about consumption of tobacco and alcohol,
occupational exposures (including exposure to sunlight), and
previous radiation exposure.
There is no substitute for a systematic, comprehensive
examination of the neck, but imaging techniques such as
computed tomography (CT) or magnetic resonance imaging
(MRI) may provide valuable supplemental information
regarding the status of regional lymph nodes.
Pathologic confirmation by fine-needle aspiration biopsy
is critical for any suspicious neck mass.
Evaluation of the mandible for bony invasion by tumor
may be best accomplished by clinical examination, although
useful supplemental information may be provided by pano-
ramic films and DentaScan imaging.
Endoscopic examination of the upper aerodigestive tract
under anesthesia provides both thorough inspection of the
primary tumor and evaluation for second primary tumors,
with the ability to biopsy suspicious sites. The oropharynx,
hypopharynx, larynx, and esophagus should be examined in
a systematic fashion.
Neoplasms of the Oral Cavity and Oropharynx 501
TREATMENT