Oral malignant neoplasms &

premalignant lesion
of the lip and oral cavity

By The Great Professor :

Dr.Razy Al-Kontar
 I . Oral Malignant Neoplasm
Classification according to the tissue of
origin:
1- Squamous cell carcinoma
2- Lymphoepithelioma
3- Basal cell carcinoma
4- Malignant melanoma
5- Sarcomas
 High-risk sites for development of oral carcinoma. The shaded
U-shaped area accounts for only about 20% of the whole area of the
interior of the mouth but is the site of over 70% of oral cancers.
1- Squamous cell carcinoma
- Definition : A common epithelial malignancy of the oral
mucosa appearing as red , white , or ulcerated area. SCC is the
most common oral cancer.
- Etiology : While the cause of oral SCC is not known with
certainly , several risk factors have been identified : Tobacco ,
alcohol , viruses & sunlight .
1) Tobacco : Oral SCC occurs 5-10 times more commonly in
cigarette smokers. The risk of developing oral SCC 5-10
times in cigarette smokers than in non-smokers .
 2- Alcohol :
• Oral SCC is more common in heavy users of alcohol. It has been long
recognized that alcohol abuse & development of oral SCC are related .
• Here again , several studies have provided the basis for this linkage. . It is
postulated that excessive alcohol use dries the oral mucous membrane
somehow making it susceptible to cancer development . Like cigarette
smoking , the incidence of oral SCC declines with cessation of alcohol use.
It has been confirmed in later studies heavy alcohol use is the major risk
factor for development of oral SCC. Oral SCC is often found in those who
both smoke & drink.
• Cigarette & alcohol are , therefore , associated with the development of
most oral SCCs . It is a common observation that heavy alcohol users are
also heavy smokers. The two combined are a powerful risk factor for
development of this disease.
3- HPV & HSV may participate in oral SCC
formation : There has been considerable
interest in the role of the human papilloma
virus ( HPV) & the herpes simplex (HSV) in the
development of oral SCC. Serologic or E/M
studies of oral SCC has demonstrated the
presence of these viruses in some cases.
While it is doubtfull that these organisms
acting alone can initiate a cancer , they may
act along with other ( alcohol ? Cigarette
smoke ? ) to cause malignant transformation “
cocarcinogen”
4- Sunlight exposure is associated in development of lip
SCC : Exposure to actinic radiation is clearly associated
with development of cancer ( SCC) of the lip. That this cancer
affects the lower , not the upper , lip & occurs commonly in
those in outdoor occupations , lead to the observation
5- Syphilis : syphilitic leukoplakia developing late in the
syphilitic patients . This leukoplakia has high malignant
potential .
6- Aging : It has already been mentioned that the incidence of
oral SCC becomes more common with increasing age.
Clinical picture : old age , sex: male than female , Site :
generally affect all mouth areas equally .
 General location Specific location incidence

Tongue -Lateral surface 26%

-Ventral surface

Oral pharynx -Soft palate 23%

-Tonsillar pillars

Lip - Vermilion surface 20%

Floor of mouth - Floor of mouth 17%

Gingiva -Gingiva 9%

Buccal mucosa - Buccal mucosa 3%

Hard palate - Hard palate 2%

Characters :
- Oral SCC can be recognised by changes in color &
texture in the oral mucosa.
- Oral SCC arises in the epithelium of the oral
mucous membrane.
-The changes associated with the development of this
malignancy produce changes that can be seen by an
observant clinician.
- These changes include alterations in colour ,
texture , & shape of the oral mucous membrane.
- The appearance of oral SCC is variable.
-It is dependent on the stage in which it is discovered , how
aggressively the neoplasm behaves , & from what part of the
mucosa did it arise.
- Oral SCC often manifests as a painless , indurated ulcer :
-As will be seen later , once a cancer originating in the
mucosal epithelium invades the underlying C.T. ( lamina
propria) it is designated as being : invasive “ .
-In the remainder of that is a centimeter or larger in diameter
-The rolled & raised edges of the lesion surround a depressed
central region.
-The lesion is usually redder than the surrounding mucosa &
easily bleeded.
-Palpation reveals the lesion to be firm & “ fixed” to the
surrounding tissues , a property known as “ induration” .
The margins of ulcer is glazed , the floor is papillomatous
with foul odour.
- Red , white , or ulcerated lesions :
By the time oral SCC becomes a 1cm crated ulcer ,
invasion has surely occurred & the possibility of
metastasis is real.
The way to prevent this tragedy , of course , is to
discover oral SCC before invasion & metastasis occurs.
It turns out , that early changes manifest in a number of
different ways.
Some lesions are white , some are red & some are
speckled red & white.
Some are raised above the surface as smooth or
papillary or warty projections . And some are small non-
indurated ulcers.
Treatment : Surgery ; radical surgery may be
necessary . - may be treated by radiation with or without
surgery , - Chemotherapy : to control dissemination
Prognosis : The prognosis depends on it is stage when
treated
1- the size tumour T ,
2- whether lymph nodes are involved N
3- whether distant has occurred M
Staging is accomplished by the TNM systems ,in the
following table :
 TNM Definition Stage Prognosis
TIS , N0 , Mo Tis = No invasion 0 100%
T1 , N0 , Mo T1= less than 2cm in diameter I 64%
T2 , N0 , Mo T2= 2-4cm in diameter II 55%
T3, N0 ,M0 T3=greater than 4cm in diameter III 33%
T1 , N1 , M0
T2 , N1 , M0
T4 , N0 , M0 T4= greater than 4cm in diameter & IV 9%
Any T , N2-3 , M0 obvious invasion
Any T , any N , M1
 Complications
Treatment complications
Surgery -Incomplete removal
-Deformity
Radiation -Osteoradionecrosis
-Radiation caries
-Xerostomia
-Mucositis
-Candida
Squamous cell carcinoma of the lip :
• The lip is the most common site of oral cancer
Defintion : it is a malignant neoplasm arising from stratified squamous
epithelium
Clinically : age : middle & old age , sex : male more than female 2:1
Site : lower lip > upper lip ( 95% lower lip – 5% upper lip .
• Usually begin on the vermilion border to one side of the middle , it starts
as a small thickening , induration & ulceration covered with a crust , later ;
hard prominent mass , or crater like ulcer
• Crater like ulcer : Everted raised edges , Glazed margins , Papillomatous
floor , bleeding Foul odour , indurated base.
• Rate of growth & histopathology :
• Slow or rapid forming a large fungating mass. Most lip carcinomas are
grade : & II so : late metastasis to submental or submandibular L.N. ,
ipsilateral (same side ) or contrlateral
Advanced carcinoma of lip. There is extensive Squamous carcinoma of lip. There is an indurated,
ulceration and necrosis and distortion. Nowadays crusted ulcer with keratosis at one margin in the
such extensive lesions are unusual. centre of the lower lip.
Squamous carcinoma. Higher power shows strands of
malignant epithelium invading the connective tissue.

A small squamous carcinoma. At low

power the epithelium is seen to invade
deeply into the connective tissue and
underlying muscle. At this early stage
there is no ulceration.
Carcinoma of the tongue :
Malignant epithelial neoplasm of the tongue
• Etiology : Sepsis , spicy food , syphilis , Spirits ( alcohol) , smoking
• Clinical picture : Age : middle & old age , sex : male more than female ,
• Site : lateral border of the anterior part of tongue.
• Characters :
1) Exophytic or
2) Ulcer , which infiltrates the deep layers of the tongue , producing
fixation & induration , The ulcer has : irregular raised edges , glazed
margins , inflammed granulating floor , bleeding , foul odour , indurated
base due to infiltration of the surrounding by the tumour & to fibrosis.
• The tongue becomes stiff & more painful ( severe pain difficulty in eating ,
swallowing & talking ) as the growth is fixed & infiltrates the tongue .
Involvement of L.Ns is common.
• Hidden carcinoma of the tongue : Affect the posterior portion of the
tongue & are usually more malignant , metastasis early & offer a poor
prognosis.
 Signs of hidden Carcinoma of the tongue :
1- Slight deviation of the tongue to the affected side on protrusion ( Deviation ) due
to : a- restricted mobility of muscles ( tumour invasion )
b- paralysis of motor nerve
2- Slight defect in speech ( Defective speech )
3- Slight surface dimpling ( Dimpling ) , or other evidence of mucous membrane
retraction.
4- A minute ulcer at the most superficial point ( Defective surfaces )
5- Bleeding with a disagreeable fetid exudate ( Discharge )
6- Induration at the base ( Hardness )
Lymphatic drainage :
1- Tip of tongue – submental L.N.
2- Dorsum & sides of tongue – submandibular L.N.
3- Abnormal routes of cancer spread may occur
So all L.N of neck must be examined ( L.N become enlarged , hard & fixed )
Metastasis :
A- same side
B- bilateral
Local spread : Destruction of adjacent parts tongue becomes
fixed . Severe pain so swallowing & speech are difficult.
Cause of death :
1- Pain & infection cause difficulty in eating.
2- Aspiration of septic material from the mouth
( bronchopneumonia)
3- Haemorrhage
4- Metastasis to vital organs.
Histopathology : Poorly differentiated SCC Grade II & grade V

21
 Verrucous carcinoma. An extensive lesion covering most
of the buccal mucosa and starting to involve the skin at
the commissure. Such longstanding lesions are likely to
develop invasive squamous carcinoma and may then
metastasis.

Verrucous carcinoma. The epithelium is thickened and

thrown into a series of folds with a spiky parakeratotic
surface. Deeply the carcinoma retains a broad pushing front.
2-Transitional cell carcinoma or lymphoepithelioma :
- It is very malignant neoplasm.
- It runs a rapid clinical course , metastasize rapidly & widely & causes very early
death.
Clinical pictures : Age : old age , Sex : male more than female.
Site : the posterior part of the tongue , the tonsil or the nasopharynx & on the palate.
Characters : it may be
Very small hidden or slightly elevated or ulcerated . Sore throat , nasal obstruction ,
defective hearing or ear pain , headach , dysphagia & epistaxis. Metastasis to the
regional L.Ns occurs early before medical advice.
Histopathology :
sheets or cords & nests of : large round or polyhedral cells , with indistinct outlines
& large , round nuclei , variable degrees of mitotic activity.
The stroma is infiltrated by lymphocytes ( it is very radiosensitive).
Treatment : radiation.
Prognosis : poor because of early widespread metastasis & early recurrence.
Basal cell carcinoma ( Rodent ulcer ) :
It is a locally malignant epithelial neoplasm .It arises from the basal cells.
Aetiology : - Ultraviolet rays of sunlight - Commonly affect blond people
Clinical features : Age : middle & old age , Sex : more common in males , site :
exposed skin surface , scalp & middle third of face . It may reach oral mucosa as it
extends from the skin.
Characters : Small elevated papule which ulcerate & heals over. Break down again &
later on superficial ulcer with smooth rolled border . The lesion invades locally all
tissue so it can erode the skull & kill the patient.
Histopathology : Nests with indistinct cell membranes or islands of cells with large
deeply stained nuclei or sheets with some mitotic figures.
- The peripheral cells of each cell nests are well polarized cells that resemble basal
cells.
- There is no or little tendency to differentiate .
- No metastasis
- But as the basal cells are pluripotential cells which form hair , sebaceous glands
sweat gland. Multiple basal cell carcinoma of the skin are a feature of the jaw cyst ,
bifid rib , basal cell naevus , syndrome
4- Malignant melanoma
• It is the most deadly neoplasm , it arise from junctional nevus
Clinical features : Age : after 30 years of age , Sex : equal , Site : skin , eye ,
vaginal mucosa.
• Uncommon oral mucosa ( maxillary alveolar ridge & palate ) , cheek ,
tongue & floor of mouth.
Characters : It appears as enlarging pigmented area often surrounded by an
erythematous zone , frequently shows crusting , bleeding or ulceration .
• Oral lesion : appears as deeply pigmented area , often ulcerates & bleeds &
tend to increase in size..
• Metastasis are common to regional lymph node & to distant sites such as
liver & lung.
Histopathology : Closely packed cuboidal or fusiform cells arranged in an
alveolar pattern , reaching deep in the C.T. , mitotic activity & melanin
pigmentation.
Treatment : radical surgical resection.
27
Kaposi's sarcoma. Lesions are red, maroon or
bluish and highly vascular. They may be flat or
form tumour masses and the gingivae or palate
are characteristic sites.

Kaposi's sarcoma. The tumour is composed of

spindled and plump cells with cytological atypia and
frequent mitoses. Many of the small holes visible
are the result of formation of capillaries.
Non- invasive diseases preceding oral cancer :
General features of premalignancy & preinvasion :
- The first step in premalignant change is the development of dysplasia
( disorganisation of epithelial cells ) in oral cavity it is called mucosal
dysplasia
- In second step : malignant transformation has taken place stopping short of
invasion , this is called carcinoma in situ means malignant cells without
invasion
- the third lesion : benign keratosis .
There are several terms :
1- Benign keratosis
2- Mucosal dysplasia
3- Carcinoma in situ
4- Nicotine stomatitis
5- Actinic cheilosis
6- Oral submucous fibrosis
 Terms used concerning early oral SCC
Term Definition
Keratosis A lesion caused by increased keratin production
Erythroplakia A red patch
Leukoplakia A white patch ( usually keratotic
Orthokeratosis Normal keratosis
Hyperkeratosis Increased thickness of the stratum corneum
Parakeratosis Retension of nuclei in the stratum corneum
Dysplasia Cellular changes indicating anaplasia will follow
Anaplasia Cellular changes indicating malignancy
Invasion Spread of malignant cells into underlying C.T
MACRO- scopic (clinical) TERMS micro-scopic (histologic) TERMS

• macule • hyperkeratosis
• patch • parakeratosis
• papule • hypergranulosis
• nodule • acanthosis
• plaque • papillomatosis
• vesicle
• acantholysis
• bulla
• blister • spongiosis
• pustule • hydropic swelling (ballooning)
• wheal • exocytosis
• scale • erosion
• lichenification • ulceration
• excoriation • vacuolization
• onycholysis • lentiginous
Treatment : complete excision will cure mucosal dysplasia .
• Because it is impossible to diagnose mucosal dysplasia from
clinical examination , it is necessary to biopsy all lesions of
the oral mucosa.
 Homogeneous leukoplakia
Speckled leukoplakia

Red lesion
Ulcer lesion
SHOKRAN

Thank You