Premalignant and malignant lesions of oral cavity and their management

1. PREMALIGNANT AND
MALIGNANT LESIONS OF ORAL
CAVITY
- - Dr. Alka Kapil
Clinical evaluation of

2. Leukoplakia
 Potentially malignant white patch that cannot be rubbed
off and cannot be characterized clinically or pathologically
as any other disease or lesion.
 Associated with tobacco ,smoking, alcohol, can be idiopathic.
 4th decade , M>F.
 MC premalignant condition of oral cavity.
 Buccal mucosa & oral commissures mc sites.
 C/f : painless whitish lesion in oral mucosa.
 
Pain or itching at the site of a leukoplakia is an ominous sign
and may indicate the presence of a squamous cell carcinoma
(6%).

3.  Paradoxically, an increased risk of malignant transformation
of leukoplakic lesions is seen more commonly in nonsmokers
 Types : homogenous, non homogenous (nodular/speckled and
verrucous)
 molecular techniques for r/m/t include detection of suprabasal
expression of the tumor suppressor gene p53, loss of
heterozygosity, DNA ploidy analysis, expression of podoplanin
and cytokeratin, and the presence of high-risk HPV types
 Management includes
I. close followup or
II. biopsy/ excision of leukoplakic patch and
III. cessation of smoking & alcohol.

4. Erythroplakia
 Red mucosal patch that doesnot arise from any obvious mechanical cause
and persists after removal of possible etiologic factors.
 50-70 , M=F
 asymptomatic, red patch of varied size and smooth or granular surface that
may be flat or slightly elevated , small white spots or macules can be
observed inside the lesion.
 The most commonly affected sites are the buccal mucosa, floor of the
mouth, palate, retromolar area and rarely tongue.
 risk for progression to carcinoma is significantly greater than for
leukoplakic lesions ,17 times of leukoplakia (90% of erythroplakia)

5. Erythroleukoplakia
Erythroplakia

6.  Management :
I. excision and close followup and
II. cessation of smoking & alcohol

7. Lichen planus
 It is a multifactorial disorder which typically presents bilaterally
with hyperkeratotic lesions comprising striae, nodules and
plaques. Below the keratinised, atrophic superficial epithelial
layers are acanthosis and aT cell infiltrate.
 female , 4th decade of life.
 Lacy pattern of white striae (wickhams striae)
 Atrophic lesions are red and smooth, whereas erosive lesions
have depressed margins and are covered by a layer of fibrinous
exudate
 Increased sensitivity to hot or spicy food & roughness in lining of
mouth
 Erosive variety of lichen planus is very painful
 Associated with skin lichen planus on flexor aspect of wrists,
forearm & thigh

8. Reticular type
Erosive type
• Described as 5
P’s –purple,
pruritic , planar ,
polygonal ,
papules
• Treatment -
steroids

9. Oral
submucous
fibrosis (OSMF)
 Premalignant disorder characterized by inflammation & progressive
fibrosis of submucosal tissue ( lamina propria & deeper connective tissue )
 Associated with betel nuts chewing or chronic exposure to arecoline
present in betel nuts
 C/f : intense burning sensation and development of vesicles & superficial
ulceration, can be accompanied by sialorrhea or xerostomia ;oral mucosa
becomes smooth, atrophic, and inelastic ;replaced with stiff fibrous tissue.
 Advance stage – Oral mucosa loses its resiliency & blanched & stiff ,
inability to open mouth.

10. Pathogenesis

12. Stages of OSMF : stomatitis n vesiculations (I) ,
fibrosis (II),
sequelae n complications(III)

13.  Medical treatment :
I. Early stage - cessation of chewing betel nuts
II. Steroids – Intralesional injection with hyaluronidase
Dexamethasone 4 mg (1 mL) combined with hylase, 1500 IU in 1 mL
is injected into the affected area biweekly for 8-10 weeks
III. Placental extract – anti inflammatory effect
IV. Antioxidants and multivitamins

14. Surgical treatment ofOSMF
 Simple release of fibrosis and skin grafting. There is high recurrence
rate due to graft contracture.
 Bilateral tongue flaps. Requires flap division at a second stage.
 Island palatal mucoperiosteal flap. It is based on greater palatine artery.
Possible only in selected cases. Requires extraction of second molar for
the flap to sit without tension. Not suitable for bilateral cases.
 Bilateral radial forearm free flap. It is bulky and hair bearing. May
require debulking procedure, third molar may require extraction.
 Superficial temporal fascia flap
 and split-skin graft

15. Coronoidectomy
Fibrotomy

16. Tongue flap
(a) Tongue flap incision. (b) Tongue flap raised

17. Nasolabial flaps. They are small to cover the defect
completely, cause facial scar and require division of flaps at
second stage.

18. Temporal flap
(a) Superficial temporal flap raised (b) Position intraoral

19. (a) Split skin harvesting. (b) Split skin graft. (c) Sutured onto
defect

20. Surgical excision and buccal fat pad graft

21. Aetiology
 Smoking
 Tobacco
 Alcohol ( spirits)
 Dietary deficiencies- PlummerVinson Syndrome
 Sun
 Sepsis
 Sharp teeth
 Syphilitic glossitis
7-S
Oral cancers

22. Lymphaticdrainage of oral cavity
Submental ( I )
upper deep cervical ( III )
preauricular
infraparotid
Submandibular
( II )

23. Sites of oral cancers

28. Investigations
1. Tissue biopsy
Incisional & excisional biopsy
Management 0f Carcinoma Lip , Oral tongue , buccal mucosa & floor of mouth

29. 2.mmmm
CECT/ MRI /Fluorodeoxyglucose (FDG) PET/CT
2.Radiolagical imaging
CECT oral cavity
T2w MRI oral cavity

30. TNM
Staging of
OralCancers
Mx M0 M1

31. 

32. A.T1 ,T2 :
i) Excision & repair
ii) Radiotherapy – Early tumors do well , radiotherapy can be
Bracthytherapy (i.e implantation of radioactive sources most
commonly iridium within tumor ) or external beam which is usually
intensity modulated radiotherapy (IMRT)
iii) Brachytherapy delivers radiation dose mainly to tumors sparing
normal tissue
ABBE FLAP – based on the main artery of the orbicularis oris, the labial
artery , a portion of the uninvolved lip is rotated across the mouth &
placed into the surgical defect of the involved lip while maintaining the
blood supply from the labial artery
After 10-14 days , the blood supply of the flap would have been
established to the point where artery could be divided
The defect of the uninvolved lip from which the flap has been taken is
sutured primarily

33. Abbe-Estlander flap
fora leftlower-lip
resectionthat extended
to the oralcommissure

34. Gillies fan flap borrow tissue from the cheek & Adjacent sites –
 Tumors of lateral border of tongue which are less than 2 cm , i.eT1
interstitial irradiation ( brachytherapy ) or excision i.e partial
glossectomy is the choice .
 IfTumor is more than 2 cm in size i.eT2 then Hemiglossectomy or
external beam radiotherapy (IMRT) is preferred

35. Karapandzicfanflapfor
midline lower-lip defect

36.  B.T3,T4 : Excision + ipsilateral / contralateral neck dissection +
radiotherapy +/- chemotherapy
2 . Carcinoma Base of tongue
T1,T2 ,T3.T4 : Concurrent chemoradiation

37. 3. Carcinoma lower gingiv0-bucc0alveolus-
Radiation to the mandible carries risk osteoradionecrosis ,
carcinoma lower alveolus /gingivo buccal is dealt surgically in all
stages
Surgical excision can be
A. Rim resection /marginal mandibulectomy
B. Segmental resection of the mandible
 Marginal mandibulectomy – involves excising a rim of mandible
but with maintenance of the mandible arch .These defects should
be made in a curvilinear manner , & at least 1cm of mandibular
height should be retained
 ADVANTAGE of the rim /marginal mandibulectomy is that it
encompasses only a rim or margin of mandible (from inner/outer
surface or upper/lower border) while leaving the mandibular arch
intact largely

38. Indications of rim/marginal resection of the mandible are
i) Tumour involving mucosa of the mandible
ii) Tumour involving mandibular periosteum
iii) Tumour involving mandibular periosteum & superficial
cortex only

39.  Segmental mandibulectomy – involves resection of a full
thickness segment of the bone , which creates a discontinuity
defect . Lack of reconstruction causes significant functional &
cosmetic morbidity
 Indications for segmental (a portion of mandible with periosteum
on both its inner & outer surfaces )resection of mandibles are –
i) Invasion of the medullary space of the mandible
ii) Tumour fixation to the occlusal surface (i.e the surface which
comes in contact with the maxilla during mouth closure ) of the
mandible in the edentulous patient (edentulous mandible is
generally hypoplastic i.e vertical height of the mandible is
decreased making rim resection difficult
iii) Invasion of tumour into the mandible via the mandibular or
mental foramen
Andy grump deformity
Ant. mandibular arch

40.  COM MA ND O ( COMbined Mandibulectomy & Neck Dissection with
Oropharyngeal resection ) operation :
radical resection of the tumour in the oral cavity /oropharyngx with
mandibulectomy (marginal/segmental/hemi) & neck dissection
 This done for T3 ,T4 tumour of the oral cavity /oropharynx involving the
mandible

41. SPOT
DIAGNOSIS
A
B
C

42. D E F