carcinoma oral cavity, premalignant lesions, neck node involvement

1. SPECIMEN: Oral cavity & Neck
UG BATCH- 2017
Date- 17/09/2021

2. Anatomy of oral cavity
Oral cavity
Vestibule
Oral cavity proper
*involvement of different subsets,
require different approach for
treatment

3. Blood supply
Facial Artery
Inferior Alveolar Artery
Maxillary Artery
Infraorbital Artery
Postero superior alveolar arteries

4. Anatomy of cervical lymph nodes

5. Anatomy of cervical lymph nodes

7. Oral & Oropharyngeal
cancers

8. Epidemiology
One of the common malignancy
 40% Indian subcontinent- highest rate in Sri Lanka,
India, Pakistan, Bangladesh
 4% Western countries
Most often involves:
 Tongue
 Tonsils & oropharynx
 Gums, floor & others (lips, minor salivary glands
etc.)

9. Epidemiology..
 Most common histology- SCC
 Twice as common in men
 Slightly more common in white people
 Usually occurs in 5th-6th decade, however 20%
cases occur in <50 years
 Overall rise in rate of new cancers over last 2
decades
 Rise in oropharyngeal cancers associated with
HPV

10. Epidemiology..
 Synchronicity:
 1.5%
 Oral cavity or aero-digestive tract
Metachronicity:
 10-40% in first 10 years after treatment
 Thus regular post treatment surveillance & life
style alteration- secondary prevention

11. Aetiology
Tobacco
 Chewing, smoking
 Carcinogen- polycyclic HC & nitrosamines
 Directly proportional effect to “pack years”
 Cessation can reduce risk, but does not fully abate
 Decrease in incidence of oral cancer in last 2
decades
Alcohol abuse
Both above risk factors are synergistic

12. Aetiology..
Poor oral hygiene
HPV infection
Wood dust exposure
Red meat intake & Salted meat consumption
HSV- suspected
Immune system alterations:
 transplant patients, HIV with AIDS
Genetic – XP, Fanconi anemia, ataxia
telengiectasia
Precancerous lesions*

13. Pathology
Squamous Cell Carcinoma- 90%
Other malignancies can arise from:
 Connective tissue
 Minor salivary glands
 Lymphoid tissue
 Melanocytes
 Epithelium

14. Pathology..
Premalignant lesions: morphologically altered
tissue in which cancer is more likely to occur,
than its apparently normal counterpart
Leukoplakia Oral submucous fibrosis
Erythroplakia Dyskeratosis congenita
Oral lichen planus Sideropenic dysphagia
Actinic keratosis & chelitis Syphilitic glossitis
Dyskeratosis follicularis Bowens disease

15. Leukoplakia
Greek word: “leucos” white and “plakia” patch
that cannot be scrapped/ stripped of easily &
characterized clinically or pathologically as any
other disease
Tobacco, alcohol, chronic irritation,
syphilis,nutrional deficiency, sun exposure &
idiopathic
Malignant transformation- 1%

16. Leukoplakia
Risk factors malignant transformation:
presence of dysplasia, female gender, long
duration of leukoplakia, location-
tongue(ventral/lateral), soft palate or floor of
mouth, > 2cm, and non-homogeneous type.
Lifestyle alteration: avoid tobacco and alcohol
use
Excision only definitive modality for accurate
diagnosis and treatment.
Chemoprevention

18. Erythroplakia
“Fiery red macule or patch” with a soft velvety
texture
Aetiology same as leukoplakia
Erythroplakia less common than leukoplakia
Higher risk of dysplasia or carcinoma
Surgical excision is recommended
Erythroplakia lesions are often found
alongside leukoplakia lesions

20. Oral Submucous Fibrosis
Appearance: “whitish mucosa lacking elasticity”
Leads to marked rigidity and trismus
Chronic progressive condition
Predominantly Asian decent
Diffuse involvement of the oral cavity, pharynx,
and upper esophagus
Use of the areca nut product disruption of the
extracellular matrix
Epithelial dysplasia- 7 to 26%
Malignant transformation- 7%

23. Clinical features
Late presentation : 5th-6th decade most
commonly
Men are twice as commonly involved
Usually painless to begin with,
 until ulcer, infected or invasion of local sensory
nerve fibres
Clinical presentation dependent on the
anatomical site

24. Clinical features..
Persistent oral swelling for
>4 weeks
Mouth ulceration for >4
weeks
Sore tongue Difficulty swallowing
Jaw or facial swelling Painless neck lump
Unexplained tooth
mobility
Trismus

25. Carcinoma Oral Tongue
Gross appearance:
Exophytic, ulcerative or submucosal masses
May be associated with pain/tenderness or
irritation during mastication
Most commonly SCC
Metastasis
Anterior- group I cervical LN
Posterior- group II & III

27. Carcinoma Lip
Lower lip (90-95%), upper lip (2-7%) &
commissures (1%)
Risk factors- sun exposure, smoking
SCC most common
 However, BCC- most common upper lip
Commonly seen as ulcerative lesion
Metastasis- group I LN

29. Carcinoma Floor Of Mouth
Anatomy
 Inner surface the mandible medially to the ventral
surface of the tongue & from anterior most
frenulum posteriorly to the anterior tonsillar
pillars
 The mucosa of the floor of the mouth contains
openings of the sublingual gland & submandibular
gland
 The muscular floor is composed of the
genioglossus, mylohyoid, and hyoglossus muscles,
with the lingual nerve located immediately
submucosally

31. Carcinoma Buccal Mucosa
Extends from the inner surface of the
opposing surfaces of the lips to the alveolar
ridges and pterygomandibular raphe
Uncommon-5% of all oral cavity ca
Metastasis- submandibular lymph nodes,
 Tumors in the posterior aspect of the cheek may
spread to level II initially

33. Carcinoma Of Palate
• Hard palate- medial to the maxillary alveolar
ridges & extends posterior to the edge of the
palatine bone.
• Necrotizing sialometaplasia is a benign, self-
limited process of the minor salivary glands
that has a predilection for the palate and can
clinically mimic malignancy
• Minor salivary gland tumors, along with SCC,
make up most hard palate tumors.

35. Investigation
Comprehensive clinical examination
 Head & Neck
 Inspection , palpation: extent , involovement of
surrounding structure, metastasis
Definitive diagnosis- biopsy*
 Some may require EUA
FNAC of enlarged LN*

36. Investigation..
Imaging:
 Plain X ray jaw- limited value
 Orthopantomogram
 CT scan- study of choice
 Bones, LNs
 MRI – complementaryinformation
 Soft tissues, perineural invasion, medullary
involvement
 PET scan- no role in diagnosis, useful for follow up

37. Staging

38. Treatment
Multidisciplinary team (MDT)
 essential for favorable outcome
Surgical resection
 Mainstay
 Status of margin,histopathology
Stage I-II
 Primary treatment-
 surgical resection (radical)- preferred
 or definitive radiotherapy- surgically unfit , early lip,
retromolar trigone, soft palate cancers

39. Treatment..
Stage III-IVB
 Surgical excision should be considered - locally
advanced; resectable
 Alternate options:
 definitive radiation therapy
 concurrent chemoradiation: current standard
of care for patients with locally advanced
squamous cell carcinoma of the head & neck

40. Treatment..
Complete resection of the tumor- negative
margins confirmed by frozen section
histopathology is the goal
Positive margins are associated with
increased recurrence and decreased survival
rates.
Metastatic neck disease (N+ disease)
requires either a modified radical neck
dissection or a radical neck dissection,
depending on the extent of disease.

41. Treatment of Cancer Lip
Lesion <2 cm- curative radiotherapy
 Brachytherapy or external beam radiotherapy
 Good cure
 Lesion > 2 cm- wide excision
 Excision of lower lip up to one-third can be
sutured primarily
 Excision of more than one-third of the lip requires
reconstruction

42. Treatment of Cancer Lip..
Extensive tumours of the lower lip, invading
adjacent tissues (T4), have a high incidence of
neck node metastasis
 require surgery that may include unilateral or
bilateral selective neck dissection and total
excision of the lower lip and chin followed by
reconstructive surgery

43. Treatment of CA Tongue
Lesion <2cm- wide excision
Lesion >2cm- hemiglossectomy
Larger primary tumour- can be given
neoadjuvant RT, then later hemiglossectomy
Same side palpable, mobile lymph nodes are
removed by radical neck dissection.
Reconstructive efforts should focus on
maintaining tongue mobility without excess
bulk
 Thin, pliable fasciocutaneous flaps used

44. Treatment of CA Buccal mucosa
Both early & advanced- Surgery is preferred
Advanced disease- neoadjuvant/ adjuvant
Small lesions- transoral WLE, advanced
lesions- may require flaps for reconstruction
Composite resection- for mandibular invasion,
while partial maxillectomy is used for superior
alveolar ridge invasion.

45. Treatment of CA Floor of Mouth
• Small lesions- WLE with primary closure, skin
grafting
• Larger lesions- post excision, reconstruction

46. Neck Dissections
• Radical Neck Dissection
• Modified Radical Neck Dissection
• Selective Neck Dissection

47. THANK YOU