This document discusses oral squamous cell carcinoma (OSCC). It covers the epidemiology, risk factors, early detection methods, premalignant lesions, investigations, management including surgery and reconstruction, and treatment including radiation and chemotherapy. OSCC is the 6th most common cancer worldwide and the most common cancer in Indian men. Tobacco and alcohol are major risk factors. Detection methods include toluidine blue staining and tissue autofluorescence. Premalignant lesions include leukoplakia and erythroplakia. Management involves wide local excision and neck dissection, with reconstruction options like flaps and grafts. Radiation and chemotherapy may be used as adjuvant or palliative treatment.

2. • ETIOLOGY
• EARLY DETECTION
• PREMALIGNANT LESIONS
• INVESTIGATIONS
• MANAGEMENT

3. EPIDEMIOLOGY
• SIXTH MOST COMMON CANCER WORLDWIDE
• COMPRISES 30% OF ALL HEAD NECK CANCERS
• IN INDIA IT IS THE COMMONEST CANCER AMONG
MEN ACCOUNTING FOR NEARLY 40% CASES
• MEN MORE COMMONLY AFFECTED THAN WOMEN (4:1)
• MEAN AGE OF INCIDENCE 6TH TO 7TH DECADE (50-
70 YEARS)

4. RISK FACTORS
TOBACCO EXPOSURE
ALCOHOL CONSUMPTION
SYNERGISTIC EFFECT OF ALCOHOL & TOBACCO
ROLE OF HPV ?
GENETIC PREDISPOSITION

5. EARLY DETECTION
• CHEMOLUMINESCENT LIGHT(VIZYLITE)
• TOLUIDINE BLUE SUPRAVITAL STAINING
• ORAL CYTOLOGY
• TISSUE
AUTOFLUORESCENCE(VELSCOPE)

6. PRE MALIGNANT LESIONS
1> Lesions considered to carry a definite risk of malignant change:
a) Leucoplakia
b) Erythroplakia
c) Chronic hyperplastic candidiasis
2>Conditions not themselves premalignant but are associated with a higher than normal
incidence of oral cancer
a) Oral Submucosal fibrosis
b) Syphilitic glossitis
c) Sideropenic dysphagia
3>Oral conditions with doubt whether their association is casual or causal with oral cancers
a) Oral lichen planus
b) Discoid Lupus Erythematous
c) Dyskeratosis congenita

7. WHO has defined it as “any white patch or plaque the cannot be characterized clinically
or pathologically as any other disease”
CLINICAL FEATURES:
Types:
a. Homogenous
b. Speckled
c. Nodular
d. Verrucous
POTENTIAL FOR MALIGNANT CHANGE
Incidence between 3-6%

8. MANAGEMENT OF LEUCOPLAKIA
• Immediate stoppage of tobacco consumption
• Biopsies from suspicious areas( Ulceration, Induration , Bright red
& hyperemic underlying tissue)
• Severe epithelial dysplasia or CIS on Biopsy
- Surgical or CO2 laser excision followed by either primary closure
& spontaneous epithelisation or skin graft
• Mild to moderate dysplasia on Biopsy
• - Follow up at 3 monthly interval

10. ERYTHROPLAKIA
Defined by WHO as “ Any lesion of the oral mucosa that presents
as bright red velvety plaque that cannot be characterized
clinically or pathologically as any other recognizable condition “
17 fold higher incidence of malignant transformation
In every case there are areas of epithelial dysplasia, CIS or
invasive carcinoma.
All areas of erythroplakia must be completely excised surgically or
with CO2 laser & sent for HPE

12. CHRONIC HYPERPLASTIC
CANDIDIASIS
1. Dense chalky plaques of keratin , usually
thick & more opaque than leukoplakia
2. Common at the oral commissure with
extension onto adjacent skin of face
3. Surgical excision recommended for persistent
or recurrent lesion

14. INVESTIGATIONS
• USG
• CECT FROM BASE OF SKULL TO
CLAVICLE
• MRI
• PET CT SCAN??
• EUA

15. TISSUE DIAGNOSIS
1. Incision biopsy from the most suspicious areas of the
lesion with adjoining normal mucosa is usually
performed
2. Punch biopsy using a punch biopsy forceps may also be
done

16. OTHER INVESTIGATIONS
TRIPLE ENDOSCOPY :
a. Direct Laryngoscopy
b. Oesophagoscopy
c. Bronchoscopy
METASTATIC WORK UP
a. CXR
b. USG/CT scan
DENTAL EVALUATION

17. TREATMENT OF ORAL
CANCERS
1.Early Stage Disease ( Stage I & II i.e T1-2 , N0 ) is treated with
unimodality therapy ( Surgery or radiation ) though surgery is
the preferred choice.
2.Advanced disease is treated with multimodality therapy that
includes surgery and adjuvant radiation therapy and
neoadjuvant or adjuvant chemotherapy if indicated

18. SURGERY FOR PRIMARY
LESION
1. 3 –D WIDE EXCISION with atleast a 2 cm clear margin is
considered adequate for the primary tumor
2. Achievement of adequate wide margins may require en-bloc
resection of adjacent structures in the oral cavity e.g. mandible,
anterior tongue ; in floor of mouth cancers .
3. Marginal Mandibulectomy is usually adequate for tumors reaching
the periosteum but not breaching it.
4. Segmental Mandibulectomy for tumors breaching the periosteum

19. CARCINOMA ANGLE OF MOUTH
EXTENDING OVER BUCCAL MUCOSA
INVOLVING MANDIBLE

20. CARCINOMA CHEEK

21. MANDIBULECTOMY

22. SEGMENTAL
MANDIBULECTOMY
MARGINAL
MANDIBULECTOMY

23. SEGMENTAL
MANDIBULECTOMY
MARGINAL
MANDIBULECTOMY

24. CARCINOMA BUCCAL MUCOSA
INVOLVING MANDIBLE-SEGMENTAL
MANDIBULECTOMY

25. MARGINAL MANDIBULECTOMY

27. MANDIBULAR SWING

28. MANDIBULAR SWING

29. TUMOR ACCESSED AFTER
SWING

30. POST OP X RAY

31. ANOTHER CASE OF CARCINOMA
TONGUE

32. Tumor excised after
mandibular swing

33. SURGERY FOR CERVICAL
METASTASES
The type of neck dissection ( Radical , Modified or Selective ) is
defined according to pre-operative clinical staging
a. N0 : Selective( At least Level 1-3 : SOND) or MRND
b. N1 : MRND
c. N2a-b: MRND
d. N2c : Bilateral MRND
e. N3 :RND

34. RADICAL NECK DISSECTION
ONLY
CAROTID
REMAINS
WITH
VAGUS

35. MRND
CAROTID
JUGULAR

36. BILATERAL MODIFIED RADICAL
NECK DISSECTION

37. BILATERAL MODIFIED RADICAL
NECK DISSECTION

39. EXCISED SPECIMEN

40. SOHD
CAROTID
SAN
JUGULAR
SCM

41. RECONSTRUCTION
‘Thou shalt provide thyself with a lifeboat’
-Sir Harold Gillies

42. A patient with
reconstruction
A patient without
reconstruction

43. RECONSTRUCTION
Reconstruction following 3D WIDE EXCISION of the primary tumor has
many options:
 Free Tissue Transfer:
a. Free Radial Forearm Flap for mucosal defect & skin
b. Free ALT Flap
c. Free Osteoseptocutaneous ( Fibula ) Flap for segmental
mandibulectomy
 Pedicle Flaps :
a. PMMC flap for inner lining
b. DP flap for outer cover
c. Forehead flap
d. Platysma flap
 Local flaps
a. Tongue flap
b. Rhomboid flap
 Skin Grafts:
 Epithelisation or Primary closure

44. LOCAL FLAPS

45. CARCINOMA RETROMOLAR
TRIGONE RECONSTRUCTED WITH
TONGUE FLAP

46. CARCINOMA ANGLE OF MOUTH –
DOUBLE RHOMBOID FLAP

47. PEDICLE FLAPS

48. PECTORALIS MAJOR MYOCUTANEOUS
FLAP

49. THE INNER LINING AND THE OUTER COVER

50. EXTERNAL COVER –
THE DELTOPECTORAL FLAP

51. DELTOPECTORAL FLAP

52. PMMC & DP FLAP

53. PMMC FLAP

54. FREE FLAPS

55. FREE RADIAL
FOREARM FLAPS

56. CARCINOMA CHEEK INVOLVING
ANGLE OF MOUTH FREE RADIAL
FOREARM FLAP RECONSTRUCTION

59. CARCINOMA TONGUE

62. CARCINOMA OF BUCCAL
MUCOSA

63. CARCINOMA OF BUCCAL MUCOSA EXTENDING
TO FLOOR OF MOUTH

65. Synchronous growth at angle of mouth & buccal mucosa

67. LONG TERM FOLLOW UP OF
FREE RADIAL FOREARM FLAP

68. FREE FIBULA FLAP

69. CARCINOMA MANDIBLE MIDDLE 1/3RD
FREE FIBULA FLAP RECONSTRUCTION

72. CENTRAL THIRD GROWTH

73. DEFECT AFTER EXCISION

74. BEFORE MICROVASCULAR
ANASTOMOSIS

75. MICROVASCULAR ANASTOMOSIS

76. AFTER ANASTOMOSIS
SITE OF
ANASTOMOS
IS

77. FREE FIBULA RECONSTRUCTION

78. COMPLETED FREE FIBULA
RECONSTRUCTION

79. AFTER RECONSTRUCTION

80. FREE FIBULA FOR
CARCINOMA ALVEOLUS

81. AFTER RECONSTRUCTION

82. FOLLOW UP

84. HAPPY MEALS AFTER FREE
FIBULA RECONSTRUCTION

85. FREE FIBULA WITH & WITHOUT

86. MAXILLARY TUMOURS
RECONSTRUCTION

94. INTERIM OBTURATOR

95. A CASE OF ADVANCED
MAXILLARY TUMOR

96. DURING EXCISION

97. DEFECT AFTER EXCISION

98. FREE TRAM FLAP TAKEN FOR
RECONSTRUCTION

99. AFTER RECONSTRUCTION

100. MAXILLARY TUMOR WITH ORBITAL
PLATE INVOLVEMENT

101. INSERTION
TITANIUM PLATE
TEMPORALIS FASCIA
FLAP

102. PLATE COVERED WITH
FASCIA
FINAL
RECONSTRUCTION

103. CA MAXILLA

105. RECONSTRUCTION BY FREE
TRAM FLAP

106. ROLE OF RADIATION THERAPY
 EBRT or Brachytherapy can be used as the primary modality of therapy in stage
1 or 2 (T1 & T2 ) cancer but surgery is usually preferred
 Radiation therapy is usually give as adjuvant therapy in oral cancers & have
following indications:
a. Large Primary Tumor ( T3 or T4)
b. Primary tumor with close or positive margins
c. Evidence of Perineural or Vascular invasion
d. Depth of invasion >4mm
e. Nodal Metastases with evidence of `
extracapsular spread
f. Multiple positive nodes

107. CHEMOTHERAPY
1. NEOADJUVANT
2. ADJUVANT
3. PALLIATIVE

109. CA MANDIBLE MIDDLE 1/3RD

110. CA ANGLE OF MOUTH

111. CA BUCCAL MUCOSA

112. VENTRAL SURFACE OF TONGUE

113. CA LATERAL MARGIN OF
TONGUE

114. CA ALVEOLUS ( LOWER)

115. RECURRENT CA CHEEK

116. CA RIGHT MAXILLA

117. FUNCTIONAL NECK DISSECTION

118. MODIFIED RADICAL NECK DISSECTION TYPE 2 –
PRESERVATION OF THE SPINAL ACCESSORY NERVE

119. RADICAL NECK DISSECTION

120. BUCCAL MUCOSA PRIMARY WITH
SUPRA OMOHYOID NECK DISSECTION

121. ORAL CAVITY
It is the portion of the aero digestive tract from the vermillion border of the lips to
the junction of the hard & soft palate & the circumvallate papillae of the tongue.
This region anatomically includes
1.Lips
2.Buccal Mucosa
3.Upper & Lower Alveolus
4.Floor of mouth
5.Anterior 2/3rd of Tongue
6.Hard Palate
7.Retromolar trigone

122. HISTOLOGY OF ORAL CAVITY CANCERS
Squamous Cell Carcinoma represents the most common
histology type accounting for >96% of tumors
Malignant tumors arising in minor salivary glands are
next in frequency
Other rare tumors include
- Lymphomas
- Malignant melanomas
- Sarcomas
- Metastatic tumor

123. SYMPTOMS OF ORAL CANCER
Non healing ulcer with typical features of malignancy
(everted margins, Necrotic floor, Indurated base)
-Bleeding
-Exophytic growth or mass
Loosening of teeth
Pain (Involvement of nerve endings, Secondary Infections,
Referred e.g. Otalgia)
Halitosis, Drooling of saliva
Neck Swelling

124. PHYSICAL EXAMINATION
A> Examination of the Oral Cavity
B> Examination of the neck

125. RADIOLOGICAL STUDIES
1. CECT SCAN:
CT Scans from the skull base to the clavicles provide
detailed information on
a. Site & extent of the tumor
b. Bony involvement by the tumor, particularly cortical
breach
c. Detection of cervical lymph node metastases.

126. 2. MRI with contrast:
a. Investigation of choice for oral & oro-pharyngeal
cancers.
b. Though cortical breach is better shown on CT,
marrow infiltration is better detected by MRI
c. Soft tissue infiltration is better delineated by MRI
3. Ultrasonography:
Cervical US is very sensitive and specific at detecting enlarged
cervical lymph nodes & is the minimum examination to be done
for a clinically negative neck prior to surgery.
4. PET CT SCAN

127. TNM STAGING
T x - tumour cannot be assessed
T 0 - no evidence of tumour
T is - carcinoma in situ
T 1 - tumour 2cm or less
T 2 - tumour 2 – 4 cm
T 3 - tumour more than 4cm
T 4 (lip) – through cortical bone , inferior alveolar nerve, floor of mouth , skin of
face.
T 4a ( oral cavity ) – through cortical bone, extrinsic muscles of tongue ,
maxillary
sinus , skin.
T 4b – invades masticator space , or skull base or encases internal carotid artery

128. N STAGE & M STAGE
N x – cannot be assessed
N 0 – no node metastases
N 1 – single ; ipsilateral ; ≤ 3cm
N 2a – single ; ipsilateral ; >3 to ≤6cm
2b – multiple ; ipsilateral ; ≤6cm
2c - bilateral/contralateral ; ≤6cm
N 3 - > 6cm

130. LICHEN PLANUS