oral squamous cell carcinoma with definition staging and clinical features

1. Preethi Agnes.R
B.D.S 2012 Batch

2.  It is a Malignant neoplasm of stratified
squamous epithelium in the oral cavity
 capable of local destructive growth and
distant metastasis

5.  Possible sites
 lower lip
 tongue
 floor of the mouth
 soft palate
 gingival / alveolar ridge
 buccal mucosa

6. Incidence
lower lip
tonguefloor of
mouth
soft palate
gingiva
buccal mucosa

7. The etiology is unknown. But a
number of etiological factors have been
implicated.
Strong Association:
• Tobacco smoking and chewing
• Chronic alcohol consumption
• Human papilloma virus infection

9.  Major source of intra-oral carcinogen.
 All forms of tobacco consumption have been
linked.
 South east Asia: bethel quid– North Africa
and Middle East: a mixture of Tobacco and
lime water or oil called naswar or nash
 It could be held in the mouth
 Smoked in crude cigars or factory made
cigarettes
 Carcinogens in tobacco: Nitrosamine
(nicotine), the polycyclic aromatic
hydrocarbons (3,4-benzopyrene)

10.  2nd major risk factor
 Associated with cancer of the floor of the mouth
and tongue.
 Excess consumption of EVERY TYPE of
alcohol(including “hard” liquor, wine, and Beer)
raises the risk status of oral cancer
 Potentiates the effects of tobacco
 Mechanism(s)
 Dehydrating effects of alcohol on the mucosa
 increasing mucosal permeability,
 Irritation of mucosa
 and it also acts as a solvent for
carcinogens(especially those in tobacco)

12. Weak association:
 Chronic irritation from ill-fitting denture
 Sub mucosal fibrosis
 Poor orodental hygiene
 Nutritional deficiencies
 Exposure to sunlight(lip cancer)
 Plummer –Vinson syndrome

13.  NEOPLASIA:The process of transformation
from a normal cell to a cancerous one.
 An abnormality of cell growth and
multiplication characterised by:
 At cellular level
 Excessive cellular proliferation
 Uncoordinated growth
 Tissue infiltration
 At molecular level
 Disorder of growth regulatory genes

14. NEOPLASTIC (malignant) CELLS
Increase
in growth
factors
Increase
in growth
factor
receptors
Increase in
signal
transduction
Increase in
activation of
transcription
- Disturbed processes of mitosis and protein synthesis

15.  Continuous reproduction
 Formation of abnormal proteins
 ANAPLASIA:
 loss of normal cell function (abnormal DNA transcription)
 proliferation
 movement of cells
 invasion of nearby tissue
 metastasis
Caused by altered DNA and altered
cellular programs which make new
signals

16.  two general types
 Monoclonal
 initial neoplastic change affects a single cell
 Field origin
 carcinogen acts on large number of cells producing
field of potentially neoplastic cells

17.  growth factors
 receptors
 signal-relay or
transduction factors
ras - colon cancer
myc - lymphoma
bcr-abl - chronic
myelogenous leukemia
(Philladelphia chromosome)

18. - code for factors that down-
regulate the cell cycle, promote
differentiation and supress
oncogenes from causing cancer
Rb-1 – retinoblastoma gene
p53

19. NEOPLASIA proto-oncogene is activated or
tumor suppressor gene is inactivated
normal growth  oncogenesis
Activation of proto-oncogene:
point mutation
translocation
gene amplification
Also - Failure of Immune Surveillance theory :
immune system responds to neoantigens as to foreign
antigens, but neoplastic cells escape recognition and
destruction --> become clinical cancers

20.  Transmission of some forms of cancer from parents to
offspring through defects in the DNA of the egg or sperm cells
 E.g.  Retinoblastoma – tumor of the retina of the eye
Polyposis coli syndrome – polyps that grow in the
colon and
rectum
Other colon, breast and kidney cancers
 Cause: loss of a segment of DNA or a change in the coding
sequence of DNA
 Detection – DNA sequencing, DNA probes
 In many cases – abnormalities in tumor suppressor genes

22.  A sore in the mouth that does not heal (most
common symptom)
 Pain in the mouth
 A persistent lump or thickening in the cheek
 A persistent white or red patch on the
gums, tongue, tonsil, or lining of the mouth
 A sore throat or a feeling that something is
caught in the throat
 Increased salivation

23.  Difficulty chewing or swallowing
 Difficulty moving the jaw or tongue
 Swelling of the jaw that causes dentures to
fit poorly or become uncomfortable
 Loosening of the teeth or pain around the
teeth or jaw
 Voice changes
 A lump or mass in the neck
 Weight loss
 Persistent bad breath

24. Grossly, squamous cell carcinoma of
oral cavity may have the following types:
 Ulcerative type
 Papillary or verrucous type
 Nodular type
 Scirrhous type
All these types appear on a background of
leukoplakia or erythroplasia of the oral
mucosa.
Enlarged cervical lymph nodes may be
present.

25.  Increased mitotic activity
 Well differentiated
 Keratin pearls (abnormal keratinization)
 Hyperchromatic nuclei
 Pleomorphism
 Epithelium islands
 Connective tissue stroma with chronic
inflammation (histiocytes, lymphocytes, etc.)

26. Keratinized
cells
Mitotic
figures
Inflamed
connective
tissue
stroma

27.  Primary:
 Photographs
 Incisional biopsy
 Fine needle aspiration biopsy
 Orthopantogram
 Mucosal staining
 CXR
 chemiluminescent light
 Routine blood investigations
 For staging
 MRI
 CT face + neck ± CT chest
 USG of neck or primary ± USG guided FNAC of suspicious
lymphadenopathy
 PET
 Endoscopy

29.  Surgery
 Removal of part or all of the jaw
 Removal of the tumor on a larger area to remove the
tumor and surrounding healthy tissue
 Maxillectomy
 Removal of lymph nodes and other tissue in the neck
 Plastic surgery, including skin grafts, tissue flaps or
dental implants to restore tissues removed from the
mouth or neck
 Tracheotomy, or placing a hole in the windpipe, to
assist in breathing for patients with large tumors or
after surgical removal of the tumor
 Dental surgery to remove teeth or assist with
reconstruction

30.  Radiation Therapy
-used alone to treat small or early-stage
tumors.
 Proton Therapy
-delivers high radiation doses directly into the
tumor, sparing nearby healthy tissue and vital
organs.
 Chemotherapy
-used to shrink the cancer before surgery or
radiation
 Tumor Growth Factor Inhibitors
-target EGF receptors and may stop cancer
cells from growing.

31.  Mucositis ,an inflammation of the mucous
membranes in the mouth.
 Infection, pain, and bleeding
 Dehydration and malnutrition due to dysphagia
 Xerostomia due to injury to the glands that
produce saliva.
 Trismus due to damage to the muscles and joints
of the jaw and neck.
 Hypovascularization (reduction in blood vessels
and blood supply.
 Affect other forms of dental disease (caries, or
soft tissue complications),
 Cause bone death (osteonecrosis).

32.  Rehabilitation of patient after surgery could
be either surgical reconstruction, prosthetic
reconstruction or both
 This is aimed at restoring esthetics, function
and speech.
 All patients must be placed on life-long
review of about 6monthly intervals during
which risk factors should be continually
assessed.

35.  Prevention involves interventions aimed at
eliminating, eradicating or minimizing the
impact of the disease.
 PRIMARY: Reduce the incidence of cancer and
precancer. It is aimed reducing the number of
new cases.
 Discourage smoking and alcohol consumption
Encourage good oral hygiene
 Encourage balanced diet
 Use of hat in sunlight for farmers
 Wearing of facemasks for factory workers involved
with chemicals and metals
 Health education

36.  SECONDARY: aimed at detection of cancer
atan early stage.
 Early detection, especially at the
precancerous stage, offers a better prognosis
with a better chance of cure.
 Public education on early signs and self-
examination
 Screening
 TERTIARY: Treat late stage of disease and
complications