Neoplasms of the oral cavity by Dr. Krishna Koirala

1. Neoplasms of the oral
cavity
Dr. Krishna Koirala
2019-01-28

2. Subsites of the oral cavity
• Lips
• Buccal mucosa
• Retromolar trigone
• Gingiva
• Hard palate
• Anterior two-thirds of
the tongue
• Floor of mouth

3. Benign neoplasms
• Fibroma
• Papilloma
• Peripheral giant cell granuloma
• Pyogenic granuloma
• Lipoma
• Hemangioma
• Lymphangioma

4. Malignant neoplasms
• Squamous cell carcinoma (90%)
• Verrucous carcinoma
• Minor salivary gland tumors (5%)
• Melanoma
• Lymphoma
• Sarcoma
2-5%

5. Risk factors
• Tobacco : Smoking , Chewing tobacco (>90% )
• Alcohol
• Diet and nutrition :
– Deficiencies of vit A, C, E, Iron, selenium, folate
• Viruses: HPV, EBV,HSV (role unclear )
• Oral hygiene : Poor oral hygiene, ill fitting dentures
• Premalignant conditions : Leukoplakia, erythroplakia
• Others : sepsis, spices, sharp tooth

6. Clinical presentation
• A red lesion ,white or mixed white and red lesion
• An ulcer with fissuring or raised exophytic margins
• An indurated lump (firm infiltration beneath the mucosa)
• A nonhealing extraction socket
• A lesion fixed to deeper tissues or to overlying skin or
mucosa
• Cervical lymph node enlargement (infection, reactive
hyperplasia 20 to tumor , or metastatic disease)

9. Screening of oral cancer
• The VELscope device
– The VELscope Hand piece emits a safe blue light
into the oral cavity, which excites the tissue from
the surface of the epithelium to the basement
membrane and into the stroma causing it to
fluoresce
– The clinician is then able to immediately view the
different fluorescence responses to help
differentiate between normal and abnormal tissue

10. • Healthy tissue appears as a bright apple-green glow
• Suspicious regions are identified by a loss of fluorescence,
which thus appear dark

11. OraScan, OraScreen , ‘OraTest’
• Tolonium chloride or toluidine blue (TB) is an acidophilic
metachromatic dye of the thiazine group that
preferentially stains nucleic acids and abnormal tissues
• Increased nuclear density and loss of intracellular
adherence in dysplastic and malignant tissues allows TB
dye to penetrate through the epithelium and be retained
in these tissues, thereby staining these areas of
abnormality as blue

12. Chemiluminescent illumination positivity

13. Toluidine blue positivity

14. Investigations
• Incisional biopsy
– Essential to confirm the diagnosis
– Performed on any oral mucosal lesion suggestive of
cancer /ulcer that does not heal within 2-3 weeks
– In vivo staining with toluidine blue followed by a
rinse with 1% acetic acid and then saline may stain
the areas most appropriate for the biopsy if
widespread lesions are present

15. Imaging studies
• B wave USG : Helpful in assessing the depth of
invasion in oral tongue
• MRI : Imaging mode of choice for soft tissue lesions
of oral cavity
• CT scan : Bone invasion
• Orthopantomogram (OPG) : To assess the state of
dentition and potential gross mandibular invasion
• Technetium Bone scan : mandibular invasion

16. CT scan of mandible

17. UICC/AJCC Staging system for oral cancer (2018)
8th ed
• Primary Tumor (T)
– T1 : Tumor 2 cm or less in greatest dimension, DOI ≤5mm
– T2 : Tumor >2 cm but < 4 cm and DOI ≤10mm or tumor ≤2
cm and DOI >5 mm≤10mm
– T3 : Tumor more than 4 cm in greatest dimension or tumor
of any size and DOI >10mm
– T4a : Locally advanced tumor
– T4b : Very advanced tumor

18. • T staging for oral cancers.
• T1 Tumor ≤2cm DOI ≤5mm
• T2 Tumor >2cm but ≤4 cm-and DOI ≤10mm or
tumor ≤2 cm-and DOI >5 mm≤10mm
• T3 Tumor >4cm or tumor of any size and DOI
>10mm

19. • Regional Lymph Nodes (N)
– NX : Regional lymph nodes cannot be assessed
– N0 : No regional lymph node metastasis
– N1 : Metastasis in a single ipsilateral lymph
node , 3 cm or less in greatest dimension

20. • N2:
– N2a : Metastasis in single ipsilateral lymph node more
than 3 cm but not more than 6 cm in greatest dimension
– N2b : Metastasis in multiple ipsilateral lymph nodes, none
more than 6 cm in greatest dimension
– N2c : Metastasis in bilateral or contralateral lymph nodes,
none more than 6 cm in greatest dimension
• N3 : Metastasis in a lymph node more than 6 cm in greatest
dimension

21. • Distant Metastasis (M)
– MX : Presence of distant metastasis cannot be
assessed
– M0 : No distant metastasis
– M1 : Presence of distant metastasis

22. Staging of oral cancer
Stage I T1, N0, M0
Stage II T2, N0, M0
Stage III T3, N0, M0
T1, T2, T3, N1, M0
Stage IV T4, N0, M0
Any T, N2 or N3, M0
Any T, any N, any M

23. Management of cancer of oral tongue
according to tumor thickness
Tumor
Thickness
Recommended management
< 3 mm Partial glossectomy alone
4-9 mm Partial glossectomy +/- Elective ipsilateral
level I - IV , selective neck dissection
> 10 mm Partial glossectomy, neck dissection and
post operative Radiotherapy tom primary
site and neck

24. • Management of Stage I – II oral tongue carcinoma
– Transoral resection and primary closure
• Wide local resection with at least 1.5 cm margin
• Partial glossectomy
• Hemiglossectomy
– Brachytherapy
– Curative radiotherapy
• 66 -74 Gy (2.0 Gy/fraction; Sunday-Thursday in 7wk)
• May be used with adequate results

25. Wide local excision of tongue carcinoma

26. • Management of Stage III - IV oral tongue cancer
– Partial to subtotal glossectomy
– Ipsilateral selective level I- IV resection for N 0 Neck
– Modified radical neck dissection type III for N positive neck
– Commando operation (composite resection) : Combined
mandibulectomy and neck dissection ( removal of the
primary tumor along with a segment of the mandible, and
ipsilateral neck dissection all as one continuous block for
FOM tumors involving the mandible)
– Postoperative radiotherapy of oral cavity and neck (66 -74
Gy (2.0 Gy/fraction; Sunday-Thursday in 7wk)

27. Classification of Tongue Defects
• Oral Hemiglossectomy : Hemiresection of the oral tongue with
resection of less than half of the base of tongue
• Hemiglossectomy : Hemiresection of the whole tongue
• Subtotal or total oral glossectomy
– Subtotal or total resection of the oral tongue with resection
of less than half of the base of the tongue
• Subtotal glossectomy : Subtotal resection of the whole tongue
• Total glossectomy
– Total resection of the whole tongue

28. Classification of Tongue Defects

29. Reconstruction techniques in oral cancers
• Aim
– Mucosal resurfacing and replacement of tongue volume
• Techniques
– Pectoralis major myocutaneous flaps ( Poor tongue
mobility, bulk )
– Local muscle flaps e.g. masseter and cutaneous flaps
– Free radial forearm fasciocutaneous flap
– Anterolateral thigh flap ( greater soft tissue volume to
improve swallowing function)

30. Reconstruction by using PMMC flap

31. Free radial forearm flap for tongue
reconstruction

32. Reconstruction of oncological oro -mandibular defects with
double skin paddled - free fibula flap

33. Chemoradiation in oral cavity cancers
• Radiotherapy
– Larger lesions where excision would compromise
speech and swallowing ability
• Combined modality therapy of surgery, radiation
therapy and chemotherapy
– Patients with local or regionally advanced disease

34. • Concomitant chemotherapy (with 5 - Fluorouracil and
cisplatin) and radiation therapy
– Most effective sequencing of treatment
– Drugs with single agent activity in this setting include
methotrexate, 5FU, cisplatin, paclitaxel, docetaxel
– Combinations of carboplatin and 5FU, and cisplatin
and paclitaxel are also used
• Palliative intent
– Patients with recurrent and/or metastatic disease
• Rehabilitation