This document discusses oral cancer, specifically squamous cell carcinoma. It defines oral cancer and squamous cell carcinoma, describing their characteristics, risk factors, clinical features, classification, grading, and TNM staging system. The major points covered include that squamous cell carcinoma represents 90% of oral cancers, risk factors include tobacco and alcohol use, clinical features vary by location but often include ulcers and lymph node involvement, and classification involves histopathological grading and the TNM system to describe tumor size, node involvement, and metastasis.

1. ORAL CANCER
Broad term that refers to various malignant diagnoses that present in
the oral tissues

2. Characteristics of Malignant lesions
• Lesion borders—they exhibit ill defined borders which are very irregular and
ragged.
• Rapid growth—it increases in size very rapidly.
• Metastasis—they always metastasize either by direct spread, by lymphatics or
through the bloodstream.
• Adjacent cortical bone—grows by invasion and cause destruction of adjacent
structures. Bony cortex will be destroyed rather than expanded.
• Radiodensity—radiolucent or may be mixed with radiopacity.
• Dental involvement—root intact and tooth in position.

3. Oral cancer classification
• The nomenclature represents basically the histopathological
characteristics of the lesion
• WHO Classification of tumors- morphology of the cells and the tissue
architecture as seen in light microscopy is used to define the
neoplasm which may correlate with the biology and behavior of the
cancer

4. T
able
8-1
WHO
Classification
of
Oral
Cancer
23
Epithelial
cancer
Squamous
cell
carcinoma
Verrucous
carcinoma
Basaloid
squamous
cell
carcinoma
Papillary
squamous
cell
carcinoma
Spindle
cell
carcinoma
(sarcomatoid
SCC)
Acantholytic
squamous
cell
carcinoma
Adenosquamous
carcinoma
Carcinoma
cuniculatum
Lymphoepithelial
carcinoma
Salivary
gland
cancer
Salivary
gland
carcinoma
Acinic
cell
carcinoma
Mucoepidermoid
carcinoma
Adenoid
cystic
carcinoma
Polymorphous
low-grade
adenocarcinoma
Basal
cell
adenocarcinoma
Epithelial-myoepithelial
carcinoma
Clear
cell
carcinoma,
NOS
Cystadenocarcinoma
Mucinous
adenocarcinoma
Oncocytic
carcinoma
Salivary
duct
carcinoma
Myoepithelial
carcinoma
Carcinoma
ex
pleomorphic
adenoma
Salivary
gland
adenomas
a
Soft
tissue
cancer
b
Kaposi
sarcoma
Hematolymphoid
cancer
Diffuse
large
B-cell
lymphoma
Mantle
cell
lymphoma
Follicular
lymphoma
Extranodal
marginal
zone
B-cell
lymphoma
of
MALT
type
Burkitt
lymphoma
T-cell
lymphoma
Extramedullary
plasmacytoma
Langerhans
cell
hystiocytosis
Extramedullary
myeloid
sarcoma
Follicular
dendritic
cell
sarcoma
Secondary
tumors

5. SQUAMOUS CELL CARCINOMA
• Represents 90% of all malignant tumors occurring in the mouth and
jaws
• Among the 10 most common cancers worldwide with a prevalence of
up to 40% in some regions like India.
• In Kenya its at 2%
• Male predilection
• > 50 years with average age of 60 years

6. Etiology and Risk factors
1)Tobacco use
Smoking
• Why it causes oral cancer—tobacco smoke contains carbon monoxide. It is an
important factor in the development of oral cancer. Study shows that cigar and
pipe smoking increase the risk of cancer than cigarette smoking.
• It has been stated that the pooling of carcinogens in saliva gives rise to cancer in
the floor of mouth and ventral and lateral tongue.
• Smoking is strongly associated with soft palate cancer than anterior sites

7. Tobacco use ctd’
Smokeless tobacco
• Major etiological factors—tobacco use is the major etiological factor for the development of oral
cancer. The effect of tobacco use, heavy alcohol consumption and poor diet can probably explain
over 90% of cases of oral cancer. Much of tobacco in the world is consumed without combustion,
by being placed in contact with mucous membrane, through which nicotine is absorbed.
• Why it causes oral cancer—it contains potent carcinogens like nitrosamine, polycyclic
hydrocarbons and polonium and metabolites of these constituents, which have been suggested
etiologic factors in oral cancer.
• Common forms of oral smokeless tobacco—it includes pan/paan/betel quid (it contains areca nut,
betel leaf, slaked lime, catechu, condiments with or without tobacco), khaini (contains tobacco
and lime), mishri (burned tobacco), zarda (boiled tobacco), gadakhu (tobacco and molasses),
mawa (tobacco, lime and areca), nass (tobacco,ash, cotton or sesame oil), naswar/niswar
(tobacco, lime, indigo, cardamom, oil and menthol), shammah (tobacco, ash and lime) and
toombak (tobacco and sodium bicarbonate).

8. 2) Alcohol
• Forms of alcohol—all forms of alcohol; including hard liquor, wine and beer has been implicated
in the etiology of oral caner.
• Mechanism—the mechanism by which alcohol affects includes the dehydrating effect of alcohol
on the mucosa which increases mucosal permeability and the effects of carcinogens on the
mucosa. Beverage congeners include nitrosamines and impurities which can act as carcinogens.
• Associated habit—most of the heavy alcohol consumers use tobacco, so it is very difficult to
separate the ill effects individually.
3) Actinic radiation
• It is a minor etiologic factor in case of lip cancer. Lip cancer occurs more commonly in fair skinned
people who are generally engaged in outdoor occupation, such as farming and fishing.

9. 4)Familial and genetics
• There is little evidence that there is familial and genetic predisposition for the development of oral cancer.
• Lip cancer is amongst the sites which show strongest cancer clustering within families. But it also reflects the
fact that families tend to have same occupation, i.e. fishing and farming, which is related with ultraviolet
exposure.
• Oral cancers are more prevalent in blacks as compared to white.
• Dyskeratosis congenita has oral cancer as a frequent feature
5)Immunosuppression
• The increasing incidence of oral cancers is clearly age related, which may reflect declining immune
surveillance with age.
• It may occur in immunosuppressed patients following organ and bone marrow transplantation, HIV/AIDS
• Due to failure to recognize and destroy newly formed cancer cells

10. 6) Infective agents
• Virus- HPV 16,18, HSV 1, HIV
• Syphilis- found in tertiary syphilis. Also In the management of syphilis, previously,
arsenic and heavy metal was used which has potential carcinogen
7)Ionizing radiation
Damages DNA and affects immunity

11. 8) Malnutrition
• Vitamin A deficiency can produce excessive keratinization of the skin and mucous membrane
predisposing to malignancy.
• Iron deficiency esp. in severe cases of Plummer Vinson syndrome or sideropenic dysphagia.
9) Trauma
• Trauma in combination with other factors like chronic cheek biting, denture use and irregular
teeth may act as a co-carcinogen and may promote transformation of epithelial cells.
10) Orodental factors
• It is more prevalent in patients with poor oral hygiene, faulty restorations, sharp teeth, ill fitting
dentures and those with syphilitic glossitis

12. 11) Atmospheric pollution
• Parts of the urban/rural difference in incidence of head and neck cancers have
been related to atmospheric pollution.
• Sulphur dioxide and smoke concentration in the atmosphere are positively
correlated with squamous cancer of larynx and pharynx. The impact on cancer of
the mouth is likely to be less, but merits careful study.
• Blue collar workers exposed to dust or inhalation of organic and inorganic agents
are at increased risk of cancers of mouth. I.e.. Wood products

13. 12) Intraoral lesions
• Chronic ulceration and fissure—it can cause oral cancer particularly of lip.
• Candidiasis—it is possible precursor of carcinoma. Candida infection is often associated with
acanthosis and parakeratosis.
• Leukoplakia—it is common pre-malignant condition seen in oral cavity. Nodular leukoplakia show
higher rates of epithelial dysplasia.
• Median rhomboid glossitis—in some cases, it has followed by cancer.
• Submucous fibrosis—it is precancerous condition occurs in oral cavity.
• Oral melanosis—it appears to be associated with oral cancers in India.
• Discoid lupus erythematosus—a number of cases of carcinoma of lip developing in the lesion of
lupus erythematosus have been reported.
• Epidermolysis bullosa—it is occasionally followed by carcinoma.

14. General clinical features
• Site—most commonly involved are the posterior and lateral borders of the tongue and lower lip
and less frequently the floor of mouth, alveolar mucosa, palate and buccal mucosa. It may be
solitary and multifocal.
• Symptoms—patient may present with awareness of a mass in the mouth and neck. Small lesion is
asymptomatic. Large lesions may cause some pain or paresthesia and swelling.
• Patients complain of persistent ulcer in the oral cavity.
• Dysphagia, odynophagia, otalgia, limited movement, oral bleeding, neck masses, and weight loss
may occur with advanced disease.
• Loss of sensory function, especially when it is unilateral, is a red flag that may indicate neural
involvement and requires that cancer be ruled out.
• Loss of function involving the tongue can affect speech, swallowing, and diet.

15. • Lower lip. 38% • Tonsil. 5%~
• Tongue. 22% • Upper lip 4%
• Floor of mouth, 17% • Buccal mucosa.
2%
• Gingiva, 6% • Uvula. 0.5%
• Palate. 5.5%

16. Ctd’
• Appearance—the clinical appearance of a carcinomatous ulcer is that one of
irregular shape indurated and raised everted edges.
• Base—usually have broad base and are dome-like or nodular. Base is firm on
palpation.
• Exophytic lesion—it has irregular, fungating, papillary and verruciform surface.
The surface is ulcerated and base is hard on palpation
• Endophytic lesion—this is depressed irregularly shaped ulcerated central area
with surrounding rolled border. The rolled border results from invasion of tumor
in the tissue

17. Exophytic growth seen in malignancy showing irregular
margins and surface ulceration
Indurated and ulcerated lesion of the right anterior
tongue in a 15-year-old girl, persisting after
removal of orthodontic appliances, proven to be
squamous cell carcinoma on biopsy

18. Ctd’
• Surface—surface may range from granular to pebbly to deeply creviced. In some
cases, surface may be entirely necrotic and have ragged whitish gray appearance.
• Color—it may be completely red or red surface may be sprinkled with white
necrotic or keratin area.
• Lymph nodes—superficial and deep cervical nodes are commonly affected. They
become enlarged and are firm to hard on palpation. The nodes are non-tender
unless associated with secondary infection or an inflammatory response.
• It may be nodular or polypoid and pink to red and have at least one ulcerated
patch on their surface.
• Fixation of nodes to adjacent tissues occur later.

19. Surface of oral malignancy is whitish gray and pebbly
Irregular leukoplakia/erythroplakia on the right lateral
tongue in the site of a previous T1N0MO cancer treated
by surgical excision. Biopsy identified recurrent
squamous cell carcinoma

20. Ctd’
• Effect on adjacent tissues—fixation of primary tumor to adjacent tissues, i.e.
overlying bone suggests involvement of periosteum and possible spread to bone.
• Field cancerization—tendency of development of multiple mucosal cancers, is
called as field cancerization. This occur due to diffuse exposure of local
carcinogen

21. a) Lip cancer
• Vermillion; chronic non healing ulcer, exophytic and verrucous
• Deep invasion appears late
• Metastasis to submental/submandibular LN(uncommon but common in poorly
differentiated lesions)
• Mostly lower lip following actinic cheilitis (better prognosis)
• Uv light and pipe smoking
• Slower growth rate
• When upper lip involved usually very aggressive(poor prognosis)

23. b) Carcinoma of floor of mouth
• Site—most frequently in the anterior portion of floor.
• Appearance—the typical carcinoma of the floor of mouth is an indurated ulcer of varying size, on
one side of the midline. It may take form of wart-like growth, which tend to spread superficially
rather than in depth.
• Symptoms—it may or may not be painful. In some cases, there may be referred pain in the ears.
The proximity of this tumor to the tongue produces some restricted/limited movements of
tongue, often induces peculiar thickening or slurring of the speech. There may be excessive
salivation.
• Teeth mobility—carcinoma in close relation to teeth may cause loosening or exfoliation and root
resorption.
• Extent—carcinoma of floor of mouth may invade the deeper tissues and may even extend into the
submaxillary and sublingual glands.
• Metastasis—metastasis from the floor of the mouth are found most commonly in the sub-
maxillary group of lymph nodes and since the primary lesion frequently occurs near the midline
where lymphatic cross drainage exists, contralateral metastasis is often present

25. c) Carcinoma of buccal mucosa
• Site—the lesions develop most frequently along or inferior to a line opposite the
plane of occlusion. It usually occurs opposite to the third molar.
• Symptoms—the lesion is often painful.
• Appearance—the tumor begins as small nodules and enlarges to form a wart-like
growth which ultimately ulcerates
• Extent—there is induration and infiltration of deeper tissues. Extension into the
muscle of neck, alveolar mucosa and ultimately into bone may occur.
• Exophytic growth—some cases appear to be growing outward from the surface
rather than invading the tissues is called as exophytic or verrucous growth.
• Metastasis—the most common site of metastasis is the submaxillary lymph
nodes.

27. d) Carcinoma of the labial mucosa
• Cause—it is frequently encountered in person who habitually keeps a mixture of
tobacco lime in the labial vestibule.
• Site—the lower labial mucosa is more commonly involved than the upper.
• Symptoms—the most common initial signs and symptoms are growth or swelling,
soreness and ulceration
• Extent—advanced lesion may be ulcerative-infiltrative type, showing exophytic
growth.
• Lymph nodes—lymph node involvement may occur, which may be unilateral or
bilateral

29. e) Carcinoma of the palate
• Cause—it is common in area where reverse smoking is practiced.
• Sex—it is seen more commonly in females as compared to men, in case of reverse
smoking.
• Appearance—palatal cancer usually manifests as a poorly defined ulcerated
painful lesion on one side of the midline.
• Base and surface—most of the lesions are exophytic and with broad base and
nodular surface.
• Extent—it frequently crosses the midline and may extend laterally to include
tonsillar pillars or even the uvula. The tumor of hard palate may invade the bone
or occasionally the nasal cavity. While infiltrating, lesions of the soft palate may
extend into the nasopharynx

31. f)Carcinoma of oropharynx
• Site—carcinoma of soft palate and oropharyngeal mucosa can occur.
• Symptoms—dysphagia, i.e. difficulty in swallowing is the most common
complaint. Patient may complain of pain which is dull and sharp and is referred to
ear.
• Appearance—it is same as that of other carcinoma.
• Size—size of the tumor is always greater than other carcinoma of the oral cavity

32. Grading
Well-differentiated
Elongated rete pegs invading lamina propria, with keratin pearls
Moderately differentiated
Irregular invading rete pegs; loss of cellular cohesion
Poorly differentiated
Sheets of invading epithelium with no obvious architecture,but severe
cellular abnormalities such as pleomorphism and hyperchromatism

33. TNM classification of malignant neoplasms.
• Staging refers to quantifying the clinical parameters of OSCC.
• The most popular staging is by the TNM system based on 3 basic
clinical features where;
• T-primary tumor size in cm
• N-involvement of local nodes
• M-distant metastasis . (The most common site of spread is to the lungs. The
next most common sites are the liver and bones.)

34. • Numbers or letters appear after T, N, and M to provide details about
each of these factors:
- The numbers 0 through 4 indicate increasing severity.
- The letter X means “cannot be assessed” because the
information is not available

35. • TX: Primary tumor cannot be assessed; information not known
• T0: No evidence of primary tumor.
• Tis: Carcinoma in situ. This means the cancer is still within the
epithelium (the top layer of cells lining the oral cavity and
oropharynx) and has not yet grown into deeper layers.
• T1: Tumor is 2 cm (about ¾ inch) across or smaller
• T2: Tumor is larger than 2 cm across, but smaller than 4 cm (about 1
½ inch)
• T3: Tumor is larger than 4 cm across. For cancers of the oropharynx,
T3 also includes tumors that are growing into the epiglottis.
T CATEGORIES FOR ORAL CANCERS

36. • T4a: Tumor is growing into nearby structures.
This is known as moderately advanced local
disease.
• For oral cavity cancers: the tumor is growing into
nearby structures, such as the bones of the jaw or
face, deep muscle of the tongue, skin of the face, or
the maxillary sinus.
• For lip cancers: the tumor is growing into cortical
bone, the inferior alveolar nerve, the floor of the
mouth, or the skin of the chin or nose.
• For oropharyngeal cancers: the tumor is growing
into the larynx, the tongue muscle, the hard palate,
or the jaw.

37. • T4b: The tumor has grown through nearby structures and into deeper areas or
tissues. This is known as very advanced local disease. Any of the following may
be true:
• The tumor is growing into other bones, such as the pterygoid plates and/or the
skull base (for any oral cavity or oropharyngeal cancer).
• The tumor surrounds the internal carotid artery (for any oral cavity or
oropharyngeal cancer).
• For lip and oral cavity cancers: the tumor is growing into an area called the
masticator space.
• For oropharyngeal cancers: the tumor is growing into a muscle called the lateral
pterygoid muscle.
• For oropharyngeal cancers: the tumor is growing into the nasopharynx (the area of
the throat that is behind the nose).

38. N categories
• NX: Nearby lymph nodes cannot be assessed;
information not known
• N0: The cancer has not spread to nearby lymph
nodes
• N1: The cancer has spread to one lymph node on
the same side (ipsilateral) of the head or neck as the
primary tumor; this lymph node is no more than 3
cm (about 1¼ inch) across

39. • N2 includes 3 subgroups:
• N2a: The cancer has spread to one lymph node on the same side as the
primary tumor; the lymph node is larger than 3 cm across but no larger than
6 cm (about 2 ½ inches). (Single ipsilateral)
• N2b: The cancer has spread to 2 or more lymph nodes on the same side as
the primary tumor, but none are larger than 6 cm across. (Multiple
ipsilateral).
• N2c: The cancer has spread to one or more lymph nodes on both sides of
the neck or on the side opposite the primary tumor, but none are larger than
6 cm across.(bilateral or contralateral)
• N3: The cancer has spread to a lymph node that is larger than 6 cm across

40. M categories
• MX: Distant metastasis cannot be assessed
• M0: No distant spread
• M1: The cancer has spread to distant sites outside the head and neck
region (for example, the lungs)

41. Stage grouping
• Once the T, N, and M categories have been assigned, this information
is combined by a process called stage grouping to assign an overall
stage of 0, I, II, III, or IV. Stage IV is further divided into A, B, and C.

42. • Stage 0
• Tis, N0, M0: Carcinoma in situ. The cancer is only growing in the
epithelium, the outer layer of oral or oropharyngeal tissue (Tis). It has
not yet grown into a deeper layer or spread to nearby structures, lymph
nodes (N0), or distant sites (M0).

43. • Stage I
• T1, N0, M0: The tumor is 2 cm (about ¾ inch) across or smaller (T1)
and has not spread to nearby structures, lymph nodes (N0), or distant
sites (M0).

44. • Stage II
• T2, N0, M0: The tumor is larger than 2 cm across but smaller than 4
cm (T2) and has not spread to nearby structures, lymph nodes (N0), or
distant sites (M0).

45. • Stage III
• One of the following applies:
• T3, N0, M0: The tumor is larger than 4 cm across (T3), but it hasn’t
grown into nearby structures or spread to the lymph nodes (N0) or
distant sites (M0).
• OR
• T1 to T3, N1, M0: The tumor is any size and hasn’t grown into
nearby structures (T1 to T3). It has spread to one lymph node on the
same side of the head or neck, which is no larger than 3 cm across
(N1). The cancer hasn’t spread to distant sites (M0).

46. Stage IVA
• One of the following applies:
• T4a, N0 or N1, M0: The tumor is growing into nearby structures
(T4a). It can be any size. It has either not spread to the lymph nodes
(N0) or has spread to one lymph node on the same side of the head or
neck, which is no larger than 3 cm across (N1). The cancer hasn’t
spread to distant sites (M0).
• OR
• T1 to T4a, N2, M0: The tumor is any size and may or may not grow
into nearby structures (T1 to T4a). It has not spread to distant sites
(M0). It has spread to one of the following:

47. Stage IVA
• 1. One lymph node one the same side of the head and neck that is
between 3 and 6 cm across (N2a), or
• 2. One lymph node on the opposite side of the head and neck that is no
more than 6 cm across (N2b), or
• 3. 2 or more lymph nodes, all of which are no more than 6 cm across.
The lymph nodes can be on any side of the neck (N2c)

48. Stage IVB
• One of the following applies:
• T4b, any N, M0: The tumor is growing into deeper areas and/or
tissues (very advanced local disease - T4b). It may (or may not) have
spread to lymph nodes (any N). It has not spread to distant sites (M0).
• OR
• Any T, N3, M0: The tumor is any size and it may or may not have
grown into other structures (any T). It has spread to one or more
lymph nodes larger than 6 cm across (N3), but it hasn’t spread to
distant sites (M0).

49. Stage IVC
• Any T, Any N, M1: The tumor is any size (any T), and it may or may
not have spread to lymph nodes (any N). It has spread to distant sites
(M1), most commonly the lungs.

50. Diagnosis
• There should be a high index of suspicion, esp of a solitary lesion
present for over 2 weeks.
• The whole oral mucosa should be examined as there may be
widespread dysplastic mucosa(‘field change’) or a second neoplasm,
and the cervical lymph nodes must be examined.
• Frank tumours should be inspected and palpated to determine the
extent of spread.

51. • Examination under GA may be indicated for patients with;
• Tumours in the posterior tongue
• Tumours where the margins cannot be readily defined.
• An enlarged cervical node but no visible primary neoplasm
• Any suggestion of a second primary tumour(SPT) who may then need pan
endoscopy of larynx, pharynx and esophagus and/or PET.
• Fluorodeoxyglucose PET (FDG-PET) will also help detect distant metastases

52. 1. Staging of Oral Cancer.
• The American Joint Committee on Cancer (AJCC) has developed Tumor-
Nodes-Metastasis (TNM) staging system of cancer, which reflects the
prognosis, thus influencing treatment strategy.
• T is the size of the primary tumor, N indicates the presence of regional
lymph nodes, and M indicates distant metastasis.
• The most common site of spread is to the lungs, liver and bones.
• The staging system for OSCC combines the T, N, and M to classify lesions as
stages 1 through 4.
• The AJCC classification is principally a clinical description of the disease.
• Many clinicians combine an imaging-based assessment of the size, lymph
nodes, and metastasis with the AJCC clinical staging.

53. T categories.
• TX: Primary tumor cannot be assessed; information not known
• T0: No evidence of primary tumor
• Tis: Carcinoma in situ. This means the cancer is still within the
epithelium (the top layer of cells lining the oral cavity and
oropharynx) and has not yet grown into deeper layers.
• T1: Tumor is 2 cm (about ¾ inch) across or smaller
• T2: Tumor is larger than 2 cm across, but smaller than 4 cm (about 1
½ inch)
• T3: Tumor is larger than 4 cm across. For cancers of the oropharynx,
T3 also includes tumors that are growing into the epiglottis.

54. T categories.
• T4a: Tumor is growing into nearby structures. This is known
as moderately advanced local disease.
• For oral cavity cancers: the tumor is growing into nearby structures,
such as the bones of the jaw or face, deep muscle of the tongue, skin
of the face, or the maxillary sinus.
• For lip cancers: the tumor is growing into cortical bone, the inferior
alveolar nerve, the floor of the mouth, or the skin of the chin or nose.
• For oropharyngeal cancers: the tumor is growing into the larynx, the
tongue muscle, the hard palate, or the jaw.

55. T categories.
• T4b: The tumor has grown through nearby structures and into deeper
areas or tissues. This is known as very advanced local disease. Any of the
following may be true:
• The tumor is growing into other bones, such as the pterygoid plates and/or
the skull base (for any oral cavity or oropharyngeal cancer).
• The tumor surrounds the internal carotid artery (for any oral cavity or
oropharyngeal cancer).
• For lip and oral cavity cancers: the tumor is growing into an area called the
masticator space.
• For oropharyngeal cancers: the tumor is growing into a muscle called
the lateral pterygoid muscle.
• For oropharyngeal cancers: the tumor is growing into the nasopharynx (the
area of the throat that is behind the nose).

56. N categories.
• NX: Nearby lymph nodes cannot be assessed; information not known
• N0: The cancer has not spread to nearby lymph nodes
• N1: The cancer has spread to one lymph node on the same side
(ipsilateral) of the head or neck as the primary tumor; this lymph
node is no more than 3 cm (about 1¼ inch) across

57. N categories.
• N2 includes 3 subgroups:
• N2a: The cancer has spread to one lymph node on the same side as the
primary tumor; the lymph node is larger than 3 cm across but no larger
than 6 cm (about 2 ½ inches). (Single ipsilateral)
• N2b: The cancer has spread to 2 or more lymph nodes on the same side as
the primary tumor, but none are larger than 6 cm across. (Multiple
ipsilateral).
• N2c: The cancer has spread to one or more lymph nodes on both sides of
the neck or on the side opposite the primary tumor, but none are larger
than 6 cm across.(bilateral or contralateral)
• N3: The cancer has spread to a lymph node that is larger than 6 cm across

58. M categories.
• MX: Distant metastasis cannot be assessed
• M0: No distant spread
• M1: The cancer has spread to distant sites outside the head and neck
region (for example, the lungs)

59. Stage Grouping.
• Once the T, N, and M categories have been assigned, this information
is combined by a process called stage grouping to assign an overall
stage of 0, I, II, III, or IV.
• Stage IV is further divided into A, B, and C.

60. Stage Grouping.
Stage O
• Tis, N0, M0: Carcinoma in situ. The cancer is only growing in the
epithelium, the outer layer of oral or oropharyngeal tissue (Tis). It has
not yet grown into a deeper layer or spread to nearby structures,
lymph nodes (N0), or distant sites (M0).
Stage I
• T1, N0, M0: The tumor is 2 cm (about ¾ inch) across or smaller (T1)
and has not spread to nearby structures, lymph nodes (N0), or distant
sites (M0).

61. Stage Grouping.
Stage II
• T2, N0, M0: The tumor is larger than 2 cm across but smaller than 4
cm (T2) and has not spread to nearby structures, lymph nodes (N0),
or distant sites (M0).

62. Stage Grouping.
Stage III
• One of the following applies:
• T3, N0, M0: The tumor is larger than 4 cm across (T3), but it hasn’t
grown into nearby structures or spread to the lymph nodes (N0) or
distant sites (M0).
OR
• T1 to T3, N1, M0: The tumor is any size and hasn’t grown into nearby
structures (T1 to T3). It has spread to one lymph node on the same
side of the head or neck, which is no larger than 3 cm across (N1). The
cancer hasn’t spread to distant sites (M0).

63. Stage Grouping.
Stage IV A
• One of the following applies:
• T4a, N0 or N1, M0: The tumor is growing into nearby structures (T4a). It
can be any size. It has either not spread to the lymph nodes (N0) or has
spread to one lymph node on the same side of the head or neck, which is
no larger than 3 cm across (N1). The cancer hasn’t spread to distant sites
(M0).
OR
• T1 to T4a, N2, M0: The tumor is any size and may or may not grow into
nearby structures (T1 to T4a). It has not spread to distant sites (M0). It has
spread to one of the following:

64. Stage Grouping.
Stage IV B.
• One of the following applies:
• T4b, any N, M0: The tumor is growing into deeper areas and/or
tissues (very advanced local disease - T4b). It may (or may not) have
spread to lymph nodes (any N). It has not spread to distant sites (M0).
OR
• Any T, N3, M0: The tumor is any size and it may or may not have
grown into other structures (any T). It has spread to one or more
lymph nodes larger than 6 cm across (N3), but it hasn’t spread to
distant sites (M0).

65. Stage Grouping.
Stage IV C
• Any T, Any N, M1: The tumor is any size (any T), and it may or may not
have spread to lymph nodes (any N). It has spread to distant sites
(M1), most commonly the lungs.

68. 2. Diagnostic Aids and Procedures.
• Early detection of potentially malignant and malignant lesions is a
continuing goal.
• Patient history, thorough head and neck and intraoral examinations, is a
prerequisite.
• There should be a high index of suspicion, esp of a solitary lesion present
for over 3 weeks.
• The whole oral mucosa should be examined as there may be widespread
dysplastic mucosa(‘field change’) or a second neoplasm, and the cervical
lymph nodes must be examined.
• Frank tumors should be inspected and palpated to determine the extent of
spread.

69. Diagnostic Aids and Procedures.
Examination under GA may be indicated for patients with;
• Tumors in the posterior tongue
• Tumors where the margins cannot be readily defined.
• An enlarged cervical node but no visible primary neoplasm
• Any suggestion of a second primary tumor(SPT) who may then need
panendoscopy of larynx, pharynx and oesophagus.

70. Diagnostic Aids and Procedures.
• When deciding which investigations to undertake, 3 principles should
be adhered to;
• Confirm the diagnosis histopathologically and determine if there is malignant
disease elsewhere.(involvement of bone,muscles or nodes;metastases;other
primary tumours)
• Ensure that the patient is as prepared as possible for the major surgery
required i.e. consent, GA, potential blood loss and ability to metabolize drugs.
• Address any potential dental or oral problems preoperatively, to avoid later
complications such as osteoradionecrosis.

71. Diagnostic Aids and Procedures.
• The definitive test for diagnosis remains tissue biopsy.
• Several aids to the oral examination have been suggested in the past,
including light technologies, vital tissue staining using toluidine blue
(TB), and computer-assisted cytology of oral brush biopsy specimens.
• Additional markers based on blood of saliva samples are under
investigation.

72. BIOPSY
• Is process of surgicaly removing tissue from a patient for histopathologic
examination
Indications of biopsy
a) Undiagnosed clinical conditions- after clinical examination and the lesion
is not identified
b) Nature of the lesion- evaluate the exact histological nature of the tissue
c) Detection of malignancy so that the treatment will be undertaken
immediately
d) Diagnostic test for non malignant lesion such as mucosal nodules,
papilloma

73. Avoidance of delay of biopsy
• Avoid delay of biopsy when the following features are present
i. Rapid growth of lesion which can be explained by edema,
inflammation and opening of new channels
ii. Absent of local factors such as irritants when the lesion is
chronically ulcerated
iii. Fixed lymph nodes enlargement to the surrounding tissues
iv. Root resorption with loosening with evidence of rapid expansion in
the jaws
v. History of malignancy else where in the body

74. Uses of biopsies
a. Diagnostic – helps in determining whether the lesion is neoplastic
or non neoplastic
b. Grading of the tumor
c. Metastatic lesion to other parts of the body
d. Recurrence of the lesions
e. Management and assessment of the lesion by differentiating
between bening and malignant lesions

75. Instruments and materials
• Excisional and incisional- Local anaesthesia with a vasoconstrictor,
scalpel holder and plate, pointed surgical incisors, tissue forceps,
surgical hemostat, sterile sponge, curved needles, suture, needle
holder
• Intraosseous biopsy- periosteal elevator, bone bur, curette
• Aspiration biopsy- large syringe ( 10-20cc) with a large needle.

76. Tissue Biopsy.
• The main types of biopsy to be use will be brush, punch and incisional
biopsy.
Oral cytology
• Oral brush cytology uses a special brush to collect epithelial cells.
• Indications- Oral brush cytology may be a good tool for "monitoring"
patients with chronic mucosal changes, such as leukoplakia, lichen planus,
post irradiation, and patients with a history of oral cancer who require
long- term surveillance of their ongoing mucosal changes.
• The greatest advantage in oral cytology is that it is a chair side test It takes
only seconds to perform, Rather than simply "observing" a suspicious
lesion, one can readily obtain a sample of cells for analysis.
• All oral lesions with abnormal brush cytology results, that is "positive" or
"atypical," require surgical biopsy and histologic evaluation.

78. Punch Biopsy.

79. Tissue Biopsy.
Incisional Biopsy
• An incisional biopsy is a biopsy that samples only a particular or
representative part of the lesion.
Indications.
• If the area under investigation appears difficult to excise because of its
extensive size (i.e., larger than 1 cm in diameter), hazardous location, or
whenever the clinician suspects malignancy, incisional biopsy is indicated.
Principles.
1.The material should be taken from the edge of the lesion to include some normal
tissue.
2.However, care must be taken to include an adequate amount of abnormal tissue.
3.It is much better to take a deep, narrow biopsy rather than a broad, shallow one,
because superficial changes may be quite different from those deeper in the tissue

80. Procedure
• Selection of site- it is best to select the
site a way from obvious ulceration and
necrosis as this sited are inflamed and
difficult to interprate the results
• Local anaesthesia Is administered around
the specimen
• Elliptical incisons the incisions must be
long enough to include the underlying
connective tissue
• Suture the area where the specimen was
removed

81. Tissue Biopsy.
Aspirational biopsy
• Aspiration biopsy is the use of a needle and syringe to penetrate a
lesion for aspiration of its contents.
• Done for two reasons:
• To determine content of lesion( fluid or air)
• To remove cellular material for diagnostic examination.
• Tissue can be acquired for histopathology by using fine-needle
aspiration (FNA) or core needle biopsy (CNB).

82. Tissue Biopsy.
• Open biopsy of enlarged lymph nodes is not recommended; in such
cases, FNA biopsy should be considered.
• FNA/CNB also may aid in the evaluation of suspicious masses in other
areas of the head and neck, including masses that involve salivary
glands, tongue, and palate, or when there is contraindication for
conventional biopsy (e.g., thrombocytopenia).
• Ultrasound may assist in guiding FNA/CNB.

83. Procedure
• Needle positioning- fist you have to
position the needle within the largest
tissue
• Application of negative pressure- plunger is
pulled to apply negative pressure . Needle
is moved back and forth within target
tissue to obtain greater field
• Releasing of negative pressure while the
needle is within the targe tissue
• Withdrawing the needle and the contents
are emptied into a slide
• Fixing is done using 95% alcohol and a little
of prolong HE stains

84. Tissue Biopsy.
Excisional Biopsy.
• An excisional biopsy implies removal of the entire lesion at the time the surgical
diagnostic procedure is performed.
• The entire lesion made available for pathologic examination, and complete excision may
constitute definitive treatment.
Indications.
• Excisional biopsy should be used with smaller lesions (less than 1 cm in diameter) that on
clinical examination appear to be benign.
• Any lesion that can be removed completely without mutilating the patient is best treated
by excisional biopsy. Pigmented and small vascular lesions should also be removed in
their entirety.
Principles.
• The entire lesion, along with 2 to 3 mm of normal-appearing surrounding tissue, is
excised.

85. Procedure
1) Local anaesthesia that contains a vasoconstrictor is injected into the
lesion
2) Elliptical incision are made with a scalpel on either side of the base
of the lesion. The blade is angulated at 45% to the center of the
lesion
3) Outward tension pulling of the tissue is made with a help of suture
or tissue forceps without crushing the specimen
4) Dissection of tissue gently with either a scalpel or a pair of scissors
5) Suturing- surgical site is closed with a surgical silk or absorbable
sutures

87. Toluidine Blue.
• Vital staining with TB may be used as an adjunctive aid in assessing
potentially malignant oral mucosal lesions.
• TB is a metachromatic dye, which has an affinity to bind with DNA.
• TB can be applied directly to suspicious lesions or used as an oral
rinse.
• Positive retention of TB (particularly in areas of leukoplakia,
erythroplakia, and uptake in a peripheral pattern of an ulcer) may
indicate the need for biopsy or assist in identifying the site of biopsy.
• False-positive dye retention may occur in inflammatory and ulcerative
lesions, but false- negative retention is uncommon.

88. MECHANISM
• Binding with the DNA- is an acidophilic metachromatic nuclear dye for
thiazine group of the nucleic acid such as the DNA and RNA.
• Intracellular canal- malignant epithelium have wider intracellular
canal which facilitates uptake of the dye
• Effects on the normal epithelium- most of the normal epithelium
stain blue after application of the 1% toluidine solution but
disappears after application of the acetic acid
• Effects on benign ulceration- boning ulceration has well defined
uptake of dye at the margins where as diffuse mariginal pattern is
characteristic of dysplasia or malignancy

89. TECHNIQUE
a) Ask the patients to rinse the mouth twice with water and followed
with 1% acetic acid
b) Dry the mucosa gently and take care not to abrade the tissues while
drying
c) Apply 1% toluidine solution with a cotton swab
d) Rinse the patients mouth again with acetic acid and then ask the
patient to rinse the mouth with water
e) If there is positive staining of the mucosa you have to repeat the
procedure after two to ensure there is no false positive due
inflammation. All the positive results are recommended for biopsies

90. Toluidine Blue.
• TB has been suggested as a diagnostic tool in potentially malignant
oral lesions at risk of progressing to squamous cell cancer, where it
may provide guidance for the selection for the biopsy site and
accelerates the decision to biopsy.
• In postradiotherapy follow-up, the retention of TB may assist in
distinguishing nonhealing ulcers and persistent or recurrent disease.
• It is used as an adjunctive marking aid in combination with a
chemiluminescence light device.

91. Toluidine blue stain applied to
lesion shown, with stain retained on
the areas of erythroplakia.
Subsequent biopsy diagnosed as
squamous cell carcinoma. The more
superior area of leukoplakia stained
with toluidine blue also diagnosed
as squamous cell carcinioma, and
would likely not have been
diagnosed without toluidine blue,
which led to change in the
surgical treatment to include this
site in the resection

92. LUGOL’S SOLUTION
• It is retained In the normal epithelium but not in the malignant cells .
Combination with toluidine solution will give better advantage.
• It binds with glycogen present in the normal oral epithelium
Mechanism includes
1. Lugol’s solution has a brown black staining by reaction of iodine with
glycogen which is removed by fixation of alcohol and formaldehyde.
2. It has inverse staining characteristics with degree keratinization.
Hyperkeratosis will show poor staining
3. There is no relationship between the glycogen and inflamed cell and in
this case the cell will stain dark brown

93. Visualization Adjunctive Tools.(vizilite)
• Chemiluminescent devices generate light based on chemical reactions. The
suspected area of mucosa appears brighter.
• Other products generate fluorescent light using a LED source, sometimes
combined with optical filtration of a viewfinder, to enhance natural tissue
fluorescence. When using the fluorescence light, the suspected area shows
loss of fluorescence, which appears dark.
• These products are promoted to assist the practitioner in discovering
mucosal abnormalities, specifically oral potentially malignant disorders and
evaluate margins of resection site.
• It is more useful in detection of squamous cell dysplasia which are not seen
in the naked eye

94. • Mechanisms normal tissue absorbs vizilite and as a reason they
appear dark, in the case of neoplastic cells, the nucleus becomes
large causing reflection of light and gives of white appearance.
• Technique application of vizilite rinse with acetic acid solution, this
will change the refractile index of the cells by causing cytoplasmic
dehydration increasing the nuclear to cytoplasmic ration of lesion e.g.
leukoplakia
• Visualizing the mucosa with vizilite , the chemilumiscent capsule is
projected on the mucosa. The abnormal mucosa like dysplastic
mucosa will show more reflection of light and will appear more white
as compared to the normal mucosa

96. Cytology.
• Cytology of the oral mucosa is used to assess cellular morphology.
• The brush is designed to sample the entire thickness of the oral epithelium.
• Originally, the cytobrush was combined with a computer-assisted analysis
of the cytologic sample, assessing the cell morphology and keratinization.
• The final diagnosis was made by a pathologist based on the standard
histomorphologic criteria.
• Further developments in cytology include molecular evaluation of
exfoliated cells for molecular markers of dysplasia or carcinoma to improve
the diagnostic and prognostic value.

97. Molecular Analysis.
• Molecular markers obtained from tissue specimens have been
suggested to assist with detection and evaluation of cancerous
lesions.
• Including c-erbB2, Cyclin D1, p53 etc.
• Studies have also shown that the biomarkers of the OSCC are present
in the saliva.

98. Imaging.
• Routine radiology, computed tomography (CT), nuclear scinti
scanning, magnetic resonance imaging, and ultrasonography can
provide evidence of bone involvement or can indicate the extent of
some soft tissue lesions.
• The selection of the appropriate imaging modality is dependent on
the type and location of the suspected tumor.
• Jaw radiography (often rotating pantomography)
• Chest radiography or CT. Important as pre-anaesthetic check,esp in
pts with known pulmonary or airways disease or to demonstrate
second primary tumours or mets to lungs or hilar lymph nodes, ribs
or vertebrae

99. Imaging.
• MRI or CT of the primary site, the head and neck, and suspected sites
of distant mets and MRI scans of the neck to delineate the extent of
cervical node mets.
• MRI is used to determine;
• Tumour spread
• Bone involvement
• Nodal metastases.

100. Periapical radiograph
demonstrating bone
destruction in the furcation of
the first molar tooth and
associated resorption of
the root. A subsequent biopsy
specimen demonstrated
squamous cell carcinoma,
which was diagnosed as a
primary intra-alveolar lesion.

101. Other Investigations.
• Electrocardiography
• Blood tests
• Full blood picture & haemoglobin
• Blood for grouping & cross-matching
• Urea and electrolytes
• Liver function tests

102. Other Investigations.
In selected cases other investigations may be indicated;
• Bronchoscopy, if chest xray reveals any lesions
• Endoscopy of the upper git, if there is a history of tobacco use.
• Gastrocopy, if a PEG(perendoscopic gatrostomy) is to be used for
feeding.
• Liver ultrasound, if there is hepatomegaly or abnormal liver function.
• Doppler duplex flow studies, in planning radial free forearm flaps
• Angiography, in planning lower limb free flaps.