1. Oral Cavity Cancer
By
Ihab Samy
Lecturer of Surgical Oncology
National Cancer Institute
Cairo University
2013

2. Introduction
• 30% of all head and neck cancers (most common head and neck
site)
• oral cavity has the highest rate of second primaries (10–40%)
• >90% of occult metastatic disease in oral cancer involves nodal
groups I–III (the supraomohyoid dissection is oncologically sound
especially in the N0 neck)
• SSx: nonhealing ulcers, denture difficulties, dysphagia,
odynophagia, trismus, halitosis, numbness in the lower teeth
(suggests mandible involvement of the inferior alveolar nerve).

3. Risk Factors
• Smoking, alcohol, and tobacco abuse; radiation and ultraviolet
radiation exposure (lip cancer).
• Human papilloma virus, poor oral hygiene.
• Oral leukoplakia (5–20% malignant potential) and erythroplakia
(approximately 25% malignant potential).
• Type of Leukoplakia
1. Keratotic: adherent, insidious development, protracted course,
nonerosive surface (higher risk of carcinoma)
2. Nonkeratotic: nonadherent, acute onset, erosive and ulcerative
features (higher risk of acute infections).

4. • floor of the mouth and tongue although 93%
of leucoplakia at this sites turn malignant.
• Erythroplakia is characterized by red velvety
patch which is not associated with any trauma
or inflammation. It may present with or
without leucoplakia. This lesion is easily
missed out but is considered to have great
malignant potential.

8. Anatomy
• Oral Cavity: extends from lips to junction of
hard and soft palate and circumvallate
papillae
• other than the mandibular periosteum there
is no finite fascial plane to inhibit tumor’s
extension in the oral cavity

9. Subsites and Regional Lymph Node Potential

10. Lips
• Most common location of oral cancer.
• 90% on lower lip
• 90% 5-year survival if <2 cm
• 90% squamous cell carcinoma (Rules of 90’s)
• Basal cell carcinoma is more common on upper lip
• 2–15% regional metastasis (for all stages)

13. • Lower lip has bilateral and ipsilateral lymphatic
drainage into level I–III nodal groups
• Upper lip has ipsilateral lymphatic drainage into
level I–III nodal groups (no contralateral drainage
due to embryological fusion plates).
• Overall 5-year survival for all stages for squamous
cell carcinoma is 70–90% for the lower lip and
40–60% for the upper lip.
• Poorer prognosis is associated with upper lip and
commissure involvement.

14. Buccal Mucosa
• Common site near mandibular third molar (site
of chewing tobacco).
• Most common site for verrucous cancer
• More common in India
• 50% regional metastasis (for all stages)
• Occult neck metastases is approximately 10%

18. Alveolar Ridge
• More common in edentulous and molar areas of
the mandible.
• Must differentiate it from invasive maxillary
cancer.
• High rate of bony involvement .
• 50–65% overall 5-year survival.

21. Retromolar Trigone
• Triangle-shaped region with the base at the last
mandibular molar and the apex at the maxillary
tuberosity.
• Typically presents in an advanced stage.
• Bony invasion is common.
• 50% regional metastasis (for all stages).
• Approximately 25–55% 5-year survival for all stages (due to
advanced initial staging and poor salvage potential).

22. Hard Palate
• Incisive foramen allows tumor extension into
anterior nose.
• Palatine foramen allows tumor extension to
pterygopalatine fossa.
• Less aggressive (10–25% occult regional
metastasis).
• Minor salivary gland tumors are common

25. Oral Tongue
• Movable portion, anterior to circumvallate
papillae.
• Second most common site of oral cancer.
• 25–66% regional metastasis (for all stages).
• 60–80% 5-year survival for early disease (T1–T2).

29. Floor of Mouth
• Dependent site for alcohol and chewing
tobacco.
• 30% present with regional metastasis.
• Overall 5-year survival is 30%–65%.

30. Staging
based on the AJCC Staging, 2010
• T1: primary tumor <2 cm
• T2: primary tumor 2–4 cm
• T3: primary tumor >4 cm
• T4: primary tumor invades adjacent structures
(e.g, through cortical bone, skin, through floor
of mouth).

31. Regional lymph nodes (N)
NX Regional 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
N2 Metastasis in a single ipsilateral lymph node > 3 cm but not more
than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none
> 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes,
none > 6 cm in greatest dimension
• N2a Metastasis in a single ipsilateral lymph node > 3 cm but not more
than 6 cm in greatest dimension
• N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in
greatest dimension
• N2c Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in
greatest dimension
N3 Metastasis in a lymph node > 6 cm in greatest dimension

32. Pathology
 Squamous Cell Carcinoma (SSC): >90% of oral cancers
• Verrucous Carcinoma: variant of SSC, broad based, warty growth,
most common site is the buccal mucosa, lateral growth, rare
metastasis and deep invasion.
• Basal Cell Carcinoma: more common on the upper lip
• Other Types: Lymphoma, Kaposi’s Sarcoma, Salivary Gland
Malignancies, Melanoma.
• NOTE: Necrotizing Sialometaplasia and Granular Cell Tumors
may be mistaken for squamous cell carcinoma in the oral cavity due
to similar histology (pseudoepitheliomatous hyperplasia).

33. Management
Early Oral Cancer (T1–T2):
• Single-Modality Therapy: excision of primary
tumor with primary reconstruction.
• May consider primary radiation (external
beam versus brachytherapy)

34. N0 Neck in Early Oral Cancer (T1–T2) :
• Elective ipsilateral or bilateral (tongue,floor of
mouth,alveolar ridge,retromolar trigone cancer)
selective neck dissection (supraomohyoid) versus
external beam therapy
• Early stage hard palate ,lower lip,buccal mucosa
do not require elective neck dissections because
of lower rate of occult metastasis (<20%)
• if surgical specimen is positive (Frozen Section)
for tumor may consider observation, completion
of a comprehensive neck dissection, or radiation
therapy to neck.

35. N1–3 Neck in Early Oral Cancer (T1–T2):
• Radical neck dissection for clinical nodes.
• Parotid nodes require a superficial
parotidectomy.

36. Advanced Oral Cancer (T3–T4):
Generally require a combination of either
surgery and radiation, radiation and chemo (or
cetuximab), or a combination of all three.

37. Neck in advanced stages
• Neck dissection is often a part of treatment
for stage III and IV cancers.
• Radiation therapy often is required after
surgery, particularly if the tumor has spread to
the lymph nodes (more than 1 LN and / or
extracapsular invasion)

38. Adjuvant Therapy
• Postoperative radiation therapy may be
considered for positive margins; multiple
positive neck nodes or extracapsular
extension; perineural or intravascular
invasion; or bone, cartilage, or soft tissue
invasion
• Chemotherapy indicated for palliation or may
be considered for adjuvant treatment for
advanced disease.

39. Targeted therapy for oral cavity
• Cetuximab (Erbitux®) is a monoclonal antibody
that targets epidermal growth factor receptor
(EGFR).
• Cetuximab may be combined with radiotherapy
for some earlier stage cancers.
• For advanced cancers, it may be combined with
standard chemo drugs such as cisplatin, or it may
be used by itself.

40. THANK YOU