1. Carcinoma of the oral cavity most commonly arises from the lips, tongue, floor of mouth, cheek and retromolar trigone. Major risk factors include smoking, alcohol, betel nut chewing and HPV infection. 2. Early lesions are typically treated with wide local excision or radiotherapy. More advanced tumors involving surrounding bone or lymph nodes may require surgery such as partial glossectomy or mandibulectomy combined with neck dissection followed by postoperative radiotherapy. 3. Prognosis depends on tumor size, location and extent of spread - tumors of the posterior tongue or those invading surrounding structures carry a worse prognosis.

1. ORAL MALIGNANCIES
General Surgery
1st Year Resident

2. ANATOMY OF ORAL CAVITY:
• Lined by non keratinized stratified
epithelium with minor salivary glands
throughout submucosa and within
muscular tissue of tongue.
• Oral cavity transitions into oropharynx at
junction b/w hard &soft palate and at ant
tonsillar pillar.
• Leukoplakia -any white mucosal lesion
• Erythroplakia -any red mucosal lesion &
more concerning than leukoplakia.
• Dyskeratosis-any abnormal keratinisation of
epithelial cells.
These 3 can be found in dysplastic lesions

3. Predisposing Factors

4. Epidemiology:
• Oral ca tightly associated with exposure to causative tobacco
carcinogens.
• HPV-associated with oropharyngeal &nasopharyngeal ca.
• EBV-responsible for subset of nasopharyngeal ca.
• Male predominance due to more males consume tobacco but
in recent years ratio is decreasing because increased incidence
of female smokers.
• HPV associated head and neck SCC has 4:1 male
predominance.
• SCC is MC head and neck tumour[88.9%].

6. STAGING OF ORAL MALIGNANCIES

7. LIP CARCINOMA
Lip begins at vermilion border. It has
got upper lip, lower lip and oral
commissure.
SCC is the commonest lip cancer (90%).
SCC is common in lower lip; BCC is
common in upper lip.
Other cancers :spindle cell carcinoma,
adenoid squamous carcinoma,
malignant melanoma, minor salivary
gland tumour.
Khaini, a mixture of tobacco and lime
kept under the lip called as khaini
chewers are more susceptible for
carcinoma lip

8. PREDISPOSING FACTORS:
• Cheilitis- actinic type
• Solar keratosis
• Papilloma
• Leukoplakia
• Smoking, U-V rays, pipe smokers,
reverse smoking.
• Tobacco chewing, Khaini chewers
(tobacco + lime).
• Agriculturists who are commonly
exposed to sunlight get carcinoma lip
called COUNTRYMANS LIP.

9. CLINICAL FEATURES:
• Non-healing painless ulcer with Everted
edge &with indurations
• Submental, submandibular and upper
deep neck nodes may get enlarged. Tender
firm lymph node may be due to infection;
• Non-tender node is due to carcinoma
spread.
• In half of the cases lymph nodes are
enlarged due to infection or as reactive
process.
• Fungation, bleeding, halitosis

10. Diagnosis:
• Wedge biopsy , FNAC of lymph nodes , CT/MRI head and
neck.
Differential Diagnosis:
• Keratoacanthoma
• Basal cell carcinoma. BCC occurs only in upper lip
• Minor salivary gland tumours
• Often carcinoma of lip is an extension from carcinoma
of cheek
• Malignant melanoma in case of pigmented sec

11. Treatment :
• If< 2 cm curative radiotherapy, either brachytherapy or
external beam radiotherapy.
• If > 2 cm wide excision is done. Excision of lower lip up to one-
third can be sutured primarily, in layers keeping vermilion
border in proper apposition without causing any microstomia.
• Excision of >1/3 of the lip requires reconstruction using
different flaps.
• Lymph nodes are dealt with by radical neck dissection on one
side and functional block or supraomohyoid block dissection
on other side.

12. • For central tumour N0 disease, bilateral elective
(prophylactic) supraomohyoid dissection is done.
• For lateral tumour N0 disease, elective ipsilateral
supraomohyoid dissection is done.
• Post-operative radiotherapy is given if tumour is large or
if lymph nodes are involved.
• When mandible is involved, segmental resection is
done

14. Carcinoma Tongue

15. Anatomy of tongue
• Tongue is a muscular organ located in the floor of the mouth.
PARTS:
1. Tip: Anterior free end lies behind upper incisor teeth.
2. Body Dorsal surface is rough due to papillae; is divided into
anterior 2/3rd (oral part) and posterior 1/3rd (pharyngeal part)
by sulcus terminalis.
Ventral surface is smooth, has a median fold, 'frenulum linguae’
deep lingual vein on either side.
3. Root Attached to the mandible above and hyoid bone below.

16. ANATOMY OF TONGUE SHOWING PARTS & PAPILLAE

17. PAPILLAE
1. Circum vallate-large, located in front of sulcus terminalis.
2. Fungiform-lies over the tip and margin of the tongue.
3. Filiform-lies over the dorsum of tongue, gives velvety
appearance.
4. Foliate-over the margin.
Muscles of Tongue
Intrinsic muscle: Superior and inferior longitudinal,
transverse, vertical.
Extrinsic muscle: Genioglossus, hyoglossus, styloglossus,
palatoglossus.

18. Development of Tongue:
• Anterior 2/3rd develop from first branchial arch through two
lingual
swellings and one tuberculum impar.
• Posterior 1/3rd develops from third arch from cranial half of
hypobranchial eminence.
• Posterior most part develops from the fourth arch.
Blood supply :Lingual artery, a branch of external carotid artery.
Venous drainage: Deep lingual vein which drains into fascial vein or
internal jugular vien.

20. Lymphatic Drainage:
• Tip of tongue drains into submental nodes.
• Lateral margin drains to submandibular
lymph nodes and into upper
deep cervical lymph nodes.
• Posterior third of tongue drain into
pharyngeal group of lymph
nodes, as well as to the upper deep cervical
lymph nodes.

21. Nerve Supply :
• Anterior 2/3rd: lingual nerve
for general sensation; chorda
tympani
for taste sensation.
• Posterior 1/3rd :
glossopharyngeal nerve for
general & taste
sensations.
• Posterior most :vagus nerve
(internal laryngeal nerve).

22. CARCINOMA TONGUE
Aetiology:
• Smoking, spirit, syphilis, sharp tooth, sepsis, spices. Incidence of oral
cancer is six times more in smokers than non smoker.
Premalignant conditions:
• Erythroplakia, leukoplakia, Chronic hyperplastic candidiasis ,
Oral submucosal fibrosis ,Sideropenic dysphagia, Syphilitic glossitis.
TYPES
Gross:1. Papillary.
2. Ulcerative or ulceroproliferative 60%.
3. Fissure with induration.
4. Lobulated, indurated mass-frozen tongue.

24. Histologically :
1. Squamous cell carcinoma-commonest.
2. Adenocarcinoma, arise from minor salivary glands or mucous
glands.
3. Melanomas.
4. Transitional cell carcinoma & lymphoepithelioma.
Clinical Features:
• Painless ulcer/swelling
• Due to involvement of lingual nerve (pain is referred to ear).
• Pain on swallowing, in case of carcinoma of posterior third of
tongue.
• Excessive salivation. Saliva is often blood stained.

25. • Visible ulcer in anterior two-thirds of tongue. Ulcer can bleed on touch. Edge
everted commonly. Ulcer may cross the midline.
• Ankyloglossia-involvement of muscles of the tongue. Movements of tongue
especially forward protrusion is commonly affected.
• Inability to articulate. Foetor (Halitosis). Due to infection& necrosis in oral cavity,
due to release of ammonia, butyric acid & mercaptan by tumour cells.
• Change in voice. Occurs in posterior third tumours. Palpable lymph nodes in the
neck are hard, nodular, get fixed to underlying tissues in advanced stages.
• Bronchopneumonia-due to aspiration during lying down/sleeping mainly to lower
segment of lung.

26. Local spread:
• Anterior 2/3rd of tongue, spread occurs to genioglossus muscle,
floor
of mouth, opposite side & mandible.
• Posterior1/3rd of tongue it spreads locally to tonsil, side of
pharynx
soft palate, epiglottis, larynx and cervical spine.

27. Lymphatic spread:
• Tip of tongue spreads to
submental nodes.
• Lateral margin spreads to
submandibular lymph nodes &
later to deep
cervical lymph nodes.
• Posterior third spreads to
pharyngeal nodes and upper
deep cervical
lymph nodes.

28. Investigations :
• Wedge biopsy
• FNAC of lymph nodes.
• Indirect and direct laryngoscopyto see posterior third growth.
• CT scan to see the extension of posterior third growth, or to see
status of lymph node secondaries.
• MRI is also very useful to assess the extent of primary tumour.
• Chest X-ray to see bronchopneumonia.

29. Treatment :
1. Surgery
• Wide excision with 1 cm clearance in margin & depth is done in tumour
less than 1 cm in size or in carcinoma in situ.
Laser (CO2/diode) can be used.
• Tumour between 1-2 cm in size, partial glossectomy is done with 2 cm
clearance from the margin with removal of 1/3rd of anterior 2/3rd.
• Tumour larger than 2 cm, hemiglossectomy is done with removal of
anterior 2/3rd of tongue on one side up to sulcus terminalis.
• Larger primary tumour can be given pre-operative radiotherapy, later
hemiglossectomy is done.
• Same side palpable, mobile lymph nodes are removed by radical neck
block dissection.

31. • Wide excision is done when growth is in the tip of tongue.
Posterior third growth can be approached by lip split & mandible
resection, so as to have total glossectomy Kocher's approach.
• When mandible is involved hemimandibulectomy is done.
• Commando Operation : procedure that involves wide excision or
hemiglossectomy, hemimandibulectomy and radical neck dissection
together .

32. Radiotherapy:
• Small primary tumour-curative radiotherapy (Brachytherapy using
caesium or iridium 192 needles).
• Large primary tumour-initial radiotherapy is given to reduce tumour
size so that the resection will be better later.
• Advanced primary as well as secondaries in the neck can be
controlled by palliative external radiotherapy.
• Post-operative radiotherapy is given in large tumours to reduce
chances of relapse. In case of growths in the posterior 3rd of tongue,
radiotherapy is of curative as well as palliative mode.
Loss of sensation like taste Trismus ,ankyloglossia Pharyngeal,
laryngeal oedema Dermatitis & severe sepsis.

33. Chemotherapy
• In post-operative period & also for palliation. Price-Hill regimen is
commonly used.
• Drugs are methotrexate, vincristine, adriamycin, bleomycin and
mercaptopurine.
• Given intra-arterially, as regional chemotherapy through external
carotid artery using arterial pump or through IV.
• Can also be given orally.
COMPLICATIONS OF CHEMOTHERAPY :Megaloblastic anaemia,
Bone marrow suppression, Alopecia, Sepsis.

34. Poor Prognostic Factors:
• Size of the tumour >4 cm caries poor prognosis.
• Site of tumour (posterior third has got poor prognosis).
• Tumour crossing the midline.
• Lymph nodes status.
• Poor differentiation.
• Bone involvement.

35. CHEEK/BUCAL MUCOSA
• Anatomy of Cheek:
• They are fleshy flaps on either side of
the face. The demarcation between
the lips and cheek is nasolabial fold.
• Composed of skin, superficial fascia
with parotid duct, buccinator muscle,
submucosa with buccal glands and
mucous membrane.
• Lymphatics- Submandibular and
preauricular nodes.

36. Retromolar trigone (coffin corner’)
• It is triangular in shape with base is superior behind the 3rd upper molar
tooth and apex inferiorly behind the lower 3rd molar tooth.
• Carcinoma in this area commonly invades the ascending ramus of the
mandible , the pterygomandibular space, Tonsillar fossa, soft palate.
• Lymphatics from this area may communicate into pharyngeal lymphatics.

37. SITES OF CARCINOMA IN ORAL CAVITY IN ORDER:
In India
• Cheek-commonest
• Tongue
• Floor of the mouth
• Palate
• Lips
In Western countries
• Tongue
• Floor of the mouth
• Lip
• Cheek

38. CARCINOMA CHEEK/BUCAL MUCOSA
SCC is mc type of ca of cheek.
Precipitating Factors:
• All 'S'-Smoking, spirit, syphilis, sharp
tooth, sepsis, spices
• Betel nut chewing (Pan, with pan quid kept
in cheek pouch for a long time) .
• Betel/areca nut, betel leaf, slaked lime, and
tobacco (often with catechu and
condiments) .

39. Clinical Features :
• Ulcer - Everted edge, induration are the typical
features of the ulcer
• Pain
• Halitosis
• Trismus and dysphagia.
• Involvement of retromolar trigone indicates
that it is an advanced disease.
• Mandible may get involved by direct extension,
through mandibular canal, or through
periodontal membrane.

40. ANDY GUM DEFORMITY
• Loss of central part of
mandible due to
destruction by tumour wi
ll cause pouting of lower
lip with drooling of
saliva-Andy
Gump deformity.

41. • Occasionally it may extend into
the upper alveolus and to the
maxilla causing swelling, pain
and tenderness.
• Once involvement of soft tissue
occurs, it may come out through
skin as fungating lesion often
with orocutaneous fistulas with
saliva dribbling through fistula.

42. • Submandibular lymph nodes and upper deep
cervical lymph nodes are involved which are
hard and nodular; initially mobile and later
get fixed to each other and then to
deeper structure
• -Horner's syndrome
• -Defective shrugging of shoulder
• -Tongue will deviate towards the same side

43. • Compression over external carotid artery leads to absence
of superficial temporal artery pulsation.
FEATURES OF ADVANCED CARCINOMA CHEEK:
• Involvement of retromolar trigone .
• Extension into the base of skull and pharynx
• Fixed neck lymph nodes
• Extension to the opposite side

44. Investigations
• 1. Wedge biopsy
• 2. FNAC from lymphnodes
• 3.CT scan (for extent of
tumor)

45. Treatment
• Treatment may be curative or palliative.
• Treatment strategy
i. Surgery: Wide excision,
hemimandibulectomy, neck lymphnodes
block dissection.
ii. Radiotherapy: Curative or palliative; external
or brachytherapy.
iii.Chemotherapy: Intra-arterial, IV or orally.

46. Indications of surgery
• Early tumour
• Tumour spreading to mandible
bone/alveolus
• Fungation, haemorrhage due to erosion
• Recurrence of tumour after RT
• Multiple sites
• Soft tissue spread
• Locally advanced but amenable to
surgical resection

47. Early growth without bone involvement:
1. Curative radiotherapy i.e. brachytherapy. Advantages:
i. Surgery is avoided.
ii. No surgical mutilation.
iii. Parts are retained.
iv. As it is a squamous cell carcinoma, primary is
radiosensitive-90% cure rate
2. Other option is wide excision with 1-2 cm
clearance(Patterson operation).

48. 3. Present advanced technology in radiotherapy, facilitates
the use of external radiotherapy also. The incidence of
dreaded complication like osteoradionecrosis of mandible
has been reduced due to better RT methods.
Growth with mandible involvement:
• Here along with wide excision of the primary tumour,
hemimandibulectomy or segmental resection of the
mandible or marginal mandibulectomy (using rotary
electric saw) is done

49. Operable growth with mandible involvement and mobile
lymph nodes on the same side (confirmed by FNAC):
• Along with wide excision of the primary,
hemimandibulectomy and radical neck lymph node
dissection is done (like commando operation). Wide
excision of primary lesion, hemimandibulectomy with
radical neck node dissection is called as composite
resection

50. Operable growth with mandible involvement; mobile
lymph nodes on same side and opposite side:
• Along with wide excision of the tumour,
hemimandibulectomy, radical neck lymph node
dissection on same side and functional block
dissection on opposite side are done, retaining the
internal jugular vein, sternomastoid, spinal accessory
nerve.

51. Operable primary tumour with mobile lymph nodes on
same side but without mandibular involvement:
• Wide excision of primary tumour and radical neck
lymph node dissection on same side are done.
Mandible is not removed.

52. Role of chemotherapy:
Drugs used are methotrexate, cisplatin,
vincristine, bleomycin, adriamycin.
• Often it is given intra-arterially through external carotid
artery using arterial pump or IV or orally-post-operatively. ,
• Initial chemotherapy to downstage the tumour followed by
surgery and later again end with chemotherapy.
• Chemoradiotherapy is used in unresectable tumours-as
consecutive therapies