Brief Description of the types, epidemiology, clinical features & management of oral cancers

1. Dr. Yogesh Belagali
Medical Advisor- Oncotherapeuitcs
CANCERS OF THE ORAL CAVITY

2. TYPES
Malignant epithelial tumors
 Squamous cell carcinoma
 Verrucous carcinoma
 Basaloid squamous cell carcinoma
 Papillary squamous cell carcinoma
 Spindle cell carcinoma
 Acantholytic squamous cell carcinoma
 Adenosquamous carcinoma
 Carcinoma cuniculatum
 Lymphoepithelial carcinoma

3. Benign epithelial tumors
 Papillomas
 Squamous cell papillomA and verruca vulgaris
 Condyloma acuminatum
 Focal epithelial hyperplasia
 Granular cell tumour
 Keratoacanthoma
TYPES

4. SALIVARY GLAND TUMOURS
Salivary gland carcinomas
 Acinic cell carcinoma
 Mucoepidermoid carcinoma
 Adenoid cystic carcinoma
 Polymorphous low-grade adenocarcinoma
 Basal cell adenocarcinoma
 Epithelial-myoepithelial carcinoma

5. Salivary gland carcinomas
 Clear cell carcinoma
 Cystadenocarcinoma
 Mucinous adenocarcinoma
 Oncocytic carcinoma
 Salivary duct carcinoma
 Myoepithelial carcinoma
 Carcinoma ex pleomorphic adenoma
SALIVARY GLAND TUMOURS

6. Salivary gland adenomas
 Pleomorphic adenoma
 Myoepithelioma
 Basal cell adenoma
 Canalicular adenoma
 Duct papilloma
 Cystadenoma
SALIVARY GLAND TUMOURS

7. Soft Tissue Tumors
 Kaposi sarcoma
 Lymphangioma
 Ectomesenchymal chondromyxoid tumour
 Focal oral mucinosis
 Congenital granular cell epulis
SALIVARY GLAND TUMOURS

8. EPIDEMIOLOGY IN INDIA
 Accounts for over 30% of all cancers in the
country
• Globocan 2008

9. EPIDEMIOLOGY- WORLD

10. SQUAMOUS CELL
CARCINOMA(SCC)
 Definition- An invasive epithelial neoplasm with
varying degrees of squamous differentiation
and a propensity to early and extensive lymph
node metastases, occurring predominantly in
alcohol and tobacco-using adults in the 5th and
6th decades of life.
 Etiology-
 Tobacco smoking & alcohol
 Tobacco chewing
 Human Papilloma Virus (HPV) infection

11. MACROSCOPIC APPEARANCE

12. MICROSCOPIC APPEARANCE
• Moderately differentiated SCC.
•Cells formlarge anastomosing
areas in which keratin pearls are
formed.
•Main component consists of cells
with pronounced cytonuclear atypia
•Well-differentiated SCC
•Characterized by abundant
formation of keratin pearls.

13.  Poorly differentiated SCC.
 Cells with atypical nuclei and a small rim of
eosinophilic cytoplasm form strands and small
nests.
MICROSCOPIC APPEARANCE

14. SIGNS & SYMPTOMS
 Small oral and oropharyngeal SCC are often
asymptomatic or may present with vague symptoms
 Red lesions, mixed red and white lesions, or white
plaques.
 Mucosal growth, pain and ulceration
 Referred pain to the ear
 Malodour from the mouth
 Difficulty with speaking, opening the mouth, chewing
 Pain with swallowing

15. DIAGNOSIS
 Physical examination- Visual inspection and
palpation of all mucosal surfaces, bimanual
palpation of the floor of the mouth and clinical
assessment of the neck for lymph node
involvement.
 Biopsy- Confirmatory test
 Fine needle aspiration cytology
 Routine pan endoscopy
 Three-dimensional imaging with computed
tomography (CT) and magnetic resonance
imaging (MRI)

16. LYMPHOEPITHELIAL CARCINOMA
 Definition- Lymphoepithelial carcinoma (LEC) is
a poorly differentiated squamous cell carcinoma
(SCC) or undifferentiated carcinoma,
accompanied by a prominent reactive
lymphoplasmacytic infiltrate.
 Etiology-Epstein- Burr Virus
 Clinical Features - Intra-oral mass, which may
be ulcerated

17. PAPILLOMAS
 Definition- Localised hyperplastic exophytic and
polypoid lesions of hyperplastic epithelium with a
verrucous or cauliflower-like morphology
 Etiology- HPV infection

18. ORAL CAVITY MANAGEMENT
 Radiation
 Surgery
 Combined therapy

19. TREATMENT OF EARLY DISEASE
Surgical Excision
 Management of choice
 Excellent cure rates with minimum morbidity
Radiotherapy (Interstitial or External)
 Equally effective as surgery for the treatment of
early disease
 Long-term sequelae including xerostomia,
dysphagia and osteoradionecrosis are major
limitations
 Requires daily therapy for 6–7 weeks
 Reserved for those patients who are unable to
undergo surgery

20. UICC/AJCC STAGING FOR
ADVANCED ORAL CAVITY
CANCER
 Small Tumor with neck metastasis
 T1-T2, N2-3
 Tumor < 4 cm with 2 or more cervical metastasis,
one or more contralateral cervical metastases, or
cervical metastasis > 3cm

21. PRIMARY SURGERY + RADIATION
INDICATED FOR ADVANCED ORAL
CAVITY CANCER
 Low local control for primary radiotherapy for
advanced oral cavity (30-40%) and poor survival
(25%)
 Increased local control with surgery +
radiotherapy (60%) and improved survival (55%)
 Zelefsky et al, Head Neck. 1990 Nov-Dec;12(6):470-5
 Local control significantly improved for locally
advanced T3, T4 oral cancers using surgery +
postoperative radiotherapy vs. primary RT
 Fein et al. Head Neck. 1994 Jul-Aug;16(4):358-65

22. SURGICAL APPROACHES
 Transoral
 Visor
 Lip Split with or without mandibulotomy
 Lip Split with Mandibulectomy

23. SURGICAL APPROACHES
 Transoral and Visor Approaches
 Cosmetic but may limit exposure
 Lip Splitting
 Modest cosmetic disadvantage with excellent
posterior exposure for mandibulotomy
 Paramedian or midline mandibulotomy
 Avoidance of alveolar nerve

24. SURGICAL APPROACHES
CAVEATS
 Approach determined before incision and
mandibulectomy or mandibulotomy
 Accurate assessment of bone erosion, involvement of neural
structures

25. SURGICAL RESECTION
ADVANCES
 Reconstruction
 Reconstruction
 Free Tissue Transfer
 Mandibular reconstruction (fibula, scapula, etc.)
 Soft tissue/tongue (radial forearm, rectus
abdominus, lateral thigh, etc.)
 Resection is rarely limited by size or extent of
tumor

26. CONTRAINDICATIONS TO
RESECTION
T4b: invasion of masticator space,
pterygoid plates, skull base, or
carotid encasement
Patient perception of
quality of life

27. SURGICAL EXCISION
 To achieve a complete resection of the tumor with
free margins
 In cases where there are positive or close
margins (tumor within 5 mm of the surgical
margin), surgical re-resection is recommended
 In cases where a re-resection is performed and
evidence of microscopically positive margins
remains or if resection cannot be reliably
performed, radiation therapy directed at the
primary site should be considered.

28. MANAGEMENT OF TUMORS
INVADING MANDIBLE
 A marginal or a segmental resection
 Tumor invasion of the periosteum or cortical
bone, without invasion of the medullary cortex,
can be appropriately managed with a marginal
resection.
 Tumors that erode into the medullary canal,
however, require a segmental resection
 Postoperative external beam radiation is
mandatory for tumors that invade mandible

29. MANAGEMENT OF TUMORS INVADING
THE BUCCAL MUCOSA
 Buccal cancer comprises10% of oral cavity
cancers
 It commonly arises from pre-existing leukoplakia.
 In early disease, surgical excision can usually be
accomplished transorally
 Advanced tumors may require a midline
labiotomy incision.

30. MANAGEMENT OF TUMORS
INVOLVING THE HARD PALATE
 Superficial lesions of the palatal mucosa are best
managed with a wide surgical resection including
the underlying palatal periosteum

31. CLINICAL EVIDENCE

32. Primary Surgical Therapy Followed by
Postoperative Chemotherapy and Radiation
I: EORTC Bernier et al. NEJM 2004
 Previously untreated SCC, all head and neck sites,
n=167, 5 year median follow up
 100 mg/m2 cisplatinum day 1, 22, 43 during
postoperative irradiation or postoperative radiation
alone

33. Primary Surgical Therapy Followed by
Postoperative Chemotherapy and Radiation:
EORTC Bernier et al. NEJM 2004
 pT3 or pT4, any N, except T3N0 of the larynx,
with negative resection margins
 pT1 or T2, N2 or N3
 T1 or T2 and N0 or N1 with pathological
extranodal spread, positive resection margins,
perineural involvement, or vascular tumor
embolism
 Oral cavity or oropharyngeal tumors with involved
lymph nodes at level IV or V

34. EORTC Bernier et al. NEJM 2004
 The overall survival rate 53% vs 40%, p=0.02
 Locoregional failure 18% vs. 31%, p=0.007
 Severe (grade 3 or higher) adverse effects 41%
vs. 21% p=0.001

35. Postoperative Chemoradiation for
Advanced Head and Neck Cancer
 Clear advantage in locoregional control
 Survival advantage
 Difference in enrollment criteria may suggest survival
advantage for locally aggressive tumors without
significant nodal disease

36. New Trials : Molecular Targeted
Therapy, EGF Inhibitors
Bonner, et al, NEJM, 2005
Radiation only Cetuximab+RT p-value
Patients randomized 213 211
Median survival
- Two-year survival
- Three-year survival
28 mo
55%
44%
54 mo
62%
57%
0.02 (log-rank test)
Grade 3/4 mucositis 52% 55% 0.50 (Fisher's exact)
Grade 3/4 infusion
reaction
- 3% 0.01 (Fisher's exact)
Grade 3/4 skin reaction 18% 34%
0.0003 (Fisher's
exact)

37. CONCLUSIONS
 Early disease (stages I–II) is generally curable
with single modality therapy.
 Surgery is preferable in most cases
 Advanced disease (stages III–IV) is best
managed with multimodality therapy, generally
with surgery followed by radiotherapy particularly
for high-risk primary lesions
 Adjuvant chemoradiotherapy to the neck is
indicated for N2 or greater disease.

38. REFERENCES
 Genden EM,Ferlito A et al. Contemporary management
of cancer of the oral cavity. Eur Arch Otorhinolaryngol
(2010) 267:1001–1017.
 Cancela M, Voti L, Guerra-Yi M, Chapuis F, Mazuir M,
Curado MP (2010) Oral cavity cancer in developed and
in developing countries: population-based incidence.
Head Neck (in press)
 Hashibe M, Brennan P, Chuang SC et al. Interaction
between tobacco and alcohol use and the risk of head
and neck cancer: pooled analysis in the International
Head and Neck Cancer Epidemiology Consortium.
Cancer Epidemiol Biomarkers Prev. 1999, 18:541–550

39. REFERENCES
 Hennessey PT, Westra WH, Califano JA (2009)
Human papillomavirus and head and neck squamous
cell carcinoma: recent evidence and clinical
implications. J Dent Res 88:300–306
 Chaturvedi AK, Engels EA, Anderson WF, Gillison ML
(2008) Incidence trends for human papilloma virus-
related and -unrelated oral squamous cell carcinomas
in the United States. J Clin Oncol 26:612–619
 Smeets SJ, Hesselink AT, Speel EJ, Haesevoets A,
Snijders PJ (2007) A novel algorithm for reliable
detection of human papillomavirus in paraffin
embedded head and neck cancer specimen. Int J
Cancer 121:2465–2472