Squamous cell carcinoma is the most common malignant neoplasm of the oral cavity.

It constitutes 5% of all body’s malignant tumors.

The lesion represents more than 90% of all head and neck cancers.

Behaviour of squamous cell carcinoma depends on its site of origin.

Each anatomic site has its own particular spread pattern and prognosis.

It is common in male compared to women

Alcohol and tobacco use

40 times higher is tobacco users and alcoholics

Mutation of p53 gene correlated to alcohol and smoking

Viral infection

EBV associated with nasopharnyeal tumours

HPV-16 oropharyngeal tumours

Environmental exposures to ultraviolet sunlight, ionizing radiation, paint fumes, plastic byproducts, wood dust, asbestos, gasoline fumes are also risk factors.

Pre cancerous lesions eg erythroplakia, actinic chelitis

Betel quid: mixture of areca palm nuts, betel leaf, slaked lime with tobacco leaves sometimes. Chewed for their psychostimulating effect. Among users 8% develop cancer and pre cancerous lesion like leukoplakia

Dietary deficiencies eg. vitamin A and iron defficiencies associated with Plumer-Vinson syndrome have been linked to oral, oesphagus and pharyngeal cancers.

Trauma: chronic trauma

Phenols: increased oral cancer risk for workers in wood product industry chronically exposed to certain chemicals such as phenoxyacctic acids. They are also at risk of developing nasopharngeal cancer.

Tongue and floor of the mouth 45%

Lip (almost 98% involving lower lip) 25%

Gingiva 10%, Palate 10% (mostly soft ) and Cheek 10%.

Others include the anterior tonsillar pillar, and the retromolar trigone, maxillary sinus

. At early stages the lesion appears as a comparatively innocent – looking surface lesion with erythema and slight elevation of the oral mucosa and it is symptomless

These early red lesions termed as “erythroplakia” or whitish lesion leukoplakia are asymptomatic and may be carcinoma in situ or invasive carcinoma.

When advanced the lesion appears papillary, ulcerative, nodular, fissured or as an atrophic ulcer. The most frequent type is the ulcerative one.

Ulcer bleeds easing on touch or from minor trauma

If the lesion is on the tongue, the tongue can be fixed with minimal or no mobility

An irregular ulcer with everted edges; there is a hard infiltrating zone ( an induration) to be felt around the visible lesion

A foul smelling ulcer/lesion in advanced carcinomas.

Lypmhadenopathy

Mobility and tooth loss when the underlying bone is involved.

Nasal obstruction and bleeding is noted

When it extends upward the eye is displaced

Downward ulcerative swelling on the palate

Backward into the pterygoid plate plates, anterior to the cheek area.

The hallmark of squamous cell carcinoma is the presence of keratin or “keratin pearls” on histologic evaluation.

Carcinoma histologically can appear as: –

Moderately well – differentiated neoplasm with some evidence of keratinization

Highly anaplastic lesion.

Well differentiated epidermoid carcinoma consisting of sheets and nests of cells with obvious origin from squamous epithelium.

Anaplastic lesion do produce metastases early, and quickly may cause death.

Poorly differentiated carcinomas bear little resemblance to their cells of origin.

Treatment

Factors that influence the choice of treatment are the site, grade, and stage of the primary tumour, patient’s age, regional lymphnodes involvement, metastases; and general medical condition.

prognosis

Time for being free of tumour the next 5 years is only 50%

The three forms of skin cancer include basal cell carcinoma, squamous cell carcinoma and malignant melanoma.

Basal cell carcinoma is the most common type of skin cancer of the face.

It is believed that it arises from the basal layer of the skin or from the hair follicles.

Exposure to the ultraviolet rays in sunlight is recognized as being carcinogenic.

radiation therapy and arsenic ingestion are also contributing factors.

The lesion shows no tendency for metastasis.

Clinical features

The head and neck are the most affected, with 85% of basal cell carcinomas occurring in sun exposed areas. It can also affect sun-protected areas such as the genitalia and breasts, but this is rare.

Men have a significantly higher incidence than women. M:F= 3:2

Fair-skinned people and a high degree of sun exposure are commonly affected, but it is rare in dark-skinned individuals.

The tumour in the face affects the area above the line drawn from the tragus to the corner of the mouth.

The tumour frequently begins as a small papule (small hard lump) on the skin that ulcerates, heals and ulcerates again, giving foundation to the name ‘RODENT ULCER’ which it has been termed.

There is only little infiltration on the surrounding skin. Either there is little infiltration to the tissues beneath the skin.

Basal cell carcinoma is only locally malignant tending to recur if not radically removed.

AIthough basal cell carcinoma rarely metastasizes,it can affect the surrounding tissues if left untreated.

Tumour cells of nodular basal cell carcinoma, sometimes called basalioma cells, typically have large, hyperchromatic, oval nuclei and little cytoplasm.

Cells appear uniform, and, if present, mitotic figures are usually few.

Surgical excision of the clinically apparent tumour and a margin of clinically normal-appearing skin followed by skin grafting or irradiation give equal chances of a 5 years survival free of tumour.

Radiotherapy is useful in patients who cannot easily tolerate surgery, like the elderly or debilitated individuals. It is also useful in postoperative BCC patients.

Osteosarcoma is the most common and most malignant of this rare group of primary bone tumours. The tumour occurs quite seldomly in the jaws especially the lower jaw.

Osteosarcoma predominantly involves long bones mainly the tibia and femur; however, it can occur in any bone.

Clinical features

The lesion occurs in young and young adults, the majority between 10 and 25 years of age; the incidence decreases with an increasing age.

Pain and swelling are early features.

Paraesthesia of lower lip when there is mandibular canal involvement.

Jaw enlargement, teethache, loosening of teeth and bleeding

In some cases trauma in the skeleton proceeds osteosarcoma at the site.

The lesion also occurs with considerable frequency in bones affected by osteitis deformans or Paget’s disease and also in bones which have received irradiation.

In the later stage when the tumour has perforated through the bone or after extraction of a tooth on the affected area the tumour grows through the perforation or the alveolus. The osteosarcoma is seen as a soft fleshy, rapidly increasing and easily bleeding tumour.

The tumour infiltrates rapidly the surrounding tissues and causes early far metastases, mostly haematogenous,but also often lymphogenous.

Radiological features

Osteosarcoma may be of the osteolytic type that is commonly observed; there is an irregular bone destruction without clear outline

In some cases irregular spicules or trabeculae of new bone may be seen radiating outward on the periphery of the lesion, producing the so called Codman’s triangle and “SUN RAY” appearance.

Treatment

Radical excision, in some cases, followed by chemoradiotherapy.

Prognosis is better than sarcoma in other bones. Highly malignant.

Direct invasion: infiltration of surrounding tissues, also infiltration along tissue planes and septal as in cancer of the breast.

Invasion of lymphatics: carcinoma and melanoma invade lymphatic vessels at an early stage, lymphatic permeation causes regional lymph node metastases.

sarcoma invades lymphatic at late stage.

3)Invasion of blood vessels cause hematogenic metastases.

hematogenic spread is common in sarcoma.

responsible for death in most cases.

limits the surgical and radiotherapic treatment of cancer.

Functional effects

Difficult and painful swallowing: impairs intake of nutrients and this can be a cause of wasting and weight loss. Loss of taste, dry mouth and pain contributes to this difficult

Impaired speech: tumors or surgical intervation can affect the ability to speech properly and clearely

Pain and discomfort oral malignancy causes persistent pain and discomfort especially during functions like eating, speaking. Also the pain is due to nerve involvement

Ulcerations and sores

Weight loss

Facial disfirgurement

Anxiety and depression the diagnosis and treatment of cancer can cause stress, anxiety

Arriving to a state of acceptance takes time.

Social isolation

Difficult in speaking, eating or chances in apperarence can lead to social withdrawl and isolation

Side effects of chemotherapy and radiation common side effect include xerostomia,nausea, vomiting, mucositis

Surgical complication

Surgery can lead to infection,disfigurement,loss of functional

Dental caries, root caries are common, also due to xerostomia self cleansing of oral cavity is reduced

Bleeding

Weight loss

Loss of sensation

Secondary infection

Insomia due to pain contributes to wasting