Oral Cancer

Rakefet Czerninski
Head, Oral Diseases Clinic
The Department of Oral Medicine
 Oral Cancer

Oral cancer – 3% of malignancies in the USA.

90% of oral cancer - Squamous cell carcinoma
(Other types -Oral lymphoma, Sarcoma ,Melanoma
Salivary Glands tumors )
Sixth most frequent of all malignancies, accounting
for 2-4% of all cancer cases
 Worldwide Prevalence

Estimated 378,500 new cases annually worldwide

Incidence & 5 years survival rate has not
changed significantly ~ 50%

Most common in:

Sri Lanka -40% of all cancer cases
India -50% of al cancer cases
Pakistan and Bangladesh
 High
Risk
Patients
 Risk Groups

Over 50

2 1
 Risk Groups

Over 50 History of Immuno - Oral lichen

Oral cancer suppressive Planus
conditions

2 1
 Oral Lichen Planus

Common chronic
inflammatory disease of
skin and mucous
membranes.
 Oral Lichen Planus

“…..Oral Lichen
Planus ,…, have
to be considered
as ‘at risk’ for malignant
transformation”

May 2005
 Risk Groups

Over 50 History of Immuno - Oral lichen

Oral cancer suppressive Planus
conditions

Tobacco usage

Alcohol

Sun exposure
In 1935
10:1
 Tobacco Use

Heavy smokers- Increased risk

of OSCC x 5- 25

Use of tobacco in any form

(snuff, chewing tobacco, cigar,
cigarette, pipe) is a major risk
factor

The relative risk is

dose & time dependant

The only definitive treatment is

smoking cessation
 Alcohol

Alcohol increases
the risk of cancer
in the upper
aerodigestive
tract ,
The relative risk of
cancer is dose-
and time-
dependent
 UV radiation
Prolonged sun exposure -
actinic cheilitis &
increased risk of
malignancy .

risk -increased in light-

skinned individuals

& primarily the lower lip.

3200-2900nm-UVB More dangerous –causes lip cancer

3200-3400nm-UVA
 ‫•‬
‫במדינת ישראל חיים כיום כ‪ 120,000-‬איש ואישה אשר אובחנו כחולים במחלות הסרטן‪ .‬חלק ניכר מהם‪,‬‬
‫הבריאו‪ .‬מחקרים בעולם ובארץ הראו שניתן כיום לרפא כ‪ 60%-‬מכלל חולי הסרטן המאובחנים‪ .‬זאת לעומת‬
‫כ‪ 20%-‬שיעור ריפוי שהושגו בתחילת המאה ה‪ .20-‬העלייה המשמעותית ביכולתנו לנצח את הסרטן תלויה‬
‫בין השאר‪ ,‬בהתפתחות המחקר‪ ,‬דרכי האיבחון והטיפול‪ .‬אך יותר מכל‪ ,‬במניעה ובאיבחון מוקדם‪.‬‬
‫בשנים האחרונות מתגבשת הדעה שהרוב המכריע של מחלות הסרטן קשור בהתנהגות‪ ,‬בסגנון חיים‪ ,‬ובחשיפה‬
‫לגורמים סביבתיים מסרטנים‪.‬‬
‫מדי שנה‪ ,‬מאובחנים בישראל כ‪ 23,000-‬חולי סרטן חדשים‪ .‬בידינו להקטין מספר זה ולהגדיל את סיכויי הריפוי‬
‫של מחלות סרטן שלא ניתנות למניעה‪.‬‬

‫סגנון חיים – המפתח למניעה‬

‫האמונה המוטעית שמחלת הסרטן היא "גזירה משמים"‪ ,‬רווחת בציבור‪ .‬היום ידוע‪ ,‬שניתן למנוע חלק ממחלות‬
‫הסרטן‪ ,‬וניתן לרפא בשיעורים גבוהים חלק נכבד מהחולים‪ .‬למרות התפתחות הידע והטכנולוגיה‪ ,‬עדיין הדרך‬
‫הטובה ביותר לנצח את מחלות הסרטן היא למנוע את התפתחות המחלה‪.‬‬
‫בחלק ממחלות הסרטן‪ ,‬ידועים גורמים אשר עשויים להגביר או להקטין את הסיכון לחלות‪ .‬כך למשל‪ ,‬הוכח כי‬
‫למעלה מ‪ 85%-‬ממקרי סרטן הריאה נגרמים כתוצאה מעישון‪ ,‬לכן הימנעות מהרגל מזיק זה‪ ,‬או הפסקתו‪ ,‬עשויים‬
‫למנוע את התפתחות המחלה אצל המעשן‪ ,‬או הנמצאים בקרבתו‪ ,‬החשופים לנזקי העישון הפסיבי‪.‬‬
‫מחקרים חדשים מצביעים על כך שמשקל עודף‪ ,‬דיאטה בעלת שיעורי שומן גבוהים‪ ,‬צריכת קלוריות רבות‪,‬‬
‫ופעילות גופנית מועטה‪ ,‬עלולים להגביר את הסיכון לחלות בסרטן המעי‪ ,‬ובסרטן השד‪ .‬שתייה מופרזת של אלכוהול‬
‫ועישון סיגריות‪ ,‬קשורים אף הם עם סרטן הפה‪ ,‬סרטן דרכי הנשימה והעיכול העליונות‪ ,‬סרטן כיס השתן‪ ,‬ועוד‪.‬‬
 Oral carcinogenesis

Multifactorial – intrinsic, extrinsic factors

 Extrinsic factors

Smoking
Tobacco chewing
Alcohol
UV radiation
Oncogenic viruses – HPV 16, 18
Inhibition of p53 à defect in DNA Repair, Lack
of apoptosis
 Intrinsic factors

• Vitamin deficiencies –
– Plummer Vinson syndrome
• Postcricoid dysphagia
• Upper esophageal webs
• Iron deficiency anemia

– Immunosuppression
 Clinical appearance

Exophytic/Indurated lesion

Irregular indurated borders

Firm, Ulcerated, Erythematous
Non tender
(may hurt in advanced stages or
with perineural invasion)
 Clinical appearance

A major clinical sign, which should

alert the physician
a chronic ulcer, which is not related
to local trauma and does not heal
within two to three weeks

Tongue – 25-40%
Floor of mouth 15-20%
Most tumors are in Non Keratinized mucosa
 SCC-Tongue
Most prevalent Carcinoma of the oral cavity
More aggressive in young
No symptoms, in advanced stages, pain and
dysphagia
Almost half cases are at the lateral side of the
tongue-late detection & poor prognosis
.
 Clinical appearance

A major clinical sign,

which should alert the
physician-
a chronic ulcer, which is
not related to local
trauma and does not heal
within 2-3 wks
‫בת ‪ ,78‬המרותקת לביתה התלוננה על כאב עז בחלל הפה ‪,‬הופנתה לביצוע ביופסיה‬
‫בחשד לקרצינומה ברצפת הפה‬
 ‫בבדיקה במרפאת ריריות הפה במחלקה לרפואת הפה בהדסה נמצא משקע אבנית‬
‫ניכר ע"י התותבת התחתונה בצד הפונה לרקמה‪ .‬ולכן האבחנה הייתה כיב טראומטי‬
‫‪.‬הומלץ על הסרת הגורם המגרה ומעקב‬
‫לאחר שבועיים נראה ריפוי של הכיב בחלל הפה )ע"י צוות יד שרה(‪.‬‬
+ 6 weeks
+ 5 month
+ 6 weeks
 Clinical manifestations

• Cervical lymph node enlargement

– Infection
– Reactive hyperplasia secondary to the
tumor
– Metastatic disease.

• Early carcinomas may not be painful

– In advanced disease may cause pain and
difficulty with speech and swallowing.
 Metastasis

• Through the lymphatics to ipsilateral

cervical lymph nodes
• Lymph node that contains metastatic
deposit of carcinoma-firm –stony hard,
non tender,
• Enlarged in advanced stage-
fixed/not easily moveable
• 2% of patients will have distant
(bellow clavicle) metastasis at diagnosis
(lung, liver, bones)
 Metastasis

• Not an early event but because of

delay in diagnosis-appx.20% of
patients have cervical metastasis in
diagnosis
• Tumors more post. in the
oropharynx prone to early
metastasis
 Delay

In the early stage,

minimal /absence of pain is often
responsible for
critical delays in diagnosis,
since patients do not seek
medical advice in time
Diagnosis – 4-8 months
after initial presentation
 Clinical staging

Determines prognosis:

Staging – TNM

T = Tumor size
N = Nodes (lymph nodes)
 Clinical staging

TX Primary tumor cannot be assessed

T0 No evidence of primary tumor
T is Carcinoma in situ
T1 Tumor 2 cm or less in greatest dimension
T2 2 cm <tumor< 4 cm --- “ ----
T3 4 <Tumor in greatest dimension
T4 (lip) Tumor invades adjacent structures
(e.g., through cortical bone, tongue, skin of neck)
T4 (oral cavity) Tumor invades adjacent structures
(e.g., through cortical bone, into deep [extrinsic] muscle of tongue, maxillary
sinus, skin)
 Clinical staging –n=lymph nodes
NX Regional lymph nodes (LN) cannot be assessed
N0 No regional lymph node metastasis

N1 single ipsilateral ,up to 3 cm in greater dimension (GD)

N2 --”--, 3 cm <LN<6 cm in GD
multiple ipsilateral LN, none more than 6 cm in GD
bilateral /contralateral LN, none more than 6 cm in GD
N2a single ipsilateral 3cm<LN<6cm in GD
N2b multiple ipsilateral,
ipsilateral none more than 6 cm in GD
N2c bilateral /contralateral,
contralateral none more than 6 cm inGD

N3 LN more than 6 cm in GD
 Clinical staging M=metastasis

MX Presence of distant metastasis cannot be

assessed
M0 No distant metastasis
M1 Distant metastasis
Clinical staging
 Pathological grading

Degree of keratinization
Cellular and nuclear pleomorphism
Mitotic activity
 Tumor grading
G1 – Well-differentiated
(Low-grade and less aggressive)
G2 – Moderately well-differentiated
(Intermediate-grade and moderately
aggressive)
G3 – Poorly differentiated
(High-grade and moderately aggressive)
G4 – Undifferentiated
(High-grade and aggressive)
 Treatment
Surgery, Radiotherapy and Chemotherapy
Temporary/Permanent effects:
mucositis, hypo salivation
dysphagia, taste disturbances,
Infections, accelerated dental decay.
Function:
• airway management,
• mastication,
• swallowing,
• speech

Cosmetic appearance

Significantly compromise the quality of life .

 5 year survival

Oral cancer survival trends over time

•Diamond, J., "C". Because cowards get cancer too. 1998, London: Vermillion.
•South West Cancer Intelligence Service. 2005
•Office for National Statistics. One- and five-year survival of patients diagnosed in 1991-95 and 1996-99: less common
cancers, sex and age, England and Wales. 2005.
•Coleman, M., P. Babb, and P. Damiecki, Cancer Survival Trends in England and Wales, 1971-1995: Deprivation and NHS
Region. 1999: TSO
 Distribution of oral cancer cases reported by the
Israel National Cancer Registry starting in 1970 until 2006,
by site.

Salivary Glands Lip

& Mouth 37%
Naso-pharynx & 14%
Mixed
38% Tongue
12%
 Solar (actinic) cheilitis

Tissue degeneration
due to prolonged
& regular exposure
to sunlight.
• Whites; fair skin
• Lower lip
• Atrophic pale-gray
areas of
hyperpigmantation
& keratosis
 Solar (actinic) cheilitis
Fissuring ,erosions,
ulcerations
Cracking, wrinkling,
crusting

Invasive cancer development

can happen after 20-30 years
 Solar (actinic) cheilitis

Histology-epithelium-atrophic/ focally &

irregularly hyperplastic+surface keratosis..
Dysplastic changes: slight atypia-Ca. in situ.
Submucosa: telangiectatic vessels, curled
elastin fibers (special stains)
 Solar (actinic) cheilitis

Management as potentially malignant disorder

In case of indurations,
persistent ulceration,
palpated ,firm area:
Biopsy
(consider vermiliomectomy & mucosal
advancement )
 Solar (actinic) cheilitis

In case of epithelial atypia; epithelial changes;

• Protection from sun:
life style, hat, sun protection lip agents
Topical application of 5-fluouracul, retinoic acid

• Periodic examination

Invasive cancer development

can happen after 20-30 years
 Survival-strongly influenced by the
disease stage at diagnosis
Survival (%)
(Stage I 80 % stage IV 30%)
.

Early Detection –
Better Prognosis

Stage at Diagnosis
African
All races White American
Ries LAG, Eisner MP, Kosary CL, et al. (eds). SEER Cancer Statistics Review, 1975–2001.
Bethesda, MD: National Cancer Institute.
 Carcinogenesis

Oral cancer -preceded by Potentially

Malignant Disorders

Early detection
Forastiere A et al - depends primarily on
N Eng J Med, 2001
careful visual examination.
 High High
Risk Risk
Patients
Lesions