«1. Introduction Oral cancer (OC) is considered a serious public health problem that causes great morbidity and mortality in the population. While OC ...»
Oral Squamous Cell
Carcinoma Clinical Aspects
Nicolás Bolesina, Fabián L. Femopase,
Silvia A. López de Blanc, Rosana A. Morelatto and María Alicia Olmos
Universidad Nacional de Córdoba, Córdoba
Oral cancer (OC) is considered a serious public health problem that causes great
morbidity and mortality in the population. While OC has a lower incidence than other
malignant tumors, it is known to produce high mortality and serious disturbances or
discomfort in the patient as a consequence of either the tumor itself or of the treatment.
The Oral Squamous Cell Carcinoma is the most common malignant tumor of the lip, oral cavity and oropharynx (90% of the cases) while the remaining 10% of the cases are mainly melanomas, sarcomas, minor salivary gland carcinomas and metastatic cancers (Scully et al., 2006).
In this chapter the attention is focused on the clinical characteristics of OSCCs.
Topics: Clinical presentation, Symptoms, Diagnosis, Prognosis, Oral and Dental Management and Psychological aspects of patient care.
2. Clinical presentation. Symptoms Oral Squamous Cell Carcinoma (OSCC) presents different clinical aspects which are related with the location of the tumor, evolution time, precancerous lesions and risk factors. The most frequent clinical aspects are: tumor, ulcer, vegetans, verrucous and mixed forms such as ulcerous-vegetans or verrucose- ulcers (Boring et al., 1994).
The diagnosis of early lesions such as in-situ or microinvasive carcinoma, represents a real challenge for health professionals. Leukoplakia, erythroplakia or erythroleukoplakia are the most frequent clinical aspects, which may present superficially eroded areas. Chorion infiltration may be suspected when increased consistency on palpation is observed. The abovementioned lesions are asymptomatic, tend to keep their size, may show changes in the surface and do not respond to local treatments. The lesion can progress and develop as an exophytic, irregular lobulated lesion or adopt an endophytic growth pattern characterized by a depressed ulcer with grayish-white edges, elevated, everted and indurate borders and an infiltrated base. In most cases, lesions are asymptomatic; pain appears only when muscles or nerves are invaded at advanced stages of the disease. (Neville et al., 2002;
Silverman et al., 1998) www.intechopen.com 22 Oral Cancer According to different authors, the lip is the most common location of OSCCs. In such cases, patients are likely to consult a physician or a dermatologist while in cases of tonguetumors, consultation to the dentist is more frequent. The paramedial area of the inferior lip is the most often region affected by lip cancer whereas the most prevalent precancerous lesions are actinic chronic cheilitis. OSCCs most common clinic manifestations are the loss of
superficial tissue, erosion, ulcers (Fig.1) and occasionally exophytic shaped lesions:
keratotic, verrucous or vegetant, with tumorous or “skin horn” aspect (Neville et al., 2002;
Silverman et al., 1998). Chronic exposure to the sun produces in affected patients an alteration of the shape of the lip called lip everted or "lip on balcony”.
A significant atrophy of the vermillion area with scales that do not tend to shed and therefore accumulate to form keratosis can often be observed. This type of lesions alternate with white lesions and erythro-leukoplakia areas that are prone to cracking, erosion or ulceration which are called actinic cheilitis. Lip cancer develops slowly and in advanced stages it can extend to the corner of the mouth or to the gingiva. It can also develop metastatic lymph nodes in submental and submandibular areas (Grinspan, 1983).
Fig. 1. In-situ carcinoma of the lower lip vermillion
Tongue carcinoma is the most commonly observed OC into the oral cavity; traumatic lesions, leukoplakia and lichen planus are predominant precancerous conditions. Tongue carcinoma represents 30-40% of OCs, the lateral tongue being the most frequent situation (80%), followed by ventral and dorsum (Brandizzi et al., 2008).
Lateral border of the tongue and ventral surface OCs are usually preceded by traumatic lesions caused by sharp cusps or sharp edged teeth, by badly positioned teeth or by maladjusted dentures that chronically rub the mentioned areas. Ulcerated forms are the most frequently observed, see Fig 2, followed by exophitic tumor, which generally produce pain irradiating to the ear. In the ventral area, ulcer-vegetant or mixed forms predominate.
Tumors on the dorsum are generally associated to lichen planus or to leukoplakia lesions.
They are clinically observable as ulcerated forms tend to expand on the surface rather than go deeper into it. The lateral border of the tongue and the floor of the mouth (with www.intechopen.com 23 Oral Squamous Cell Carcinoma Clinical Aspects extensions to the back lateral soft palate and tonsillar areas) combine to form a horse shoeshaped region in the oral mucosa that was described by Jovanovic et al., (1993) as highly risky for cancer development and also as a bad prognostic area.
These tumors tend to evolve towards the ventral side and to the floor of the mouth. In the first consultation, 40% of the patients have lymph nodes. When the lesion has more than 4 cm, lymph nodes are present in 90% of the cases (Grinspan et al., 1983). Tumors located in the anterior half of the tongue usually lead to lymphadenopathy in the suprahyoid region while those located in the posterior half lead to submaxillary, carotid and lateropharyngeal nodes. Contralateral nodes are more frequent from tumors in the ventral surface and floor of the mouth (Shah et al., 1990; Grinspan, 1983).
Fig. 2. Tongue infiltrant SCC, T2 N1 Mo
According to our experience in Argentina, OSCCs in gum and alveolar ridge are the 2nd most frequent locations (Brandizzi et al., 2008.) which is not the case in other countries (Boudewijn et al., 2009, Chandu et al., 2005). It is difficult to detect previous lesions when the carcinoma is located in the gingival or alveolar ridge. In such locations, however, it is common to associate them with periodontal disease.
Chronic inflammatory processes would release genotoxic mediators that would stimulate the accumulation of genetic defects leading to the appearance of malignant cells. In its initial stage, gingival carcinoma looks like a red or/and white spot slightly vegetant, extending on the surface due to the resistance offered by the periosteum (Fig 3). As OSCC advances, it adopts a tumoral shape, it may invade the bones, produce loosening of teeth and cause pain or trismus. Its progress through the lymph affects the submental, submandibular and carotid regions, these ones becoming the most common bilateral metastases. The antero inferior lesions progress towards the floor of the mouth and to the ventral side of the tongue. If the tumor is located in the posterior zone, it invades the floor of the mouth as well as the masticatory muscles.
Fig. 3. Gum carcinoma, the tooth was lost due to bone tumor invasion The floor of the mouth OSCC starts mainly in the anterior area as red and/or white spots, plaque or nodular, ulcerated lesions, later indurated at palpation (Fig. 4). It is not painful at an early stage although the tongue´s mobility can eventually be impaired. It advances from the surface to the depths of the tissues, invading the floor of the mouth muscles, the submental, submaxillary and cervical nodes.
Fig. 4. Floor of the mouth, infiltrant SCC, two foci born in a leukoplakia
Most buccal mucosa SCC is characterized by developing on previous lesions. The leukoplasiform and erythroplastic forms are commonly observed in the anterior part of the buccal mucosa while in the posterior one it is more often secondary to traumatic lesions or lichen planus. One of the first signs of the transformation is the induration of erythoplastic lesions that tend to develop an exophytic aspect as they grow (Fig. 5). This type of SCC rarely presents ulcers whereas differentiated histopathologic forms are predominant. When SCC appears in the posterior third of the buccal mucosa, it usually presents itself as endophytic or ulcers; undifferentiated histological types is the most frequent that have a worse prognosis than in the anterior third. The affected nodes are generally situated in the submaxillary area and less frequently in the cervical or facial ones (Grinspan, 1983; Jovanovic et al., 1993).
Fig. 5. OSCC of the buccal mucosa, an exophytic aspect.
When we analized the habits associated to OSCC location, we observed that 85%-90% of the patients affected with floor of the mouth and oropharygeal carcinoma were smokers and drinkers. Fewer than 40% of those with gum and tongue carcinoma had both habits (Fig. 6).
Fig. 6. Risk factors and location of the tumor To highlight: It is essential for everyone to undergo a proper oral examination. Pain in itself is not a reliable indicator of malignancy; in many of the studied cases, early lesions were associated with only minor discomfort.
2.1 Lymph nodes According to the natural history of OSCCs, invasive lesions would lead to their spreading through the lymph nodes. Mobile, painless nodes whose volumes increase in course of time, and fix to surrounding tissue in the advanced stages, are those clinically suggestive of malignancy.
www.intechopen.com 26 Oral Cancer Union for International Cancer Control (UICC) recommended to classify the location of
lymph nodes in the following levels:
Level I: submandibular and submaxillary nodes.
Level II: upper jugular nodes.
Level III: jugular media.
Level IV: lower jugular.
Level V: nodes in the posterior triangle, bounded at the back by the anterior border of the trapezius muscle, anteriorly by the posterior border of the sternocleidomastoid and below by the clavicle. Descriptive purposes can be divided into high, medium and low by two horizontal planes: the superior plane is situated below the hyoid bone and the inferior one in the lower edge of the cricoid cartilage.
Level VI: lymph nodes in the central compartment, which extends from the suprasternal notch to the hyoid bone. Lateral boundaries are formed on each side by the body´s internal carotid sheath.
Level VII: lymph nodes located in the upper mediastinum, below the suprasternal notch.
2.2 TNM system and staging According to the literature, the first classification of malignant tumors is Pierre Denoix´s (1944) Tumor Node Metastasis (TNM), based on the extent of primary tumor (T), involvement of regional lymph nodes (N) and metastasis at distance (M). Such classification also applies to OSCCs of the mouth. Proper classification and staging allows the physician to determine treatment more appropriately, evaluate results of management more reliably and compare worldwide statistics reported from various institutions.
Currently, the American Joint Committee on Cancer (AJCC) and the UICC periodically update cancer staging, which is used by physicians and health care professionals throughout the world to facilitate the uniform description of neoplastic diseases. UICC rules
to classify tumors are:
- The classification applies only to carcinomas in the lip vermilion, in the oral cavity, pharynx, larynx, sinuses mucous including minor salivary gland tumors.
- There should be histological confirmation. When the histology comes from another institution, it is recommended to have it reviewed by the pathologist in the working team.
- The extent of the disease should be evaluated by clinical examination, endoscopy and imaging.
In patients with advanced OSCC plus a history of heavy smoking, chest Computer Tomography (CT) is recommended before deciding on treatment because of the considerable possibility of undetected metastases in previous X-Ray tests.
The staging of each case must be determined before treatment and should not be changed whatever findings emerge after starting it. You can add such findings but you cannot change the staging. If doubts arise concerning it, assigning the patient the lowest category is the most convenient procedure.
Tables 1 shows the TNM classification and Table 2 describes the staging.
3. Variables that influence diagnosis
3.1 Diagnostic delay Oral cancer is a global health problem of increasing incidence and mortality rates; more than 500,000 patients worldwide are estimated to have oral cancer (Parkin et al., 2005). The International Association for Cancer Research (IARC) and the World Health Organization (WHO) latest records show an incidence of 263,020 cases (3.8 rate) with high mortality 127,654 (1.9 rate ), (Ferlay et al., 2010).
Unfortunately, the 5-year survival rate has not changed during the last half of the century, still being around 50–55% in spite of the advances in diagnosis and treatment (Neville and Day, 2002). Early diagnosis is a foremost step for reducing cancer mortality (Boyle et al., 2003), since the identification of smaller lesions allows less aggressive and debilitating treatments. However, almost half of intraoral cancers have late diagnosis (stages III or IV).
Diagnostic delay is, therefore, the main reason why most patients´ OSCCs are discovered in advanced stages when their diagnoses are finally made. Late diagnosis is the result of either patient or professional delay (Kerdpon & Sriplung, 2001, Rogers et al., 2007).
There is a vast literature about the results of research on this interesting topic carried out in populations from all over the world (Table 5).