causes, clinical features and treatment of carcinoma oral cavity

1. By
Lt Col Saeed Ullah MBBS, MCPS, FCPS
Classified ENT, Head and Neck Surgeon
CMH Quetta

2. Definition
 Tumour is an abnormal mass of tissue, the growth of
which exceeds and is uncoordinated with that of
normal tissues and persists in the same excessive
manner after cessation of stimuli which evoked the
change.

3. Oral cavity
 Subsites of oral cavity
 Upper and lower lips
 Buccal cavity
 Upper and lower alveolus
 Buccal mucosa
 Floor of mouth
 Anterior 2/3 of Tongue
 Hard palate

4. Ca lip

5. Ca tongue

6. Ca buccal mucosa

7. Ca hard palate

8. Ca lower alveolus

9. Ca upper alveolus

10. Risk factors
 Smoking
 Alcohol
 Paan
 Gutka
 Naswar
 Reverse smoking
 sheesha

11. Tissue of origin
 Epithelium
 Connective tissues
 Muscles
 Bone
 Lymphoid tissues
 Salivary glands
 Minor
 Major

12. Prognostic factors
 Length of the tumor
 Depth of the tumor
 Location of the tumor
 Involvement of bone
 Involvement of vessels and nerves
 Metastasis
 Lymph nodes
 Distant metastasis

13. TNM classification
 Tumore
 Nodes
 Metastasis

14. Primary Tumor
 TX Primary tumor cannot be assessed.
 T0 No evidence of primary tumor.
 Tis Carcinoma in situ.
 T1 Tumor ≤2 cm in greatest dimension.
 T2 Tumor >2 cm but ≤4 cm in greatest
dimension.
 T3 Tumor >4 cm in greatest dimension.

15. Primary tumor
 T4a Moderately advanced local disease.b(Lip) Tumor
invades through cortical bone, inferior alveolar nerve,
floor of mouth, or skin of face, that is, chin or
nose.(Oral cavity) Tumor invades adjacent structures
only (e.g., through cortical bone [mandible or maxilla]
into deep [extrinsic] muscle of tongue [genioglossus,
hyoglossus, palatoglossus, and styloglossus], maxillary
sinus, or skin of face).
 T4b Very advanced local disease. Tumor invades
masticator space, pterygoid plates, or skull base and/or
encases internal carotid artery.

16. Regional Lymph nodes
 NX Regional lymph nodes cannot be assessed.
 N0 No regional lymph node metastasis.
 N1 Metastasis in a single ipsilateral lymph node, ≤3 cm in
greatest dimension.
 N2 Metastasis in a single ipsilateral lymph node, >3 cm
but ≤6 cm in greatest dimension.Metastases in multiple
ipsilateral lymph nodes, none >6 cm in greatest
dimension.Metastases in bilateral or contralateral lymph
nodes, none >6 cm in greatest dimension.

17. Regional lymph nodes
N2a Metastasis in single ipsilateral lymph node, >3 cm
but ≤6 cm in greatest dimension.
N2b Metastases in multiple ipsilateral lymph nodes,
none >6 cm in greatest dimension.
N2c Metastases in bilateral or contralateral lymph nodes,
none >6 cm in greatest dimension.
N3 Metastasis in a lymph node >6 cm in greatest
dimension

18. Distant Metastasis
 M0 No distant metastasis.
 M1 Distant metastasis.

19. How to report
 T1N1M0
 T2N2M1

20. Investigations
 Biopsy
 OPG
 CT scan
 MRI

21. Treatment policy
 Curative:
 Radiotherapy
 Surgery
 Surgery plus post-operative radiotherapy
 Palliative:
 Radiotherapy
 Radiotherapy and chemotherapy
 Tracheostomy
 Pain relief

22. Surgery
 Resection of primary tumor
 Neck dissection
 Primary closure
 Flaps and grafts

23. Tumors of oropharynx

24. Anatomy
Oropharynx
hard palate
superiorly to
the level of
hyoid bone
inferiorly.

25. Anatomy
Anterior faucial
pillar which is
contiguous
with retromolar
trigone

26. Retromolar Trigone
It is a small
mucosal area on
the mandibular
ramus, behind
the last molar
tooth.

27. Boundaries of Oropharynx
 The Anterior wall
 base of tongue, the valeculla
and lingual surface of the
epiglottis.
 The Lateral wall
 anterior pillar, palatine tonsil
and posterior pillar.
 The roof
 soft palate
 The oral surface of soft
palate is part of oropharynx
and the nasopharyngeal
surface is part of
nasopharynx.

28.  The posterior wall
 hard palate to the level
of hyoid bone and is
anterior to second and
third cervical vertebrae.
It comprises of superior
and middle constrictor
muscles and
buccopharyngeal facia
which separates it from
prevertebral facia.

29. Tongue Base
 The most important
part area in the
oropharynx is the
tongue base.
 Genioglossus muscle,
which is attached to
hyoid bone. Tumour
infiltration into this
muscle by definition
almost always involves
whole of the tongue.

30. Types of tumors
 The oropharynx is lined by squamous
epithelium
 squamous cell carcinoma represents the
most common tumour.
 Abundant lymphoid tissue
 head and neck lymphomas.
 Soft palate
 minor salivary glands.

31.  Squamous cell
carcinoma
 most common
malignancy (90%).
 Lateral wall (60%)
 Tongue base
(25%)
 Soft palate (10%)
 Posterior wall
(5%)

32.  The minor salivary
gland tumours have
a predilection for
soft palate.
 Minor salivary gland
tumours are
pleomorphic
adenomas.
adenoid-cystic and
muco-epidermoid
types.

33. Lymphomas
Lateral wall (90%)
Tongue base (10%)

34. Staging
 T1- Tumour measuring 2 cm or less in
size.
 T2- Tumour measuring more than 2 cm
or less than 4 cm in size
 T3 - Tumour measuring more than 4 cm
in size in its largest diameter
 T4 – Tumour invades adjacent
structures e.g. Pterygoid muscles,
mandible, hard palate, deep muscle of
the tongue or larynx.

35. Lateral wall tumors
 Most common tumour (50%) and often involves
tonsil.
 Anteriorly spreads to retromolar trigone, on to
buccal mucosa as well as muscles of tongue
base. If the invasion gets deeper the pterygoid
muscles are involved resulting in trismus.

36. Lateral wall tumors
 Lateral spread involves
 angle of mandible.
 Inferiorly the growth involve lateral
pharyngeal wall, pyriform sinus,
aryepiglotic folds and para-glottic space
 The lesions of the lower pole
 often difficult to see
 primary tumours can lurk with in
tonsillar crypts as ‘occult primaries’

37.  Symptoms frequently
apperas late
 Tongue is a mobile
structure
 tumors spread through
genioglossus muscle
and across midline and
very quickly involve
entire tongue.

38. Base of tongue tumours
 60% to 70% have positive palpable lymph
nodes on presentation.
 20% to 30% have bilateral lymph nodes..
 20% of patients will present with neck nodes
and no apparent primary.
 It is important to assess retropharyngeal lymph
nodes.

39.  Soft palate
tumours:
 It may occur with
leukoplakia
 heavy smokers or
tobacco chewers.
 involve palatine
nerves, back of the
maxillary antrum
and superior pole of
the tonsil.

40. lymphoma
 The lymphomas
particularly affect
younger individuals,
who present with
unilateral tonsillar
enlargement.

41. Symptoms
 Sore throat
 Otalgia
 Dysphagia
 Ulcers
 Pain
 Trismus
 Neck masses

42. Investigations
 CT
 to evaluate tongue base. To see the laterality of
the lesion
 To asses mandibular invasion
 MRI
 Orthopantomogram
 CXR

43. Biopsy
 Panendoscopy
 Laryngoscopy and esopahagoscopy.
 synchronous lesions and to assess neck.
 Incisional biopsy
 If there is smooth regular involvement of
tonsil then tonsillectomy
 Deep biopsy for base of tongue

44. Treatment policy
 Curative:
 Radiotherapy
 Surgery
 Surgery plus post-operative radiotherapy
 Palliative:
 Radiotherapy
 Radiotherapy and chemotherapy
 Tracheostomy
 Pain relief

45. Thank you