Otolaryngology: Oral Cavity Cancer

Oral Cavity Cancer

General

  • Lower Lip is the Most Common Site of Oral Cancer Overall (Due to Sun Exposure)
  • Strongest Risk Factors: Tobacco (#1) & Alcohol
  • Typically Metastasize to Cervical Lymph Node Levels I, II and III
  • Risk of Occult Spread to Regional Lymphatics: > 20%
    • Elective Treatment of Regional Lymphatics is Warranted

Pathology

  • Squamous Cell Carcinoma (SCC) – Most Common
  • Variants of Squamous Cell Carcinoma:
    • Verrucous Carcinoma
      • Low-Grade Variant with Low Risk of Regional Spread
      • Most Common on Buccal Mucosa (50%)
    • Sarcomatoid Carcinoma (Spindle Cell Variant)
    • Basaloid Carcinoma
  • Osteosarcoma
  • Ameloblastoma
    • Odontogenic Epithelium Malignancy
    • Locally Destructive but Rarely Metastasize or Involve Lymph Nodes
    • Soap Bubble Appearance on Radiograph

Presentation

  • Mouth/Dental Pain
  • Nonhealing Ulcers
  • Bleeding
  • Dysphagia
  • Odynophagia
  • Halitosis
  • Loose Teeth
  • Poor-Fitting Dentures
  • Referred Otalgia – Earache

Site Specifics

  • Lip Cancer:
    • Squamous Cell Carcinoma (SCC) is Most Common on the Lower Lip
    • Basal Cell Carcinoma (BCC) is Most Common on the Upper Lip
    • Lips Cancers Are Most Aggressive if Along the Commissure
  • Tonsil Cancer:
    • Most are Asymptomatic Until Large
    • 80% Have Regional Lymph Node Metastases at Diagnosis
    • Requires Tonsillectomy to Biopsy Prior to Wide Local Excision

Diagnosis

  • Primary Diagnosis: Punch Biopsy of the Lesion
  • Other Measures:
    • Fine-Needle Aspiration (FNA) for Any Suspected Regional Metastases
    • CT/MRI to Evaluate Extent of the Lesion & Any Lymph Node Metastases

TNM Staging

  • TNM
T N M
1 < 2 cm Single Ipsilateral LN < 3 cm Distant Mets
2 > 2 cm 2a: Single Ipsilateral LN > 3 cm or Extra-Nodal Extension (ENE)
2b: Multiple Ipsilateral LN < 6 cm
2c: Bilateral/Contralateral LN < 6 cm
3 > 4 cm 3a: LN > 6 cm
3b: ENE-Positive (Not a Single Ipsilateral LN < 3 cm)
4 4 (Lip): Invades Cortical Bone, Inferior Alveolar Nerve, Floor of Mouth or Facial Skin
4a (Oral): Invades Adjacent Structures (Cortical Bone, Deep Tongue, Maxillary Sinus) or Facial Skin
4b (Oral): Invades Masticator Space, Pterygoid Plates, Skull Base or Encases the Internal Carotid Artery
  • Staging
  T N M
I   T1 N0 M0
II   T2 N0 M0
III   T3 N0 M0
T1-T3 N1 M0
IV A T4a N0-N1 M0
T1-T4a N2 M0
B Any T N3 M0
T4b Any N M0
C Any T Any N M1

General Treatment

  • Primary Treatment:
    • Early-Stage (Stage I-II): Wide Local Excision (WLE)
      • Margin: 5-mm (Some Now Advising 1-mm as Sufficient)
      • Also Include Neck Management: Sentinel Lymph Node Biopsy (SLNB)
    • Advanced-Stage (Stage III-IV): Surgical Resection & Adjuvant Radiation
      • Also Consider Adjuvant Chemotherapy
      • Basic Indications: > 4 cm, Positive LN or Bony Invasion
  • Neck Management:
    • Early-Stage (Stage I-II): Selective Neck Dissection (SND) or Sentinel Lymph Node Biopsy (SLNB)
      • SND: Levels I-III, Possibly Level IV for Select Cancers
    • Advanced-Stage (Stage III-IV): Selective Neck Dissection (SND) or Modified Radical Neck Dissection (MRND)
    • *Neck Management is Evolving with Extent of Dissection Controversial