Oral Cancer 26.3.19

Oral Cancer
Introduction
• Oral cancers are defined as cancer of
lips, mouth and tongue.
• They rank amongst top three

malignancies in our country.
• Different studies indicate that about 5

to 12 % of all malignancies in India
arise in relation to oral cavity.
• Amongst oral cancers, more than 90%

are squamous cell carcinoma.
Etio - pathogenesis
• Etiology of oral SCC is multifactorial.
• Factors implicated are
– Use of tobacco
– Alcohol
– Different ingredients of 'Paan'
– Actinic radiation
– HPV infection
• Some other associated factors are:
– Poor oral hygiene,
– Iron deficiency,
– Syphilis, and
– Candidiasis
• Predominant causative factor varies in different parts of the world.
It may also differ depending on site of origin of the tumour.
• For carcinoma of lip in fair skinned persons, excessive
exposure to UV rays is implicated. To a lesser extent, smoking
and repeated trauma also plays a role.
• In India and Asia, use of smokeless tobacco and betel quid

chewing is a major predisposing factor.
• For cancer of the oropharynx, tobacco and alcohol abuse are

the major culprits.
• In carcinoma of tonsil, oropharynx and base of tongue,

presence of oncogenic variants of HPV (HPV -16) has been
demonstrated in ~ 50% of cases.
• Oral SCC is often preceded by leukoplakia.
• The tumour is encountered more often in males.
• Its incidence is increasing in persons younger than 40 years,

who do not have any known risk factors. Cause unknown.
Role of tobacco as an etiological factor
Epidemiological studies in India show that:
– Daily consumption of 40 cigarettes - risk increases five folds.
– daily consumption of 80 cigarettes - risk increases seventeen

folds.
– Use of smokeless tobacco increases the risk four folds.
– Tobacco + Paan + SMF- risk increases nineteen times.
– Tobacco + Alcohol - risk increases the fifteen times.
– In our country ~ 40% individuals > 15 years of age consume

tobacco in some form (1993).
– Epidemiological studies in western countries, show that heavy

smoking in conjunction with alcohol abuse raises the risk to
about 100 folds in females, and 38 times in males.
Molecular biology of SCC
• For tobacco induced cancers

– Mutations are seen in
• p53,
• p63 and
• NOTCH 1
• For HPV induced cancers

– Over expression of p16 and
– Inactivation of p53 and RB pathways
Clinical and Gross Features
• Oral SCC can present as a solitary ulcer, a lump, leukoplakia,
erythroplakia, numbness of lips in absence of trauma or
infection, trismus or cervical lymphadenopathy.
• Tumor is found most commonly on ventral surface of the

tongue, floor of mouth, lower lip, soft palate and gingiva.
• Lesions on hard palate are found more frequently in reverse

smokers.
• Irrespective of the initial appearance of the lesion, all tumors

progress to produce either a protruding mass (exophytic
lesion) or an ulcer with rolled out edges (endophytic mass).
• Oral cancers are notorious for exhibiting the phenomenon of

field cancerization.
Squamous Cell Carcinoma
Squamous
Cell
Carcinoma
Site specific peculiarities of oral SCC
• Tumors of lip vermillion are slow growing. They also
metastasize late.
• Lesions of floor of the mouth are the ones most likely

to arise from pre-existing leukoplakia. They are also
more likely to give rise to a second primary lesion.
• Tumors of gingiva and alveolus can mimic benign

lesions like pyogenic granuloma.
• As oropharyngeal cancers are located posteriorly,

they are more likely to present, initially as cervical
lymphadenopathy, or in an advanced stage of the
disease.
Histological Features
Squamous Epithelium – Normal Maturation
SCC – well
differentiated
• Initially dysplastic lesions
are seen. For oral SCC,
invasion may occur even
without development of
carcinoma in situ (cf -
cervical scc)
• Tumours may range from

well differentiated to
anaplastic to
sarcomatoid.
• Degree for keratinization

does not correlate with
clinical behaviour.
SCC – Moderately Differentiated
SCC – Poorly Differentiated
Prognosis
• In oral SCC, stage of the tumor is more important than grade for
determining the prognosis.
• Metastasis occurs initially to ipsilateral lymph nodes followed by

contalateral or distant lymph node involvement. Lung, liver and
bones are the most frequently involved sites for blood borne
metastasis.
• Stage of the disease and the site of the primary tumor, are the best
indicators of prognosis
– Cancer of tongue
• If localized: five year survival is 50%
• Stage 4 tumor: five year survival is 10%
– Cancer of palate and tonsillar area
• If localized: five year survival is 65%
• Stage 4 tumor: five year survival is 17%
• Tumors of lip has the best ,and palate the worst
prognosis.
• Presence of desmoplasia indicates more

aggressive behavior.
• Tissue eosinophilia is a favorable prognostic

sign.
• Over expression of P21 and amplification of

3q26.3 locus indicates poor prognosis
– Overall survival
• For stage 1: five year survival is 85%
• For stage 4: five year survival is 10%

Deaths from Oral Cancer
SCC
Post
Surgery

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Oral Cancer

• They rank amongst top three

• Different studies indicate that about 5

• Amongst oral cancers, more than 90%

• In India and Asia, use of smokeless tobacco and betel quid

• For cancer of the oropharynx, tobacco and alcohol abuse are

• In carcinoma of tonsil, oropharynx and base of tongue,

• Oral SCC is often preceded by leukoplakia.

• The tumour is encountered more often in males.

• Its incidence is increasing in persons younger than 40 years,

– daily consumption of 80 cigarettes - risk increases seventeen

– Use of smokeless tobacco increases the risk four folds.

– Tobacco + Paan + SMF- risk increases nineteen times.

– Tobacco + Alcohol - risk increases the fifteen times.

– In our country ~ 40% individuals > 15 years of age consume

– Epidemiological studies in western countries, show that heavy

• For tobacco induced cancers

• For HPV induced cancers

• Tumor is found most commonly on ventral surface of the

• Lesions on hard palate are found more frequently in reverse

• Irrespective of the initial appearance of the lesion, all tumors

• Oral cancers are notorious for exhibiting the phenomenon of

• Lesions of floor of the mouth are the ones most likely

• Tumors of gingiva and alveolus can mimic benign

• As oropharyngeal cancers are located posteriorly,

• Tumours may range from

• Degree for keratinization

• Metastasis occurs initially to ipsilateral lymph nodes followed by

• Presence of desmoplasia indicates more

• Tissue eosinophilia is a favorable prognostic

• Over expression of P21 and amplification of

• For stage 1: five year survival is 85%

• For stage 4: five year survival is 10%

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