Clinical features

Signs and symptoms

Patients with small oral and oropharyngeal SCC are often asymptomatic or may present with vague symptoms and minimal physical findings. Hence, a high index of clinical suspicion is needed to diagnose small lesions, especially if the patients have tobacco and alcohol habits. Patients may present with red lesions, mixed red and white lesions, or white plaques. Co-existing white plaques (leukoplakia) may be observed adjacent to carcinomas and this implies an origin in a pre-existing white lesion though the prevalence of this association varies considerably in different populations. However, most patients present with signs and symptoms of locally advanced disease. The clinical features may vary according to the affected intraoral subsite. Mucosal growth and ulceration, pain, referred pain to the ear, malodour from the mouth, difficulty with speaking, opening the mouth, chewing, difficulty and pain with swallowing, bleeding, weight loss, and neck swelling are the common presenting symptoms of locally advanced oral and oropharyngeal cancers. Occasionally, patients present with enlarged neck nodes without any symp toms from oral or oropharyngeal lesions. Extremely advanced cancers present as ulceroproliferative growths with areas of necrosis and extension to surrounding structures, such as bone, muscle and skin. In the terminal stages, patients may present with orocutaneous fistula, intractable bleeding, severe anaemia and cachexia.

Cancer of the buccal mucosa may present as an ulcer with indurated raised margin, exophytic or verrucous growth or with the site of origin depending upon the preferential side of chewing and placement of betel quid. In advanced stages, these lesions infiltrate into the adjacent bone and overlying skin. Cancer of the tongue may appear as a red area interspersed with nodules or as an ulcer infiltrating deeply, leading to reduced mobility of the tongue. These tumours are

Fig. 4.7 Poorly differentiated SCC. A Cells with atypical nuclei and a small rim of eosinophilic cytoplasm form strands and small nests. B Cells in a poorly differentiated SCC tend to have more vesicular nuclei. The cells in this tumour are more cohesive, forming larger tumour areas than the lesion shown in A.

Fig. 4.7 Poorly differentiated SCC. A Cells with atypical nuclei and a small rim of eosinophilic cytoplasm form strands and small nests. B Cells in a poorly differentiated SCC tend to have more vesicular nuclei. The cells in this tumour are more cohesive, forming larger tumour areas than the lesion shown in A.

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Fig. 4.8 Squamous cell carcinoma (SCC). A Growth pattern of a diffusely infiltrating SCC. In this moderately differentiated lesion, the tumour cells form tiny strands. This growth pattern is a prognostically unfavourable feature. B Moderately differentiated SCC growing in large cohesive fields. This pattern is prognostically more favourable than the diffuse growth shown in Figure A.

painful. Cancers of the floor of mouth may arise as a red area, a small ulcer or as a papillary lesion. Most patients present with discomfort or irritation at the site of the tumour. Advanced stages are associated with drooling. Cancers of the lower lip usually arise in the vermilion border and appear as a crusty indurated or ulcerated lesion. Cancers of the upper lip are rare, often originate on the skin and spread to the mucosa. Cancer of the gingiva usually presents as an ulceropro-liferative growth. Tumours of the alveolar ridge may occasionally present as difficulty in wearing denture plates or as loosening of teeth associated with pain and bleeding during brushing of teeth. Tumours of the hard palate often present as papillary or exophytic growths, rather than a flat or ulcerated lesion. Cancer of soft palate and uvula often appear as an ulcerative lesion with raised margins or as fungating masses. Tonsillar cancers generally appear as an exophytic or ulcerative lesion. Sometimes they can present as enlarged neck nodes without any other signs and symptoms. Cancer of the base of tongue presents late in the course of the disease as a grossly ulcerated, painful, indurated growth.

More than two-thirds of the patients with buccal mucosal and gingival cancers in South Asia present with submandibular lymph node enlargement. More than three fourths of patients with tongue, floor of mouth and oropharyngeal cancers in South Asia present with neck swellings implying clinically obvious lymph node metastasis. In the West lymph node involvement is common at presentation in oropharyngeal SCC.

Imaging

Intraoral and dental radiographs, in combination with orthopantomograph^ may help in identifying involvement of the underlying bone. Three-dimensional imaging with computed tomography (CT) and magnetic resonance imaging (MRI) is frequently used to supplement the clinical evaluation and staging of the primary tumour and regional lymph nodes. CT scan or MRI give more information about the local extent of the disease and also help to identify lymph node metastases. CT scanning is useful in evaluating involvement of cortical bone. MRI is more informative when evaluating the extent of soft tissue and neurovascular bundle involvement. The combination of soft tissue characterisation and anatomical localization afforded by CT and MRI make them valuable tools in the

Fig. 4.9 Squamous cell carcinoma (SCC). A In this moderately differentiated SCC, the tumour stroma contains a dense lymphoplasmacytic infiltrate. B SCC with perineural growth, spreading alongside the inferior alveolar nerve.
Fig. 4.10 Periodontal ligament involvement by a squamous cell carcinoma (SCC).

preoperative assessment of patients with oral or oropharyngeal cancers. Distant metastasis from oral and oropharyngeal cancer is uncommon at presentation. At minimum, a routine radiograph of the chest is performed to rule out lung metastases.

Relevant diagnostic procedures

Optimal therapy and survival from oral cancer depend on adequate diagnosis and assessment of the primary tumour and its clinical extent. Physical examination should include visual inspection and palpation of all mucosal surfaces, bimanual palpation of the floor of the mouth, and clinical assessment of the neck for lymph node involvement. The diagnosis is confirmed by biopsy. The specimen is taken from the clinically most suspicious area, avoiding necrotic or grossly ulcerated areas, and more than one biopsy site may need to be chosen. In patients with enlarged cervical lymph nodes and an obvious primary in the oral cavity or oropharynx, the biopsy is always taken from the primary site and not from the lymph node. In such situations, fine needle aspiration cytology may be carried out to verify the involvement of the node.

If no obvious primary site is found in patients presenting with neck nodes, fine-needle aspiration of the lymph node can be performed to help establish the diag

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Fig. 4.11 Squamous cell carcinoma (SCC). A Superficial erosion of the mandibular bone has perforated the cortical bone. As there is no spread in the bone marrow, this case of SCC does not meet the requirements for classification as T4. B Saucerization by SCC. In this case of, there is substantial loss of bone due to endocortical tumour growth (meets the requirements T4). C Permeative infiltration of bone by SCC growing diffusely in the marrow cavities of the mandibular bone (T4). There is also heavy osteoclast-mediated bone resorption. D Bone invasion by SCC with diffuse growth in the mandibular bone.

Fig. 4.11 Squamous cell carcinoma (SCC). A Superficial erosion of the mandibular bone has perforated the cortical bone. As there is no spread in the bone marrow, this case of SCC does not meet the requirements for classification as T4. B Saucerization by SCC. In this case of, there is substantial loss of bone due to endocortical tumour growth (meets the requirements T4). C Permeative infiltration of bone by SCC growing diffusely in the marrow cavities of the mandibular bone (T4). There is also heavy osteoclast-mediated bone resorption. D Bone invasion by SCC with diffuse growth in the mandibular bone.

nosis. In patients for whom fine needle aspiration is non-diagnostic and SCC is strongly suspected, excisional lymph node biopsy is a last resort, as subsequent curative therapy may be compromised by this procedure. The search for an occult primary tumour may include direct pharyngolaryngoscopy with biopsy of high-risk sites like base of tongue, nasopharynx, and usually a diagnostic tonsillectomy, as well as other imaging modalities. Open lymph node biopsy is carried out only when the lesion cannot be identified by aspiration biopsy or in patients with suspected lymphoma. Patients with SCC of the oral cavity or oropharynx have a risk of multiple primary tumours in the pharynx or larynx, as well as in the tracheobronchial region and oesophagus so routine panendoscopy is often performed to evaluate these sites.

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  • albina
    Is infiltrative squamous cell carcinoma of the tongue a terminal diagnosis?
    3 years ago

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