Oral Cavity Cancer
What Is Oral Cavity Cancer?
Oral cancer is a term used to address malignancies in the oral cavity, and is the most common of all head and neck cancers. The oral cavity is the region between an individual’s lips and their soft palate. When discussing oral cavity cancer, there are different subsites that may be used to better define the site of location better guiding management decisions: lips, tongue, the alveolus (gums), the buccal mucosa (inner cheek), floor of mouth, and hard palate. The vast majority of cancer arising in the oral cavity involve the epithelial lining. It is within this lining that the cells begin to abnormally proliferate and replicate causing an overgrowth of cells and subsequent tumors. Not all lesions are malignant, with each type of lesions guided by different managing principles
Types Of Oral Cavity Cancer
Type of Cancer. The overwhelming majority of cancers of the oral cavity are squamous cell carcinoma. However there are other cancers that also occur in this region that are on the differential diagnosis that must be considered
- Squamous Cell Carcinoma. The vast majority of oral cavity cancers or squamous cell carcinoma. These cancers involve the malignant transformation of the mucosal lining within the oral cavity.
- Carcinoma In-Situ. This refers to the earliest stage of squamous cell carcinoma. This may also be referred to as severe dysplasia. It indicates that the abnormal proliferation of cells has not extended beyond the deepest layer of tissue. A diagnosis of carcinoma in-situ may not rule out the presence of full squamous cell carcinoma in other regions. However, this is indicates the earliest stage of cancer, and can be removed prior to further invasion.
- Salivary Gland Tumors. The oral cavity houses small salivary glands that can be subject to malignant transformation. These cancers have a distinct behavior different from that of cancer involving the epithelial lining. Distinction is often made on biopsy, with appropriate treatment guidance.
- Lymphoma. Lymphoma may present as a lesion in the head and neck, although rare.
- Mucosal Melanoma. Melanoma, similar to the type of melanoma found in the skin, may also manifest in the oral cavity. Although rare, this is an important consideration, with impact on treatment decisions and outcomes.
- Jaw Cancers. There is a wide range of jaw cancers and cysts that may also present as masses in the oral cavity. Identification of these cancers occurs on physical exam in conjunction with radiological imaging.
What Are The Causes Of Oral Cancer?
The causes of tumor growth in the oral cavity is likely multifactorial with many contributing factors. Overall, the chronic and long-term use of irritants such as tobacco and alcohol are the leading causes of oral cavity cancers. Other predisposing factors include the use of Betel Nut (prominent in India and Southeastern Asian countries), UV light exposure (lip cancer), marijuana, poor dentition, genetic predisposition, and Human papilloma virus (HPV).
What Are The Signs And Symptoms Of Oral Cavity Cancer?
Oral cavity cancers may present in different forms, but generally speaking they are often times found in earlier stages due to earlier detection by patients or other healthcare providers during routine examinations.
Pain. Frequently patients may present with sores in or around their mouth that are painful and longstanding that do not resolve over time. As lesions increase in size, they may become increasingly painful, and may not respond to normal pain medications.
Lesions. Patients or other healthcare providers (e.g. dentists) may notice a lesion that does not resolve or appear abnormal. These lesions may appear as patches, sores, ulcerations, plaques, or masses. Sores that do not resolve in 2-3 weeks usually require further evaluation by a specialist with potential for further workup.
Bleeding. Bleeding from a site within the oral cavity may be a presenting sign. Often times, chronically irritated skin may bleeding due to infections, chronic irritation (brushing), or dentures. However, bleeding from a particular site or lesion should be evaluated by a specialist.
Speaking and Swallowing Difficulties. The presence of a tumor or lesion often times will impact a patients ability to speak or swallow. As lesions grow in size, patients may find it difficult to open their mouths (trismus), chew, or move their tongue. Tongue lesions may also impact a patients ability to properly articulate words.
Poorly Fitting Dentures. Patients may find increasing difficulty in the use of dentures. This usually occurs in patients with hard palate lesions that prevent the proper fitting of their dentures.
Tooth Problems. Lesions involving the gum line may result in invasion of the tooth socket. This may cause tooth pain there is involvement of the nerves, or may even cause the tooth to become loose or fall out. Also, a non-healing site of a previously extracted tooth may also be a sign of an underlying cancer.
Lump in the Neck. Rarely cancers of the oral cavity can present as a single or multiple lumps in the neck. These enlarged nodes may be reactive due to tumor or an associated infection, or may be a sign of regionally metastatic disease
What Are The Risk Factors Of Oral Cancer?
The most common risk factors of developing oral cancer is tobacco use (both smoking and smokeless tobacco), and chronic alcohol use. Other causes may relate to Betel Nut (prominent in India and Southeastern Asian countries), UV light exposure (lip cancer), marijuana, poor dentition, genetic predisposition, and Human papilloma virus (HPV).
How Is Oral Cancer Diagnosed?
Diagnosis and Workup. In addition to routine history and physical examination, the physician may perform ancillary tests and procedures in order to confirm the presence and type of oral cavity cancer, as well as to determine the presence of second primary cancers (SPC) or the spread of malignant disease elsewhere.
Biopsy. Often times the first step in the diagnosis of an oral cavity cancer is to perform a biopsy. Several types of biopsies may be performed, in the clinic or operative setting depending on how easily visualized the lesion is, its size, and patient preferences. Taking a biopsy will confirm the presence of abnormal cells under microscopic view, and is imperative in making the diagnosis of oral cavity cancer.
- Incisional Biopsy. Your physician may perform this by removing a piece of the abnormal appearing tissue allowing for microscopic assessment. Typically, results from a biopsy may take up to 1 week to get final results. Multiple biopsies may be needed if insufficient tissue was previously sampled, or if there are multiple suspicious appearing lesions. This may be performed under local anesthesia in the office, depending on size and location, as well as patient comfort and preference.
- Excisional Biopsy. This is a biopsy in which the whole suspicious lesion is excised with a perimeter of normal tissue and examined. This type of biopsy is not routinely performed, at the risk of removing normal tissue unnecessarily.
- Lymph Node Biopsy. If a patient presents with a neck mass, particularly in the setting of no identifiable oral cavity lesion, the physician may sample tissue from lymph node. There are several types of lymph node biopsy.
- Fine Needle Biopsy (FNB). If the mass can be felt by the clinician, then a small needle can be introduced with an attempt at extracting cells for microscopic assessment. The appearance of abnormal cells will help support the diagnosis of cancer. Sometimes, not enough cells are extracted, and repeat biopsies may need to be performed. This may also be performed with the help of ultrasound or computed tomography (CT) guidance.
- Core Biopsy (CB). Similar to the Fine Needle Biopsy, a core biopsy is performed by introducing a larger caliber needle, with extraction of tissue as opposed to cells. This core biopsy allows for extraction of more tissue and can be more useful, but often times not necessary, as an FNB is sufficient. This can also be done with or without ultrasound or CT-guided assistance
- Operative Biopsy. If the location of the node is too deep, or not readily felt by a clinician, the surgeon may elect to perform biopsy under general anesthesia in an operating room.
Blood Work. The physician may elect to perform routine blood analysis to assist in determining the presence of oral cavity cancer or other present diseases. Blood work may not be necessary, and the decision to obtain blood work is individualized to every patient.
- Liver Function Tests (LFTs): Can be utilized to determine the presence of concurrent liver disease that may be associated with risk factors for the development of oral cavity cancer (alcohol consumption, hepatitis). Furthermore, abnormal values may indicate the presence of metastatic liver disease.
- Complete Blood Count (CBC): This will identify the presence of any anemia that can sometimes be associated with poor nutrition, or chronic illness.
- Nutritional Blood Work: If a patient seems nutritionally depleted, particularly in advanced cases, the clinician may elect to obtain laboratory work up to measure nutrition markers in the blood work. This may assist in determining if a patient requires supplemental nutrition.
Imaging. Oftentimes a physician may elect to obtain imaging that will help in better understanding the presence of cancer and any other underlying issues. Imaging may be performed of the primary site, or of the general region to better define disease extent. The physician may elect to obtain further imaging in situations in which they are concerned for local invasion (e.g. into bone, muscle, adjacent sites), or regional invasion (to the neck). Imaging is not necessary in the diagnosis of all oral cavity cancers, and the decision to obtain imaging or the type of imaging will be best dictated by each patient’s individualized care.
- Chest X-rays: Chest radiography may be obtained in order to define the presence of disease in the lungs. Often times patients with larygneal cancer, have a longstanding history of smoking may have associated lesions in their lungs that should be identified.
- Computed Tomography (CT): CT-Scans usually provide a more detailed image of the head and neck region, identifying parts of the tumor that is not readily seen on exam, as well as the presence of regional disease not readily detected (e.g. in the neck). CT-Scans can be obtained with or without contrast. Given the complexity of the region, usually CT scans are obtained with scans, to help in identify the vascular architecture within the neck. However, this is not always necessary, and CT scans may be obtained without contrast in circumstances that preclude patient receiving contrast (iodine allergies, kidney disease).
- Magnetic Resonanice Imaging (MRI): MRI can also be utilized with or without contrast in order to provide superior visualization of soft tissue as well as the brain. Often times an MRI may be needed if there is indeterminate findings on other imaging modalities, with a need for more accurate mapping.
- 18-Fluorodeoxyglucose Positron Emission Tomography (18-FDG PET): FDG-PET scans may be performed with CT or MRI imaging modalities and are utilized for the identification of regional or distant metastases.
- Ultrasound (US): Ultrasound may be utilized to better characterize neck masses, or used in conjunction with biopsy techniques. US can indicate suspicious characters of lesions that would direct a physician to more aggressive workup (biopsy, excision).
- Dental X-rays (Panorex): Panorex scans may be obtained to determine the status of teeth, gum, or jaw involvement.
What Are The Possible Treatments For Oral Cancer?
Treatment Plan. Depending on the site of disease, the clinical staging, and patient factors (co-morbid health conditions, patient preferences) a patient specific treatment plan should be outlined. Broadly speaking there are 3 types of treatment that can be used in combination or separately depending on the type and stage of cancer. The decision to embark on a particular treatment plan should be made involving a multidisciplinary team of doctors (surgeons, radiation oncologists, and medical oncologists) and the patient. Patient specific goals and outcomes should be defined, with a thorough discussion of the risks, benefits, and alternatives of all the separate treatment types.
Surgery. Surgery involves the operative extirpation of tumor and all involved tissue obtaining clear margins (i.e remove any evidence of disease present). The vast majority of oral cavity cancers are treated with surgery initially. Early staged cancers, Stage I or II, can be treated with surgery alone. Depending on the location the surgery can be used with reconstructive options if the defect cannot be closed using simple techniques.
Radiation. Radiation can be performed in three settings, definitive and (neo)adjuvant.
- Definitive Radiation (with or without chemotherapy). This type of radiation treatment involves using radiation as the primary mode to treat the tumor. The goals of definitive radiation therapy is complete removal of all tumor with external sources of radiation. It is rare that this radiation is used in the definitive setting, and is usually used in the adjuvant setting.
- Adjuvant Radiation (with or without chemotherapy). This refers to the use of radiation in combination with surgery. The goal of adjuvant radiation is to treat any remaining disease after surgical removal (e.g in circumstances with positive margins).
- Neoadjuvant Radiation (with or without chemotherapy). Radiation given prior to surgery is referred to as neoadjuvant radiation. This is not routinely performed in oral cavity cancer, and is used in academic centers as part of larger studies.
Chemotherapy. The use of systemic medications is used adjunctively with either surgery or radiation, and is used to target disease distant from the local site. It is not used as a primary treatment modality as it does not facilitate eradication at the primary site. Chemotherapy is often used in circumstances of advanced disease (Stage III or IV), or when certain risk factors for distant disease are present. Such risk factors include lymphnodes with disease that have extended out of their capsule (not contained), positive surgical margins, or involvement of nerves.
- Induction Chemotherapy. This refers to chemotherapy performed prior to surgery or radiation. This may be used to see the biological response of the tumor to chemotherapy, as well as “shrink” tumors to a manageable size that can be better removed with surgery or radiation.
- Adjuvant Chemotherapy. This refers to chemotherapy given after definitive treatment with another modality was performed (either surgery or radiation).
- Concurrent Chemotherapy. This refers to the decision to administer chemotherapy and radiation concurrently after surgery. This may be the case in situations of predictors of aggressive disease on pathology.
Other Considerations. Specific attention should be given to the presence or absence of neck disease in the patient. Oral cavity cancer has a higher percentage of occult disease (disease not present on imaging or physical examination). Part of the treatment algorithm is to determine if the neck should be treated.
- Therapeutic Neck Interventions. If there is any presence of disease in the neck it should be addressed therapeutically. Positive neck disease is usually treated through surgical resection of the actual positive nodes, and all intervening nodes in the neck. This is to ensure accurate pathological characterization of the nodes in the neck, and prevent recurrence in the neck (from missed disease). Definitive neck measures can also include definitive radiation to the neck.
- Elective Neck Interventions. In the absence of any clinical evidence of disease, an elective neck intervention may be performed. This means to treat the neck (with radiation or surgery) in circumstances that there is an “occult” or hidden disease that is not clinically apparent. Specific to oral cavity, all disease with primary (T-staging) greater than 2 (>T2), an elective treatment of the neck should be undertaken. In smaller T1 lesions (smaller than 2 cm), the decision to treat the neck is based on the depth of invasion. If the depth of invasion is beyond 4 mm, the risk of occult disease increases, and an elective neck dissection should be performed.
Are There Preventative Steps Or Measures To Avoid Oral Cavity Cancer?
The best method to prevent the development of oral cancer is to avoid irritants and carcinogens such as tobacco and alcohol. Additionally, proper dental hygiene and frequent visits to the dentist may reduce the risk of developing cancer, or help in obtaining an early stage diagnosis.
What Are The Risks If Oral Cavity Cancer Is Left Untreated?
If oral cancer is left untreated will continue to progress and cause significant detriment to a patient’s health. As the tumor grows patients will experience progressive worsening of their ability to swallow, speak, and breathe. Ultimately this can cause severe nutritional problems, airway problems, speech impediment, and ultimately result in the untimely death of a patient.
What Makes Dr. Mourad The Right Doctor For Oral Cancer?
Select Relevant Publications
Mofiyinfolu Sokoya, Arash Bahrami, Jason Cohn, Sameep Kadakia, Moustafa Mourad, Yadranko Ducic. Orbital Skull Base Reconstruction with Temporalis Muscle: The Sphenoid Keyhole Technique. CMTR Open. 2018; 02(01): e27-e30. Link to Article.
Moustafa W Mourad, M. Z. Mat Saman, Yadranko Ducic. Internal to External Jugular Vein Bypass Allowing for Simultaneous Bilateral Radical Neck Dissection. Laryngoscope. 2015 Nov;125(11):2480-4. Link to Article.