Oral Cancer Clinical Presentation Flashcards
1
Q
Clinical presentation of early, low stage oral squamous carcinoma
A
- red patch
- speckled patch
- soft or minimally firm
- flat or slightly depressed
- superficially non-healing ulcer
2
Q
Clinical presentation of established carcinoma (high stage or late)
A
- Indurated (firm and hard as a result of inflammation, fibrosis and infiltration of tissues)
- ulcerated
- rolled ulcer margins
- nerve pain
- paraesthesia or anaesthesia
- loose teeth
- bone loss
- pain
- reduced mobility of tissue/tongue
- spontaneous bleeding
- non healing tooth socket
- palpable lymph node in neck
- may find enlarged cervical lymph nodes
3
Q
Common sites of oral cancer
A
- Tongue is most frequently affected particularly lateral borders and ventral tongue
- FOM and lingual aspect of alveolus and retromolar region
- Forms a U-shaped area extending back to oropharynx (possibly due to pooling of carcinogens in saliva)
- Also: buccal mucosa, soft palate, lip
4
Q
Less common sites of oral cancer
A
- Gingivae
- Dorsal tongue
- Hard palate
5
Q
When does metastasis of carcinomas of the tongue occur and what route does it take?
A
- Carcinomas of the tongue only have to invade 1cm before they enter muscle
- Unpredictable spread; growth is directed along muscle bundles which radiate in all directions
- Metastases at an early stage
6
Q
When does metastasis of carcinomas of the FOM occur and what route does it take?
A
- Spread laterally producing broad superficial tumours
- Treatment is difficult
- Poor prognosis
- Often poorly differentiated, and metastases occur early
7
Q
When does metastasis of carcinomas in the retromolar region occur and what route does it take?
A
- May spread to underlying bone, medial to the ramus and pharynx, laterally into the cheek or up to the tuberosity region and infratemporal fossa
- Treatment is difficult
- Half of cases present with metastasis
8
Q
When does metastasis of carcinomas in the alveolar ridge and gingivae occur and why is diagnosis of gingivae carcinomas often delayed?
A
- Tend to be well differentiated and more slowly growing than tongue carcinomas but erode bone at an earlier stage, making tx more complex
- Gingival carcinoma often delayed diagnosis, being mistaken for inflammatory periodontal disease or denture trauma
- Important not to extract teeth adjacent to such a carcinoma as it allows carcinoma to spread into medullary cavity
9
Q
How does the carcinoma on the buccal mucosa spread?
A
- Erode the soft tissue and eventually penetrate through to skin
- Some are associated with betal quid chewing
10
Q
What are the symptoms of carcinomas
A
- Pain considered little value in dx
- Early carcinoma is often painless, but can experience burning or sharp stinging pain localised to carcinoma (possibly associated with ulceration)
- Pain increases with carcinoma size and is typically severe only in the late stages (can get referred pain to ear)
- Involved nerves produce neuropathic pain, paraesthesia or anaesthesia in that nerves distribution
11
Q
What is the pathology of SCC: how do the epithelial cells grow into the lamina propria
A
Invasion:
- Cells become spindle shaped and motile
- They induce surrounding fibroblasts and endothelial cells to produce fibrous tissue that is easy to migrate through (tumour stroma)
- They induce growth of new vessels (angiogenesis) to supply the increased nutrient requirements of the malignant cells
- Lesion appears red clinically
12
Q
How to cells with metastatic ability emerge from SCC
A
- Each carcinoma comprises many genetically different clones of cells
- Each clone can only survive with nutrients or signals from its neighbouring cells
- With time and continuous proliferation of the genetically damaged cells, a diverse population of clones of cells develops with different properties
- Eventually, a clone with metastatic ability emerges
13
Q
What are the histological features of SCC and how are SCCs graded? Which grade has the better prognosis and what is the exception?
A
- Features of malignancy: large and irregularly shaped nuclei, darkly stained nuclei, abnormal mitosis
- SCC graded according to its degree of differentiation; the degree to which the malignant cells differentiate to form prickle cells and keratin (poorly differentiated show little evidence of prickle cell differentiation or keratinisation)
- Poorly differentiated carcinomas are more likely to metastasise and carry a poorer prognosis (exception is HPV carcinoma which is poorly differentiated but is responsive to tx unless untreated which makes it aggressive and metastasise early)
14
Q
How do carcinomas spread and how does this affect the prognosis
A
- Spread is by direct invasion of surrounding tissues and by lymphatic metastasis
- Prognosis deteriorates sharply with local spread and nodal involvement
15
Q
How do carcinomas spread locally on a cellular level?
A
- Invading cells grow into the tissues by direct extension
- Poorly differentiated carcinomas, single cells and small clusters of cells detach along invasive front (discohesive invasive front) - higher risk of metastasis than cohesive front
- Aggressive carcinomas show perineurial infiltration or vascular invasion (vascular invasion more likely to metastasise)
- Tumour cells invade and eventually destroy all tissues (muscle fat nerves and bone).
- Induces resorption of bone until it can invade medullary cavity
- Invading cancer cells excite and inflammatory and immune reaction and become surrounded by lymphocytes and plasma cells which kill the carcinoma cells but provides no significant protection
