Soft Tissue Lesions and Malignancies of the Jaws

Question 1

Clinical investigations to differentiate malignant from benign lesions

Answer 1

High risk sites? Lateral borders of tongue, floor of mouth, lips, alveolus
Fixed/attached or mobile? Fixed is bad
Pedunculated? Rarely cancerous
Bleeding/ulcerated? Bad
Smooth surface? Lobulated?
Pulsatile? Likely vascular
How long has it been there? >10 days may require biopsy
Static in size or growing rapidly?
Texture? Indurated/firm is bad

Tenderness, size and mobility of draining lymph nodes

Question 2

Histopathologic findings of SCC

Answer 2

Eosinophilic cells
Abnormal mitoses, mitotic bodies
Underlying lymphocytic infiltration
Keratin pearls
Increased N:C ratio
Hyperchromatic nuclei

Question 3

TNM classifications

Answer 3

Tumour size (0-4)
Regional lymph Nodes (0-3)
Distant Metastasis (0-1)

Regional lymph nodes? Already stage II+
Distant lymph nodes? Stage IV

Question 4

How does SCC metastasize

Answer 4

Through lymphatics
Which lymph nodes are involved depends on the site of the primary tumour and which nodes drain that area

Question 5

SCC epidemiology

Answer 5

Most common oral malignancy
Prevalent globally but higher in SEA and australia
Male > female
Median age of diagnosis is >66yo
5y survival is 45-50%, prognosis poor

Question 6

SCC etiology

Answer 6

From mucosal epithelium of oral cavity and pharynx

Question 7

Types of premalignant lesions

Answer 7

Leukoplakia
Erythroplakia
Actinic cheilitis
Erosive lichen planus

Question 8

Risk factors of H&N carcinomas

Answer 8

Tobacco consumption
Excessive alcohol
Exposure to environmental pollutants
UV exposure
Infection with viral agents (e.g. HPV 16&18, EBV)
Betel nut chewing
Poor OH
Diet lacking in vegetables

Question 9

Progression of normal mucosa to carcinoma?

Answer 9

Normal mucosa
Hyperplasia
Dysplasia
Carcinoma-in-situ
Invasive carcinoma

Question 10

Common lymph nodes involved for primary tumour in oral cavity

Answer 10

Level I: Submental, submandibular
Level II: Upper jugular
Level III: Middle jugular

Question 11

Common lymph nodes involved for primary tumour in oropharynx

Answer 11

Level II: Upper jugular
Level III: Middle jugular
Level IV: Lower jugular

Question 12

Common lymph nodes involved for primary tumour in nasopharynx

Answer 12

Retropharyngeal lymph nodes

Question 13

When is biopsy indicated

Answer 13

Clinical suspicion of malignancy:
Enlarging mass
Chronic ulceration
Tissue friability
Induration
Persistence despite removal of local irritants
New or enlarging pigmented lesions
Irregular border
Non-homogenous coloration

Question 14

What is basal cell carcinoma

Answer 14

Most common form of skin cancer
Slow growing, locally invasive
Arises from chronic exposure to UV radiation
Basal layer of epithelium proliferates and invades underlying dermis

Question 15

What is melanoma

Answer 15

Very rare in oral cavity, common skin cancer
Prognosis for oral melanoma is poor, only 45% 5y survival rate
Metastasizes to lymph nodes then spreads hematologically
Treated by wide excision and excision of regional lymph nodes, immunotherapy and targeted therapy

Question 16

Treatment of SCC

Answer 16

Excision with at least 1cm margin
Reconstruction
External beam radiation therapy after surgery (often for oropharyngeal cancer)

Question 17

Side effects of radiotherapy treatment

Answer 17

Soreness or open sores of mouth/throat
Dry mouth
Trouble swallowing
Changes in taste
Nausea
Earaches
Tooth decay
Swelling in gums, throat or neck

Question 18

Types of chemotherapy

Answer 18

Adjuvant chemotherapy - after surgery to kill any cancer cells left behind

Nonadjuvant chemotherapy - before surgery to shrink larger tumours
Generally used for advanced stage IV cancers that have spread too far to be removed by surgery, slowing growth of cancer

Question 19

What is chemoradiation

Answer 19

Chemotherapy and radiation together
Shown to reduce oropharyngeal tumours more than either treatment alone

Often use the targeted drug cetuximab along with radiation