Oral Cavity Neoplasms

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Oral Cavity Neoplasms

Head and Neck Surgery
Author Credentials 

Erik T. Interval, MD
Fellow, Creighton University and Nebraska Methodist / Head & Neck Surgical Oncology

William Lydiatt, MD
Chair Department of Surgery Nebraska Methodist Hospital
Clinical Professor of Surgery Creighton University
Nebraska Methodist Hospital
Head and Neck Surgery
8303 Dodge Street
Omaha, NE 68154
Email: William.lydiat@nmhs.org

Module Learning Objectives 
  1. Recognize the risk factors for development of oral cavity carcinoma.
  2. Describe the differential diagnosis of benign and malignant lesions of the oral cavity.
  3. Review staging of oral cavity carcinoma.
  4. Explain the diagnostic techniques for determining extent of disease and their utility in oral cavity cancer.
  5. Review the treatment options for oral cavity carcinoma.
  6. List the rehabilitation options for patients with oral cavity carcinoma.
  7. Describe the treatment of the patient as a whole, including post-oncologic treatment survivorship.

Embryology

Learning Objectives 

Review the embryological tissue planes and derivation of structures in the oral cavity.

References 
  1. German RZ and Palmer JB. Anatomy and development of oral cavity and pharynx. GI Motility online (2006) doi:10.1038/gimo5.
  2. Hollinshead, WH. Anatomy for surgeons, vol. 1. The head and neck. Philadelphia: Harper and Row; 1982:325-88.

Anatomy

Learning Objectives 
  1. Explain the anatomic relationships that define the oral cavity.
  2. Describe how the anatomic distribution of structures defines the areas at risk for specific tumors.
  3. Recognize the anatomic boundaries of the subsites of the oral cavity.
References 
  1. Ridge JA, Lydiatt WM, Patel SG, et al. Lip and Oral Cavity, in: Amin MB, editor. AJCC Cancer Staging Manual, Eight Edition. New York: Springer, 2017:79-94.
  2. Christopoulos A. Mouth Anatomy. Online. https://emedicine.medscape.com/article/1899122-overview. Accessed on April 4, 2018. 
  3. Shah JP, Patel SG, Singh B. Chapter 17 Lips, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier, 2007:204-231
  4. Shah JP, Patel SG, Singh B. Chapter 18 Oral Cavity, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier, 2007:232-289.

Pathogenesis

Learning Objectives 
  1. Review the types of benign and malignant lesions that arise in the oral cavity.
  2. Explain the risk factors for development of squamous cell carcinoma of the oral cavity.
  3. Describe the concept of and molecular basis for field cancerization.
  4. Recognize that second primary tumors occur frequently (2-5% per year) and know some of the strategies that have been tested to prevent their occurrence.
  5. Review the differential diagnosis, natural history and management options of white and red lesions of the oral cavity.
  6. Review the pathogenesis of mandibular invasion by tumor.
References 
  1. Dal Maso L et al. Combined effect of tobacco smoking and alcohol drinking in the risk of head and neck cancers: a re-analysis of case-control studies using bi-dimensional spline models. Eur J Epidemiol. 2016 Apr;31(4):385-93.
  2. Winn DM, Lee Y-CA, Hashibe M, Boffetta P. The INHANCE consortium: toward a better understanding of the causes and mechanisms of head and neck cancer. Oral Dis. 2015 Sep;21(6):685-93.
  3. Rothman K, Keller A. The effect of joint exposure to alcohol and tobacco on risk of cancer of the mouth and pharynx. J Chronic Dis.1972;25:711-716.
  4. Gabusi A et al. Oral field cancerization: history and future perspectives. Pathologica. 2017 Mar;109(1):60-65.
  5. Jaiswal G et al. Field cancerization: concept and clinical implications in head and neck squamous cell carcinoma. J Exp Ther Oncol. 2013;10(3):209-14.
  6. Lydiatt WM, Anderson PE, Bazzana T, Casale M, Hughes CJ, Huvos AG, Lydiatt DD, Schantz, SP. Molecular support for field cancerization in the head and neck. Cancer. 1998 Apr1;82(7): 1376-1380.
  7. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral stratified squamous epithelium; clinical implications of multicentric origin. Cancer.1953;6:963-968.
  8. Leemans CR, Braakhuis BJM, Brakenhoff RH. The molecular biology of head and neck cancer. Nat Rev Cancer. 2011 Jan;11:9-22.
  9. Benner SE, Pajak TF, Lippman SM, Earley C, Hong WK. Prevention of second primary tumors with isotretinoin in patients with squamous cell carcinoma of the head and neck: long-term follow-up. J Natl Cancer Inst. 1994;86:140-1.
  10. Quon H, et al. Photodynamic therapy in the management of pre-malignant head and neck mucosal dysplasia and microinvasive carcinoma. Photodiagnosis and photodynamic therapy. 2011;8, 75-85.
  11. Hong WK, Lippman SM, Itri LM, Karp DD, Lee JS, Byers RM, et al. Prevention of second primary tumors with isotretinoin in squamous-cell carcinoma of the head and neck. N Engl J Med. 1990;323:795-801.
  12. Panwar A, Lindau R, Wieland A. Management for premalignant lesions of the oral cavity. Expert Rev Anticancer Ther. 2014;14(3):349-357.
  13. Kadakia S, et al. Topical oral cavity chemoprophylaxis using isotretinoin rinse: a 15-year experience. Laryngoscope. 2017 Jul;127:1595-1599.
  14. McGregor AD, MacDonald DG. Patterns of spread of squamous cell carcinoma within the mandible. Head Neck. 1989;11:457-61.
  15. McGregor AD, MacDonald DG. Routes of entry of squamous cell carcinoma to the mandible. Head Neck Surg. 1988;10:294-301.
  16. Brown JS et al. Patterns of invasion and routes of tumor entry into the mandible by oral squamous cell carcinoma. Head Neck. 2002 Apr;24(4):370-83.

Incidence

Learning Objectives 
  1. Know the incidence of squamous cell carcinoma of the head and neck at various sites.
  2. Know the incidence of nodal metastasis in oral cavity carcinoma.
References 
  1. Shah J, Candela FC, Poddar AK. The patterns of cervical lymph node metastases from squamous cell carcinoma of the oral cavity. Cancer. 1990;66:109-13.
  2. Ebrahim A et al. The Prognostic and Staging Implications of Bone Invasion in Oral Squamous Cell Carcinoma. Cancer. 2011;117:4460-4467.

Patient Evaluation

Learning Objectives 
  1. Know the proper use and importance of history, physical examination, radiographic evaluation, dental evaluation, laboratory evaluation and examination under anesthesia.
  2. Understand the importance of clinical examination supplemented by radiographic assessment to determine mandibular invasion.
  3. Understand the importance of clinical estimation of depth of invasion, rather than thickness, as an independent prognosticator.
  4. Confirmatory testing
    • This consists of examination and biopsy as outlined above.
References 
  1. Koch W et al. Cancer of the Oral Cavity: General Principles and Management, in: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA, 2014:357-361.
  2. Shah JP, Patel SG, Singh B. Chapter 18 Oral Cavity, in Shah JP, Patel SG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier, 2007:232-289.
  3. Bennet JA. Cancer of the Oral Cavity: Radiologic Imaging Concerns, in: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA, 2014:362-365.
  4. Huang SH, Hwang D, Lockwood G, Goldstein DP, O'Sullivan B. Predictive value of tumor thickness for cervical lymph-node involvement in squamous cell carcinoma of the oral cavity: a meta-analysis of reported studies. Cancer. 2009;115(7):1489-97. 
  5. Liao CT, Lin CY, Fan KH, Wang HM, Ng SH, Lee LY, Hsueh C, Chen IH, Huang SF, Kang CJ, Yen TC. Identification of a high-risk group among patients with oral cavity squamous cell carcinoma and pT1-2N0 disease. International journal of radiation oncology, biology, physics. 2012;82(1):284-90. 
  6. Pentenero M, Gandolfo S, Carrozzo M. Importance of tumor thickness and depth of invasion in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the literature. Head & neck. 2005;27(12):1080-91. 
  7. Bolzoni A, Cappiello J, Piazza C, Peretti G, Maroldi R, Farina D, et al. Diagnostic accuracy of magnetic resonance imaging in the assessment of mandibular involvement in oral-oropharyngeal squamous cell carcinoma: a prospective study. Arch Otolaryngol Head Neck Surg. 2004;130:837-843.
  8. Farrow ES et al. Magnetic resonance imaging and computed tomography in the assessment of mandibular invasion by squamous cell carcinoma of the oral cavity. Influence on surgical management and post-operative course. Rev Stomatol Chir Maxillofac Chir Orale. 2016;117(5):311-321. 

Measurement of Functional Status

Learning Objectives 
  1. Be aware of the importance of assessing the entire patient including his or her general medical and nutritional state with specific attention to the patient’s ability to tolerate therapy.
  2. Functional status should be an important aspect of the decision-making process regarding treatment selection.
  3. Functional status should also include an assessment of potential psychological morbidity.
    • The clinician must prepare the patient as much as possible for the ravages of treatment.
References 
  1. American Head and Neck Society.
  2. Lydiatt WM, Johnson PJ. Cancers of the mouth and throat: a patient’s guide to treatment. Omaha: Addicus Books, Inc. 2001.
  3. Panwar A, Cheung VW, Lydiatt W. Supportive Care and Survivorship Strategies in Management of Squamous Cell Carcinoma of the Head and Neck. Hematol Oncol Clin N Am. 2015 Dec;29(6):1159-68. 
  4. Nieman CL, et al. Frailty, hospital volume, and failure to rescue after head and neck cancer surgery. Laryngoscope. 2017 Oct 17. doi: 10.1002/lary.26952. [Epub ahead of print]
  5. Lydiatt WM, et al. Prevention of depression with escitalopram in patients undergoing treatment for head and neck cancer: double-blind, placebo-controlled clinical trial. JAMA Otolaryngol Head Neck Surg. 2013 Jul;139(7),678-86. 
  6. de Leeuw JR, de Graeff A, Ros WJ, Blijham GH, Hordijk GJ, Winnubst JA. Prediction of depressive symptomatology after treatment of head and neck cancer: the influence of pretreatment physical and depressive symptoms, coping, and social support. Head Neck. 2000;22:799-807.
  7. Piccirillo JF. Inclusion of comorbidity in a staging system for head and neck cancer. Oncology. 1995;9:831-836.
  8. Support for People with Oral and Head and Neck Cancer. 

Imaging

Learning Objectives 
  1. Understand when and when not to utilize diagnostic imaging.
    • Imaging should be determined on an individual basis, and may include computed tomography (CT), magnetic resonance imaging (MRI), panoramic radiographs, or dental films to determine extent of disease.
  2. Cervical nodes may be evaluated using CT, MRI, ultrasound, or possibly positron emission tomography (PET) scanning. However, if the treatment plan is not going to be changed by the results of radiography, then none should be obtained. Additionally, no imaging modality is sensitive to the presence of occult regional metastasis.
References 
  1. Bennet JA. Cancer of the Oral Cavity: Radiologic Imaging Concerns, in: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA, 2014:362-365.
  2. Keberle M. Neoplasms of the Oral Cavity. In: Hermans R, editor. Head and Neck Cancer Imaging. Heidelberg, Germany. 2008:103-128.
  3. C.M. Glastonbury, S.K. Mukherji, B. O'Sullivan and W.M. Lydiatt. Setting the Stage for 2018: How the Changes in the American Joint Committee on Cancer/Union for International Cancer Control Cancer Staging Manual Eighth Edition Impact Radiologists. AJNR Am J Neuroradiol.2017 Dec;38(12):2231-2237.

Pathology

Learning Objectives 
  1. Understand that squamous cell carcinoma is the most common malignancy of the oral cavity. Recognize the multiple variants of squamous cell carcinoma of the oral cavity.
  2. Recognize that other malignancies may occur in the oral cavity, and be familiar with their clinical presentation.
References 
  1. Fritsch VA, Gerry DR, Lentsch EJ. Basaloid squamous cell carcinoma of the oral cavity: an analysis of 92 cases. Laryngoscope. 2014;124(7):1573-1578.
  2. Peng Q, et al. Oral verrucous carcinoma: From multifactorial etiology to diverse treatment regimens (Review). Int J Oncol. 2016;49(1):59-73.
  3. Daley T, Darling M. Nonsquamous Cell Malignant Tumours of the Oral Cavity: An Overview. J Can Dent Assoc. 2003;69(9):577-582.

Treatment

Learning Objectives 
  1. Understand that benign and malignant oral cavity neoplasms are typically treated with surgery with or without adjuvant therapy. Understand that adjuvant can comprise radiation or chemoradiation therapy.
  2. Know that alternate forms of therapy, such as brachytherapy and multimodality therapy, are also available; know their relative strengths and weaknesses.
References 
  1. Bernier J, Domenge C, Ozsahin M, Matuszewska K, Lefebvre JL, Greiner RH, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med. 2004;350;1945-52.
  2. Cooper JS, Pajak TF, Forastiere AA, Jacobs J, Campbell BH, Saxman SB, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous-cell carcinoma of the head and neck. N Engl J Med. 2004;350;1937-44.
  3. Bernier J, Cooper J, Pajak T, van Glabbeke M, et al. Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC (#22931) and RTOG (#9501). Head Neck. 2005 Oct;27(10):843-50.
  4. Koch W et al. Cancer of the Oral Cavity: General Principles and Management, in: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA, 2014:357-361.
  5. Harrison LB, et al. Cancer of the Oral Cavity: Radiation Therapy Technique, in: Harrison, LB, editor. Head and Neck Cancer: A Multidisciplinary Approach, 4th ed. Philadelphia PA, 2014:366-372.
  6. D’Cruz AK, et al. Elective versus therapeutic neck dissection in node-negative oral cancer. New England Journal of Medicine. 2015;373:521-529.

Surgical Therapies

References 
  1. Shah JP, Patel SG, Singh B. Chapter 17 Lips, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier, 2007;204-231.
  2. Shah JP, Patel SG, Singh B. Chapter 18 Oral Cavity, in Shah JP, Patel SSG, Singh B, editors. Head and Neck: Surgery and Oncology, 4th ed. Philadelphia PA, Elsevier, 2007;232-289.
  3. Lydiatt WM. Transoral Resections, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier, 2011;269-286.
  4. Lydiatt WM. Composite resection with segmental mandibulectomy, in Cohen JI and Clayman GL, editors. Atlas of Head & Neck Surgery. Philadephia: Elsevier, 2011;307-317.

Staging

Learning Objectives 

Know how to stage oral cavity carcinoma both clinically and pathologically.

References 
  1. Ridge JA, Lydiatt WM, Patel SG, et al. Lip and Oral Cavity, in: Amin MB, editor. AJCC Cancer Staging Manual, Eight Edition. New York: Springer; 2017;79-94.

Complications

Learning Objectives 

Be aware of the complications of therapy and how to manage them.

References 

Chambers MS et al. Radiation-induced xerostomia in patients with head and neck cancer: pathogenesis, impact on quality of life, and management. Head Neck. 2004;26(9):796-807.

Payakachat N, Ounpraseuth S, Suen JY. Late complications and long-term quality of life for survivors (>5 years) with history of head and neck cancer. Head Neck. 2012;35(6):819-825.

Beadle BM, et al. Evaluating the impact of patient, tumor, and treatment characteristics on the development of jaw complications in patients treated for oral cancers: a SEER-Medicare analysis. Head Neck. 2013;35(11):1599-1605.

Rice N, et al. The management of osteoradionecrosis of the jaws—a review. Surgeon. 2015;13(2):101-109.

Costa DA et al. New perspectives on the conservative management of osteoradionecrosis of the mandible: A literature review. Head Neck. 2016;38(11):1708-1716.

Review

Review Questions 
  1. List the major risk factors for squamous cell carcinoma of the oral cavity.
  2. Describe the presenting signs and symptoms of oral tumors.
  3. What is the risk of transformation to malignancy over a 5- to 10-year period of a leukoplakic lesion of the oral tongue?
  4. How would you stage a 62-year-old with a 2 centimeter carcinoma of the lateral tongue, with a depth of invasion of 1 cm, with one palpable lymph node measuring 2.3 centimeters, without clinical evidence of ENE, with normal chest x-ray and normal liver function?
  5. Suppose the patient from question 4 undergoes successful surgical resection with reconstruction. The patient has a good functional status and minimal comorbidities. Final pathology shows a 2 cm tumor with a depth of invasion of 8 mm, with one positive lymph node with extranodal extension, lymphovascular invasion, and perineural spread. How would you stage this patient, and what would be the recommendation for adjuvant therapy?
Resources 

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  1. Evidenced-Based Approach to Oral Cavity Cancer: Update 2020
  2. Prevention, Screening and Diagnosis of Oral Cancers and OPMD
  3. Sentinel Node Biopsy for Oral Cavity Cancer: Making the Case
  4. Teaching an Old Dog New Tricks: Managing Depth of Invasion in Oral Cavity Cancer