para>Greater incidence >55 years of age
Peak age of 60 to 70 years
‚
Prevalence
- Oral cancers comprise 1/3 of all head and neck cancers (2)[A]; 3% of all new cancers occurring in men and 2% in women
- Occur most often in lip 30% > tongue 20 " “30% > tonsils and oropharynx 20% > gums, floor of mouth, other parts of mouth 10 " “20% > minor salivary gland <10%
ETIOLOGY AND PATHOPHYSIOLOGY
- Of neoplasms, 90% are squamous cell carcinomas; the others include lymphomas and adenocarcinomas from minor salivary gland origin and sarcomas.
- Variety of cellular differences at molecular level among oral squamous cell carcinomas (3)[A]
- Use of tobacco (smokeless or smoked, including cigars); 85% of head and neck cancers linked to tobacco
- Excessive alcohol consumption
- Use of both alcohol and tobacco greatly increases risk as compared with those who use tobacco or alcohol alone (synergistic effect).
- Exposure to ultraviolet (UV) light (i.e., sun bathing, outdoor jobs) in the case of lip carcinoma
- Radiation exposure from treatment of other facial cancers increases risk of salivary gland cancers.
- HPV 16 DNA is involved in ~25% of oral cancers but 2/3 of oropharyngeal cancers. Prevalence is rising (2,4)[A].
- Associations:
- Epstein-Barr virus
- Graft-versus-host disease
- Betel nut with and without tobacco use
- Certain occupational chemical exposures, including formaldehyde, perchloroethylene, and pesticides; may be associated with nasopharyngeal and laryngeal cancer
- Poor nutrition and oral hygiene (5)[B], presence of oral lichenoid, and leukoplakic lesions may act as predisposing factors.
- Weakened immune system. HIV disease " ”higher incidence of head and neck malignances
Genetics
A family history of oral cancer should be noted. ‚
RISK FACTORS
- Most patients with proliferative verrucous leukoplakia (PVL) progress to oral carcinoma (6)[A].
- Lichen planus (1)[A]
- Low socioeconomic status (1,7) [A]
- Tobacco, alcohol, UV light exposures, HPV infection, previous head and neck radiation (8)[C]
- Chronic mechanical irritation (e.g., sharp tooth edge, poor-fitting denture, reverse smoking) and poor oral hygiene (2)[A]
- Poor nutrition, weakened immune system, graft-versus-host disease (American Cancer Society " “ oral cavity and oropharyngeal cancer)
- Fanconi anemia, dyskeratosis congenital (American cancer society " “oral cavity and oropharyngeal cancer)
GENERAL PREVENTION
- Avoid tobacco (including smokeless) and betel nut.
- Limit alcohol use.
- Limit sun exposure/UV light; wear sun block and hats with visors/large rims.
- Avoid HPV infection; role for HPV vaccine presexual activity.
- Diet high in fruits and vegetables (rec. 2.5 cups/day)
- Annual complete oral exam, including bimanual palpation of mouth floor by dental or medical provider, especially for those at risk (smokers) may be beneficial (3,8)[A], but this is a level C recommendation from the U.S. Preventive Services Task Force (USPSTF) (9)[A].
- If detected at an early stage, survival from oral cancer is >90% at 5 years, whereas late-stage disease survival is only 30%.
- Close follow-up of PVL and lichen planus with early and aggressive treatment
COMMONLY ASSOCIATED CONDITIONS
- Leukoplakias or erythroplakias should be biopsied because they are considered premalignant and are associated with carcinoma at least 10% of the time.
- Riboflavin deficiency or iron-deficiency anemia and Plummer-Vinson syndrome associated with oral cancers
DIAGNOSIS
HISTORY
- Nonhealing ulcer or mass in mouth or on lip
- Area that bleeds easily or unexplained pain
- Dysphagia/odynophagia
- Chronic sore throat or hoarseness
- Unexplained ear pain
- White +/ ¢ ˆ ’ red lesion on gums, tongue, tonsils
- Problems articulating or swallowing
- Regurgitation of liquids secondary to nasopharyngeal incompetence from the tumor
- Lump or mass in neck
- Weight loss
- History of risk factors (e.g., tobacco exposure, chronic alcohol use, radiation treatment, excessive UV light exposure)
PHYSICAL EXAM
- Friable granular exophytic and/or infiltrative mass or ulcer that frequently tender/ confused with infection
- White and/or red lesions noted
- Hard, indurated margins extending beyond the borders of the ulcer noted on palpation
- Hard neck mass suggesting metastatic disease in the nodal chain along the internal jugular vein
- Cranial sensory and motor nerves may be compromised.
DIFFERENTIAL DIAGNOSIS
- Exudative tonsillitis (usually bilateral involvement)
- Stomatitis or glossitis secondary to infectious etiology, most commonly candidiasis
- Benign tumors of the oral cavity (slow to grow and usually not erosive or ulcerative)
- Kaposi sarcoma
- Mycosis fungoides
- Premalignant, dysplastic lesions such as leukoplakia or erythroplasia; lichen planus
- Benign tumors; for example, fibroma, leiomyoma, pyrogenic granuloma, condyloma acuminata, lipoma
DIAGNOSTIC TESTS & INTERPRETATION
- Physical exam, including an extensive bimanual intra- and extraoral, head, and neck exams
- Panendoscopy pharyngoscopy, laryngoscopy, bronchoscopy
- A transoral biopsy of any ulceration or erythroplasia/leukoplakia lesion present for 4 weeks provides the definitive diagnosis.
- Plain films of head and neck
- CT scan (for bony involvement) or MRI (for soft-tissue involvement) or PET scan may be necessary in some cases; modified sugars are preferentially absorbed by cancer cells (10)[C], if clinical suggestion of intracranial metastasis; techniques have advantages and disadvantages.
- A chest x-ray to assess metastasis to the lungs, the most common site of spread outside the neck
- Imaging bone scans, if bone pain suggests bone metastasis
- Abdominal CT scan if liver metastasis is suspected
Test Interpretation
- Premalignant
- Malignant changes characteristic of cell types
- Staging of malignancy
- Most common is squamous cell (90%) followed by salivary gland, lymphomas, and sarcomas (1)[A]
- Those originating in the lip and buccal mucosa are usually well differentiated; those originating in the oral pharynx and floor of mouth are less well differentiated and have higher risk for metastasis.
TREATMENT
GENERAL MEASURES
- Treatment varies depending on the location (e.g., tongue, buccal wall, pharynx, palate, lip) (11)[A].
- Surgery and radiotherapy for early disease are comparable.
- Small, superficial lesions can be treated with combined external beam radiation therapy (EBRT) and intraoral cone or surface mold (11,12)[A].
- Altered fractionation radiotherapy is associated with an improvement in overall survival and locoregional control in patients with oral cavity and oropharyngeal cancers (13)[B].
- Primary radiotherapy (and/or chemotherapy for palliation) is suggested for unresectable tumors and patients not amenable to surgery.
- Chemotherapy reserved for palliative treatment in late-stage cancers (11)[A]
- Obtain a dental consult prior to any treatment to prevent serious complications later. Treat or eliminate questionable tooth and gum disease, fabricate mouth guards to wear during radiation treatments, and fabricate fluoride trays.
ISSUES FOR REFERRAL
Biopsy any suspicious lesions ‚
ADDITIONAL THERAPIES
Good oral hygiene, possible chlorhexidine rinse treatment, and frequent dental visits, especially for patients treated with radiotherapy that have higher incidence of poor oral hygiene and caries. Also, treat aggressively due to mucositis/xerostomia (8)[A]. ‚
SURGERY/OTHER PROCEDURES
- Wide resection ‚ ± radiation therapy and/or chemotherapy are the treatments of choice.
- Radiotherapy will be used on occasion prior to surgery to debulk large cancers.
- There is some evidence that concomitant radio-/chemotherapy with surgery is more effective than radiation therapy with surgery in the treatment of head and neck cancers in general (2)[A].
- For a neoplasm such as a melanoma, surgery is believed to be the most effective treatment. The role of radiation, however, is controversial. Many experts believe melanoma neoplasms to be radioresistant.
- A tracheotomy may be necessary if the patient has problems handling secretions or difficulty breathing.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Inpatient for surgery, airway management, infection
- Outpatient for radiation therapy and chemotherapy
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
As indicated by patient 's nutritional and physical status ‚
Patient Monitoring
Routine periodic head, mouth, and neck exams by medical and dental professionals to detect possible second primary or recurrence in the upper respiratory and digestive tracts, especially within the first 36 months and if radiology was used ‚
DIET
- Depends on the extent of disease and whether the patient is able to chew or swallow
- Usually, early lesions can be managed with a regular diet. As disease progresses, a soft diet is necessary.
- Nutrition is of prime importance for normal wound healing, especially if the patient requires surgery. Patients may need nasogastric and/or gastrostomy feedings if they are orally disabled.
PATIENT EDUCATION
Secondary prevention should include avoidance of risk factors especially alcohol and smoking prevention because 34 " “57% of those diagnosed with oral cancer continue these risky behaviors. ‚
PROGNOSIS
- Early lesions with adequate treatment leads to a >80% cure.
- 5-year relative survival rate for localized stage: 82%
- 5-year relative survival rate for all stages combined: 59%
- 5-year survival rates have changed very little in the past decade; however, quality of life is much improved (2,11)[A].
- Patients under age < 45 years have a higher 5-year survival rate (2)[A].
- HPV-related oral cancers have lower recurrence rates than non " “HPV-related cancers after excision (14)[A].
COMPLICATIONS
- Functional and/or cosmetic disabilities proportional to the degree of surgery, location, and stage of tumor
- Stomatitis with or without candidiasis, tissue hypoxia, tongue mucositis, hypocellularity, and fibrosis secondary to radiation therapy or chemotherapy
- 10 treatments can help prevent or reduce the severity of mucositis during treatment compared to no treatment or placebo including aloe vera, amifostine, cryotherapy, granulocyte colony " “stimulating factor (G-CSF), IV glutamine, honey, keratinocyte growth factor, laser, polymyxin/tobramycin/amphotericin (PTA) antibiotic pastille/paste, and sucralfate.
- Patients frequently experience xerostomia secondary to surgery and radiation therapy, causing increased dysphagia and dental caries.
- Persistent problems with articulation or deglutition, depending on the amount of tongue resection and age of patient
- Radiation may cause new neoplasms.
REFERENCES
11 American Cancer Society. Cancer Facts & Figures 2015. Atlanta, Ga: American Cancer Society; 2015.22 Majchrza ‚ E, Szybiak ‚ B, Wegner ‚ A, et al. Oral cavity and oropharyngeal squamous cell carcinoma in young adults: a review of the literature. Radiol Oncol. 2014;48(1):1 " “10.33 Genden ‚ EM, Ferlito ‚ A, Silver ‚ CE, et al. Contemporary management of cancer of the oral cavity. Eur Arch Otorhinolargyngol. 2010;267(7):1001 " “1017.44 Patton ‚ LL, Epstein ‚ JB, Kerr ‚ AR. Adjunctive techniques for oral cancer examination and lesion diagnosis: a systematic review of the literature. J Am Dent Assoc. 2008;139(7):896 " “905.55 Pytynia ‚ KB, Dahlstrom ‚ KR, Strugis ‚ EM. Epidemiology of HPV-associated oropharyngeal cancer. Oral Oncol. 2014;50(5):380 " “386.66 Rajesh ‚ KS, Thomas ‚ D, Hedge ‚ S, et al. Poor periodontal health: a cancer risk? J Indian Soc Periodontol. 2013;17(6):706 " “710.77 Conway ‚ DI, Petticrew ‚ M, Marlborough ‚ H, et al. Socioeconomic inequalities and oral cancer risk: a systematic review and meta-analysis of case-control studies. Int J Cancer. 2008;122(12):2811 " “2819.88 Worthington ‚ HV, Clarkson ‚ JE, Bryan ‚ G, et al. Interventions for preventing oral mucositis for patients with cancer receiving treatment. Cochrane Database Syst Rev. 2011;(4):CD000978.99 Rethman ‚ MP, Carpenter ‚ W, Cohen ‚ EE, et al. Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc. 2010;141(5):509 " “520.1010 Brocklehurst ‚ P, Kujan ‚ O, Glenny ‚ AM, et al. Screening programmes for the early detection and prevention of oral cancer. Cochrane Database Syst Rev. 2010;(11):CD004150.1111 Glenny ‚ AM, Furness ‚ S, Worthington ‚ HV, et al. Interventions for the treatment of oral cavity and oropharyngeal cancer: radiotherapy. Cochrane Database Syst Rev. 2010;(12):CD006387.1212 Bessell ‚ A, Glenny ‚ AM, Furness ‚ S, et al. Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment. Cochrane Database Syst Rev. 2011;(9):CD006205.1313 Severino ‚ P, Alvares ‚ AM, Michaluart ‚ PJr, et al; Head and Neck Genome Project GENCAPO. Global gene expression profiling of oral cavity cancers suggests molecular heterogeneity within anatomic subsites. BMC Res Notes. 2008;1:113.1414 Sturgis ‚ EM, Ang ‚ KK. The epidemic of HPV-associated oropharyngeal cancer is here: is it time to change our treatment paradigms? J Natl Compr Canc Netw. 2011;9(6):665 " “673.
SEE ALSO
Algorithm: Bleeding Gums ‚
CODES
ICD10
- C10.9 Malignant neoplasm of oropharynx, unspecified
- C00.9 Malignant neoplasm of lip, unspecified
- C02.9 Malignant neoplasm of tongue, unspecified
- C04.9 Malignant neoplasm of floor of mouth, unspecified
- C00.4 Malignant neoplasm of lower lip, inner aspect
- C02.4 Malignant neoplasm of lingual tonsil
- C00.3 Malignant neoplasm of upper lip, inner aspect
- C00.2 Malignant neoplasm of external lip, unspecified
- C00.6 Malignant neoplasm of commissure of lip, unspecified
- C00.8 Malignant neoplasm of overlapping sites of lip
- C00.1 Malignant neoplasm of external lower lip
- C01 Malignant neoplasm of base of tongue
- C00.0 Malignant neoplasm of external upper lip
- C02.0 Malignant neoplasm of dorsal surface of tongue
- C02.1 Malignant neoplasm of border of tongue
- C02.2 Malignant neoplasm of ventral surface of tongue
- C00.5 Malignant neoplasm of lip, unspecified, inner aspect
- C04.8 Malignant neoplasm of overlapping sites of floor of mouth
- C05.9 Malignant neoplasm of palate, unspecified
- C06.0 Malignant neoplasm of cheek mucosa
- C06.1 Malignant neoplasm of vestibule of mouth
- C06.2 Malignant neoplasm of retromolar area
- C06.80 Malignant neoplasm of ovrlp sites of unsp parts of mouth
- C06.89 Malignant neoplasm of overlapping sites of oth prt mouth
- C05.2 Malignant neoplasm of uvula
- C02.3 Malig neoplasm of anterior two-thirds of tongue, part unsp
- C05.0 Malignant neoplasm of hard palate
- C06.9 Malignant neoplasm of mouth, unspecified
- C04.1 Malignant neoplasm of lateral floor of mouth
- C04.0 Malignant neoplasm of anterior floor of mouth
- C03.9 Malignant neoplasm of gum, unspecified
- C03.1 Malignant neoplasm of lower gum
- C03.0 Malignant neoplasm of upper gum
- C02.8 Malignant neoplasm of overlapping sites of tongue
- C05.8 Malignant neoplasm of overlapping sites of palate
- C05.1 Malignant neoplasm of soft palate
- C10.1 Malignant neoplasm of anterior surface of epiglottis
- C10.2 Malignant neoplasm of lateral wall of oropharynx
- C10.3 Malignant neoplasm of posterior wall of oropharynx
- C10.4 Malignant neoplasm of branchial cleft
- C10.8 Malignant neoplasm of overlapping sites of oropharynx
- C11.0 Malignant neoplasm of superior wall of nasopharynx
- C11.1 Malignant neoplasm of posterior wall of nasopharynx
- C11.2 Malignant neoplasm of lateral wall of nasopharynx
- C11.3 Malignant neoplasm of anterior wall of nasopharynx
- C11.8 Malignant neoplasm of overlapping sites of nasopharynx
- C11.9 Malignant neoplasm of nasopharynx, unspecified
- C10.0 Malignant neoplasm of vallecula
ICD9
- 146.9 Malignant neoplasm of oropharynx, unspecified site
- 140.9 Malignant neoplasm of lip, unspecified, vermilion border
- 141.9 Malignant neoplasm of tongue, unspecified
- 144.9 Malignant neoplasm of floor of mouth, part unspecified
- 145.6 Malignant neoplasm of retromolar area
- 144.8 Malignant neoplasm of other sites of floor of mouth
- 145.0 Malignant neoplasm of cheek mucosa
- 145.1 Malignant neoplasm of vestibule of mouth
- 145.2 Malignant neoplasm of hard palate
- 145.3 Malignant neoplasm of soft palate
- 145.4 Malignant neoplasm of uvula
- 145.5 Malignant neoplasm of palate, unspecified
- 144.1 Malignant neoplasm of lateral portion of floor of mouth
- 145.8 Malignant neoplasm of other specified parts of mouth
- 145.9 Malignant neoplasm of mouth, unspecified
- 146.0 Malignant neoplasm of tonsil
- 146.1 Malignant neoplasm of tonsillar fossa
- 146.2 Malignant neoplasm of tonsillar pillars (anterior) (posterior)
- 146.4 Malignant neoplasm of anterior aspect of epiglottis
- 143.1 Malignant neoplasm of lower gum
- 146.5 Malignant neoplasm of junctional region of oropharynx
- 146.6 Malignant neoplasm of lateral wall of oropharynx
- 146.7 Malignant neoplasm of posterior wall of oropharynx
- 146.8 Malignant neoplasm of other specified sites of oropharynx
- 146.3 Malignant neoplasm of vallecula epiglottica
- 141.1 Malignant neoplasm of dorsal surface of tongue
- 140.0 Malignant neoplasm of upper lip, vermilion border
- 140.1 Malignant neoplasm of lower lip, vermilion border
- 140.3 Malignant neoplasm of upper lip, inner aspect
- 140.4 Malignant neoplasm of lower lip, inner aspect
- 140.5 Malignant neoplasm of lip, unspecified, inner aspect
- 140.6 Malignant neoplasm of commissure of lip
- 143.9 Malignant neoplasm of gum, unspecified
- 141.0 Malignant neoplasm of base of tongue
- 144.0 Malignant neoplasm of anterior portion of floor of mouth
- 141.2 Malignant neoplasm of tip and lateral border of tongue
- 141.3 Malignant neoplasm of ventral surface of tongue
- 142.8 Malignant neoplasm of other major salivary glands
- 140.8 Malignant neoplasm of other sites of lip
- 143.8 Malignant neoplasm of other sites of gum
- 142.9 Malignant neoplasm of salivary gland, unspecified
- 143.0 Malignant neoplasm of upper gum
- 142.2 Malignant neoplasm of sublingual gland
- 142.1 Malignant neoplasm of submandibular gland
- 142.0 Malignant neoplasm of parotid gland
- 141.8 Malignant neoplasm of other sites of tongue
- 141.6 Malignant neoplasm of lingual tonsil
- 141.5 Malignant neoplasm of junctional zone of tongue
- 141.4 Malignant neoplasm of anterior two-thirds of tongue, part unspecified
SNOMED
- Primary malignant neoplasm of oral cavity
- Primary malignant neoplasm of lip
- Primary malignant neoplasm of tongue
- Primary malignant neoplasm of floor of mouth
- Primary malignant neoplasm of gum
- Primary malignant neoplasm of salivary gland duct
CLINICAL PEARLS
- Primary and secondary prevention about risk factor avoidance can be provided by medical and dental providers during complete oral exams at annual visits.
- Leukoplakias or erythroplakias should be biopsied because they are considered premalignant and are associated with a carcinoma at least 10% of the time.
- Patients should see dentists prior to undergoing treatment of head and neck tumors to allow planning to reduce potential dental-related complications.
- Concomitant radio-/chemotherapy together with surgery is likely more effective than only radiation therapy and surgery in the treatment of head and neck cancers, in general.