Oral mucosal carcinomas

Oral mucosal carcinomas

Introduction

• CB cancers are inseparable from VADS cancers
• In 90% of cases, they are squamous cell carcinomas. 
•  Tumors are generally clearly visible and palpable.
• The etiology being 80% alcohol and tobacco poisoning in a poor oral health context
• The at-risk population is easy to target

1. Definitions 

• Cancer:   excessive proliferation of abnormal cells. 
• Carcinoma = epithelioma: Malignant tumor arising from an epithelial covering
•                                             Baso cell 
•                                            Spinocellular
• Differentiated carcinoma: 

A tumor where it is possible to recognize cells from the original tissue, less aggressive 

• Undifferentiated carcinoma

An epithelial tumor in which the morphology of the cells of the original tissue is not recognized: more aggressive 

2. Epidemiology 

• Oral cavity cancers represent 30% of VADS tumors
• 90% of CB kC: squamous cell carcinoma  
• Men aged 50 to 70: +++ 

3. Etiology 

•  Chronic smoking + alcoholism + poor oral health.
• Nutritional factors.
• Chronic irritations and traumas 
• Viral factors (HPV in particular HPV16, HPV18)
• Radiation 
• Professional factors 
• Potentially malignant conditions 
• Depressive subjects
• Genetic predisposition

4. Histopathology

• Intraepithelial carcinoma or carcinoma in situ:

Involves the full thickness of the epithelium without invasion of the underlying connective tissue

• Invasive or infiltrating squamous cell carcinoma: 

The tumor crosses the basement membrane and invades the underlying connective tissue      

• Invasive or infiltrating squamous cell carcinomas 
• Differentiated carcinomas: 

• Cells connected to each other by intercellular bridges, 
• A keratotic maturation. 
• Poorly differentiated carcinomas: 

• Cells have few bridges of union between them
• With some mitotic activity
• Low keratinization 
• Undifferentiated carcinomas: 

• formed from immature cells without union bridges. 
•  With high mitotic activity.

Oral mucosal carcinomas

5. Clinical forms 
6. Ulcerative form +++: the tumor ulceration presents:  

• A more or less irregular edge, Raised, Sometimes everted 
• The background is finely vegetating or budding
• Indurated base, more or less extended in depth, overflowing 
• largely the visible limits of the ulceration
• Easily bleeding on contact most often

Oral mucosal carcinomas

2. Vegetative or budding or exophytic form 

Bud, more or less thick, protruding from the healthy mucosa

3. Ulcerative-vegetative form  : it combines the two previous aspects

Oral mucosal carcinomas

4. Fissure form:

• It has the particular appearance of a thin crack,
•  Often in a crevice within the tumor. 
•  In book leaf in a reflection area of ​​the mucosa

Oral mucosal carcinomas

5. Infiltrative or ulcero-infiltrative or endophytic form 

•  the importance of the tumor in depth.
•   In view of often minimal inspection signs,
•    the often significant induration is a major element of dg orientation

6. Interstitial nodule:

• Unusual and rare appearance  
• It is perceived under healthy mucosa;
• But its hardness and the infiltrating character giving the awakening,
• The nodule ulcerates when the tumor volume increases

Oral mucosal carcinomas

7. Superficial erosive form 

• It is observed on an erythroplastic or lichenial beach 
• It has slightly raised clean edges, which can sometimes be detached in places. 
•  The induration is slight. 

8. Hyperkeratotic papillomatous form:

•  It comes in the form of buds more or less              
• keratinized at their summit
•  Corresponds to the third and final stage of epithelial dysplasia and florid oral papillomatosis 

Oral mucosal carcinomas

6. Diagnosis 
   1. Differential diagnosis 

• Traumatic ulceration. 
• Giant canker sores.
•  Some potentially malignant lesions 
• Specific infectious lesions .

2. Positive diagnosis 

• The clinic. 
• X-rays: juxta-osseous lesions.
• Blood tests. 
• The biopsy +++

7. Topographical forms
   1. Tongue cancer

• Epidemiology 

• Account for 2–5% of all malignant tumors in men and about 25% of oral cavity cancers 
•  Male predominance at age 60 
• Cancers of the mobile portion 80%
• Cancers of the base 20%
• Topographic distribution

• Cancers of the mobile portion of the tongue are located in front of the lingual V and correspond to the anterior 2/3 of the organ,
•   They include the lateral edges, the dorsal face and the ventral face 
•   Cancers of the base of the tongue affect the posterior 1/3 of the tongue behind the lingual V 
• Mobile tongue cancers
  • Clinical 
    • Circumstances of discovery

• Discreet and inconstant functional signs.
• Subjective observation of a nodule, ulceration, fissure, etc. 
• Discovery of a lingual anomaly during dental treatment 
• Sialorrhea, sometimes bloody 
• Difficulty swallowing or speaking. 
• Burning sensation or glossodynia
•  Neuralgia, tingling, reflex earache. 
• Rarely an angulo-maxillary or submandibular ganglion. 
• The general condition is perfectly preserved for a very long time as long as the diet remains sufficient.
• Description of the lesion 

• 30% ulcerative-budding or pure budding 
• 10% will occur on precancerous lesions 
• Palpation assesses the essential sign which is induration 
• Major anteroposterior axis.
• Seat: marginal (50%)
• Extension report 

• Local oral extension: 
• Bottom: the floor of the mouth 
• Behind: base of the tongue and the pillar of the tonsil 
• Inside: the midline

• Lymph node extension 
• Common, especially towards the jugulodigastric ganglion +++
• Involvement of the dorsal surface and crossing of the midline rapidly results in bilateral ADPs
• The absence of palpable lymph nodes does not prejudge the absence of lymph node invasion.
• Remote extension: pulmonary or hepatic 

• Clinical forms 
• Marginal location: 

• 1/2 of the cases of the lateral edge in its middle third 
• Rarely the tip and the anterior 1/3
• The ventral face 
• quickly becomes a pelvic lingual form
• the dorsal face 

• she is rare 
• it extends over the tongue and the base 
• 10% develops around the insertion of the anterior pillar of the tonsil
• Differential diagnosis 

• Traumatic ulceration 
• Giant canker sore, lichen planus
• Specific ulceration 
• Evolution and prognosis 

• Superinfections +++ in advanced stages
•  Extension of the tumor to the jaws is possible 
• Prognosis: good in limited stages, bad in extensive forms
• Recurrences after treatment are possible (often diffuse and poorly limited) 
• Death following local, pulmonary superinfection or hemorrhage by vascular rupture, sometimes in a picture of true cachexia.
• Base of tongue cancer

• Developed behind the lingual V on the anterior wall of the oropharynx,
•  It represents 20% of tongue cancers
• Clinical  
  • Circumstances of discovery 

• Discovery in advanced stages. 
• Limitation of tongue protraction. Throat pain, foreign body sensation, dysphagia, earache 
• Lesion is highlighted during an assessment for cervical ADP.
• Description of the lesion 

• Rarely purely budding, it is often ulcerative-budding or pure ulcerous,
• Peripheral infiltration is generally more significant and deeper
• Extension report 

• Local extension: along the geniohyoid muscles, difficult to assess clinically (MRI)
• Lymph node extension: +++ (subdigastric, submandibular or jugulo-carotid homo or bilateral)
• Distant extension: second pulmonary or hepatic localization
• Differential diagnosis 

• Hypertrophy of the lingual tonsil 
• Specific ulceration 
• Vincent’s Angina
• Evolution and prognosis 

• Several complications may occur: hemorrhage, asphyxia, 
• difficulty in feeding and extension to other territories. 
• Bad prognosis

2. Cancer of the floor of the mouth

• Epidemiology 

• Ranks 2nd after tongue carcinomas  
•  they represent 17% of CB cancers, common in men (58 years old) 
• The risk factors are always the same (10% on a precancerous lesion) 
• Circumstances of discovery 

• A lingual gene 
• Difficulty protracting or mobilizing the tongue 
• Odynophagia 
• A change in voice, difficulty speaking 
• tingling when acidic foods come into contact 
• Bloody sputum 
• The lesion sometimes self-discovered 
• (+) rarely an ADP can lead the patient to consult
• Description of the lesion 

• Ulcerative, budding, or fissured appearance. 
• The infiltrative nature is suggested by the reduction in lingual mobility and specified by palpation which is painful and hemorrhagic.
• Imaging assessment 

• Rx standards —> dental condition
• Ultrasound —> lymph node invasion
• CT scan —> bone extension 
• MRI —> extension to soft parts
• Extension report 
  • Local extension

• It can remain superficial as a sheet 
• Inside 🡪 lingual muscle 
• Below 🡪 sublingual gland and floor musculature 
• Outward and forward 🡪 gum, alveolar bone, inferior dental nerve
• Lymph node extension 
• Major lymphophilia: palpable lymph node on first examination
• Remote extension 
• Pulmonary and hepatic localizations 
• Clinical forms 

• Kc of the posterior floor
• Kc of the pelvic-lingual groove
• Differential diagnosis 

• Traumatic ulceration 
• Specific ulceration
• Dermoid cyst
• Evolution and prognosis 

• The prognosis is severe, serious in the event of gingival involvement. 
• Overall 5-year survival is 25%

3. Cancer of the inner side of the cheek 

• Epidemiology 

• Uncommon tumors  
• More frequent in men from 60 years of age and the proportion
•    (+) more important in women than other Kcs.
• Compared to other CB Kc, these tumors are linked to tobacco and alcohol, and to the transformation of LPM 
• Circumstances of discovery 

• At the beginning: often, it is a simple discomfort, little or not painful, 
• hypersialosis sometimes tinged with blood, or even the perception by the tip of the tongue of a modification of the mucous membrane. 
• Late: localized pain or pain radiating towards the ear,
•  trismus, ADP. 
• Description of the lesion 

• Seat: mid-cheek height
• Appearance: vegetating or exophytic bud, sometimes ulcerated or infiltrating
• Imaging assessment 

• Cervical ultrasound —> ADP. 
•  MRI —> Mucosal extension.  
• CT -> Bone extension
• Extension report 
  • Local

• Outward towards the skin (late). 
• Deep towards the maxilla or mandible. 
• Forward towards the intermaxillary commissure. 
• Late lymph node, parotid and cervical
• Differential diagnosis

• Traumatic ulceration 
• Specific ulceration
• LPB
• NOMA
• Prognosis 
• He is reserved and relapses are possible.

4. Cancer of the upper gingiva and palatine mucosa 

• Epidemiology 

• 05% of VADS kc
• It predominates among women. 
•  For palatal forms: the veil is more affected than the bony palate: 71% for the veil versus 29% for the palate. 
•  Uvula carcinoma is extremely rare.
• Upper Gum Cancer 
  • Clinical 

• The lesion is ulcerative-vegetative or ulcerative, purplish red, surrounding one or more teeth.
•  More often on the vestibular side
•  Amputating an interdental gingival strip
•  Infiltrative forms rapidly invade the alveolar bone (dental mobility)
• Palatal form 

• The carcinoma may take on an ulcerated or ulcero-vegetative appearance. 
• More advanced; the carcinoma takes the appearance of a slightly exophytic granular mass with an ulcerated center.
•  Carcinoma can invade the maxillary sinus, the nose, at the level of the veil
•  it extends to the anterior pillar and invades the pterygomaxillary fossa. 
• Depending on the location, the tumor may present manifestations
• oral, nasal-sinusal, ophthalmic and facial.

• When the evolution is naso-sinusal 
• Silent, progressively deforming the palatine vault, epistaxis, rhinorrhea, nasal obstruction, late on revealed by orbital signs, phonation disorders are frequent

• When evolution is oral 
• Attention is drawn to a budding or ulcerating lesion often related to a traumatic mobile prosthesis 
• Tooth pain and mobility, gingival bleeding, facial swelling and deformation, hypoesthesia, facial pain 

• Imaging assessment 
• osteolytic image, with blurred, irregular contours, hanging teeth
• Extension report 

• Local extension: Towards the soft parts and especially the underlying bone,                           
•  (soft palate, sinus cavity, nasal passages)
• Lymph node extension: submaxillary. Jugulo-digastric
• Remote extension: very rare 
• Differential diagnosis 

• Traumatic ulceration
• Specific ulceration
• Ulcerated papilloma
• Prognosis more often poor 

5. Lower Gum Cancer 

• Clinical 

• Gingival table: gum bud that can envelop a molar, making it mobile.
• Bone or osteo-mucosal picture: pain, mobility, facial deformation.
• Imaging assessment 

• diffuse decalcification
• the roots are in contact with the gap: hanging teeth 
• Pathological fractures 
• Extension report 

• Local extension: 
• In the soft parts: vestibule, cheeks, floor, tongue. 
• Mandibular extension. 
• Lymph node extension: rare
• Remote Extension: Rare 
• Differential diagnosis 

• Traumatic ulceration
• Specific ulceration
• Oral manifestations of hematopathies (leukemia)
• Osteitis 

6. Lip cancer 

• Epidemiology 

• 6% of oral cavity Kc. 
• Sex ratio: 9 men to 1 woman 
• Anatomically, the tumor is located in 90% of cases on the lower lip.
• Clinical 

• Oral discomfort, tingling on contact with acidic foods, bleeding on contact
• We can find the 03 forms:
• crusted erosion, infiltrating ulceration, rarely vegetative
• Imaging assessment 

• Ultrasound —> ADP
• Lung X-ray —> metastases.
• Extension report 

• Local extension 
• On the surface of the skin and mucous membranes 
•   In depth; towards the mandible, the labial commissure 
• Lymph node extension: Submental, submaxillary and jugulo- carotid lymph nodes
• Remote extension: pulmonary 
• Clinical forms 

• On the upper lip  : 
•   Rare, it is a basal cell carcinoma, usually located on the cutaneous side (often ulceration) 
• On the lower lip 
• the typical seat is the middle 1/3;
• If they are primitive, they often appear in the form of fissures.
• The extension is made towards the other lip and towards the cheek; 
•   Lymph node involvement is rare, often bilateral. 
• Diagnosis 
  • Differential diagnosis 

• Traumatic, herpetic, specific ulceration 
• Actinic cheilitis 
• Chronic lupus erythematosus. 
• Some benign tumors (papilloma or nodule)
• Positive diagnosis 

• It should be noted that there is frequent pre-existence of cheilitis-type lesions
• The area of ​​choice is the vermilion of the lower lip. 
• The most typical aspect is that of +/- crusty erosion,  
• Suspicious signs: hard base, bleeding on contact 

Conclusion 

Epithelial carcinomas present in different clinical forms depending on the part of their topographical location

Despite the best management, the diagnosis remains bleak if the diagnosis is not made early enough

Prevention and screening, the only truly effective measures to change the prognosis, should be strengthened with the fight against alcohol and tobacco poisoning.

Oral mucosal carcinomas