L23 Oral cancer: clinical presentation and importance of early diagnosis

Question 1

Name some promoters of malignancy.

Answer 1

• Cigarettes, cigars, pipes
• Chew/spit tobacco
• Snuff (very low risk)
• Paan
• Alcohol

Question 2

What are the effects of Paan on the oral mucosa?

Answer 2

• Paan contains betel/areca nut and tobacco
• Can cause oral submucous fibrosis: tissues become hard and stuff with a mottled marbling appearace
• Seen on the buccal mucosa and palate

Question 3

What is snus?

Answer 3

• Small sachets of tobacco held in the labial sulcus
• Low risk of malignant transformation orally, but has been linked to other malignancy (stomach cancer)
• Causes a hyperkeratotic lesion aka tobacco pouch keratosis

Question 4

Is alcohol associated with oral cancer?

Answer 4

• Alcohol is implicated in oral squamous cell carcinoma
• Can be challenging to isolate the independent effects of alcohol on oral cancer separate to those of tobacco as they are often consumed together
• Greatest effect may be in the pharynx/oropharynx
• Alcohol and tobacco combined is extremely high risk

Question 5

What are the effects of alcohol on the mucosa?

Answer 5

• Alcohol increases mucosal permeability
• Theorised that this permeability allows carcinogens through the epithelium

Question 6

Why are younger people getting oral and oropharyngeal cancer?

Answer 6

HPV infection

Question 7

What has caused these palatal lesions?

Answer 7

Reverse smoking

Question 8

What are the 2 different types of biopsy?

Answer 8

• Incisional biopsy: sampling the lesion for investigation and diagnosis
• Excisional biopsy: excising the lesion entirely

NB: biopsy is the gold standard for diagnosis

Question 9

What are the features of dysplasia?

Answer 9

• Basal cell crowding
• Drop-shaped rete ridges
• Loss of basal cell polarity
• Nuclear hyperchromatism
• Nuclear polymorphism
• Increased nuclear-cytoplasmic ratio
• Suprabasal mitoses
• Bizarre mitoses
• Inflammatory reaction

Question 10

How are dyplasias categorised?

Answer 10

• Mild
• Moderate
• Severe

One system classifies according to the amount of dysplastic features evident, another classifies according to the distribution of the altered cells.

Question 11

How should dysplastic lesions be managed?

Answer 11

Clinicians are not 100% certain about how to manage dysplasias, but current recommendations are:
- Stop any associated habits
- Treat infections/deficiency where applicable
- Biopsy to assess degree of dysplasia
- Assess risk of change of clinical & histological grounds
- Maintain regular observation & review
- Consider ablation of lesions : Evidence is poor in relation to management of dysplasia, most surgeons would recommend excision and outcomes may/may not be affected

Question 12

What guidelines are followed for suspected oral cancer?

Answer 12

NICE (2015)

Question 13

Why is an early diagnosis important?

Answer 13

Improves chances of survival.
Once cancer spreads to lymph nodes chance of survival is signifcantly decreased.

Question 14

How do patient related factors impact prognosis?

Answer 14

Question 15

How do tumour related factors impact prognosis?

Answer 15

• Site: further back in the oropharynx = worse prognosis
• Stage
• Tumour thickness: >5mm strong predictor of nodal metastasis
• Extracapsular (extranodal spread) lymph node spread: associated with higher local recurrence rates, distant metastases, lower survival rate
• Histologic differentiation: poorer differentiation of tumour correlated with poorer prognosis (not always)