Clinical
presentation and diagnosis of oral cancer
Early diagnosis of oral cancer should lead to
better treatment results and, ideally, the clinical diagnosis of oral cancer
should be easy. Oral lesions, unlike those at many other sires, give rise to
early symptoms. In general, patients become aware of and usually complain about
minute lesions within the mouth and biopsy may be carried our under local
analgesia.
Yet, despite all the above, between 27 and 50 per cent of patients present for
treatment with late lesions. Many of these patients are elderly and frail and,
therefore, delay the effort of visiting their doctor or dentist. Many of this
group
The tongue
The majority of tongue cancers occurs on the
middle third of the lateral margins, extending early in the course of the
disease on to the ventral aspect and floor of the mouth (Fig.
Early
tongue cancer may manifest in a variety of ways. Often the growth is exophytic
with areas of ulceration. It may occur as an ulcer in the depths of a fissure or
as an area of superficial ulceration with unsuspected infiltration into the
underlying muscle. Leucoplakic patches may or may not be associated with the
primary lesion. A minority of tongue cancers may be asympromatic, arising in an
atrophic depapillated area with an erythroplakic patch with peripheral streaks
or areas of leucoplakia.
Later
in the course of the disease a more typical malignant ulcer will usually
develop, often several centimetres in diameter. The ulcer is hard in consistency
with heaped-up and often everted edges. The floor is granular, indurated and
bleeds readily. Often there are areas of necrosis. The growth infiltrates the
tongue progressively causing increasing pain and difficulty with speech and
swallowing. By this stage pain is often severe and constant, radiating to the
neck and ears. Lymph node metastases at this stage are common — indeed 50 per
cent may have palpable nodes at presentation. Because of
The floor of the mouth is the second most
common sire for oral cancer (Fig. 41.9). It is defined as the U-shaped area
between the lower alveolus and the ventral surface of the tongue; carcinomas
arising at this sire involve adjacent structures very early in their natural
history. Most tumours occur in the anterior segment of the floor of the mouth to
one side of the midline.
The
lesion usually starts as an indurated mass which soon ulcerates. At an early
stage the tongue and lingual aspect of the mandible become involved. This early
involvement of the tongue leads to the characteristic slurring of the speech
often noted in such patients. The infiltration is deceptive but may extend to
reach the gingivae, tongue and genioglossus muscle. Subperiosteal spread is
rapid once the mandible is reached. Lymphatic metastasis, although early, is
less common than with tongue cancer. Spread is usually to the submandibular
and jugulodigasrric nodes and may be bilateral.
Cancer
in the floor of the mouth cancer is associated with a pre-existing leucoplakia
more commonly than at other sites.
The gingiva and
alveolar ridge
Carcinoma of the lower alveolar ridge occurs
predominantly in the premolar and molar regions (Fig.
41.10).
The
patient usually presents with proliferative tissue at the gingival margins or
superficial gingival ulceration. Diagnosis is often delayed because there is a
wide variety of inflammatory and reactive lesions which occur in this region
in association with the teeth or dentures. Indeed, there will often be a
history of tooth extraction with subsequent failure of the socket to heal prior
to definitive diagnosis. Another common story is that of sudden difficulty in
wearing dentures.
The buccal
mucosa
The buccal mucosa extends from the upper
alveolar ridge down to the lower alveolar ridge and from the commissure
anteriorly to the mandibular ramus and retromolar region posteriorly (Fig.
41.11). Squamous cell carcinomas mostly arise either at the commissure or along
the occlusal plane to the retromolar area, the majority being situated
posteriorly. Exophyric, ulcero-infiltrative and verrucous types occur. They are
subject to occlusal trauma with consequent early ulceration and often become
secondarily infected. The onset of the disease may be insidious, the patient
sometimes presenting with trismus due to deep neoplastic infiltration into the
buccinaror muscle. Extension posteriorly involves the anterior pillar of the
fauces and soft palate with consequent worsening of the prognosis. Ulcero-infiltrative
lesions will often involve the overlying skin of the cheek resulting in multiple
sinuses. Lymph node spread is to the submental, submandibular, parotid and
lateral pharyngeal nodes.
Verrucous
carcinoma occurs as a superficial proliferative exophytic lesion with minimal
deep invasion and induration. Often the lesion is densely keratinised and
presents as a soft white velvety area mimicking benign hyperplasia. Lymph node
metastasis is late and the tumour behaves as a low-grade squamous cell
carcinoma.
The hard
palate, maxillary alveolar ridge and floor of antrum
These three sites are anatomically distinct,
but a carcinoma arising from one site soon involves the others (Fig.
41.12).
Consequently, it can be difficult to determine the exact site of origin. Except
in countries where reverse smoking is practised, cancer of the plate is
relatively uncommon. The
Carcinomas
arising in the floor of the maxillary anrrum often present as palaral tumours.
Although the fully established picture of antral carcinoma is difficult to
miss, the early symptoms are nonspecific and may mimic chronic sinusitis. tumours of the lower half of the antrum below Ohngren’ s line usually present
with ‘dental’ symptoms because of early alveolar invasion. The commonest
presenting feature is pain, swelling or numbness of the face. Later symptoms of
nasal obstruction, discharge or bleeding, and dental symptoms such as painful or
loose teeth, ill-fitting dentures, oroantral fistula or failure of an
extraction socket to heal, soon follow. Lymph node metastasis from carcinomas of
the palate and floor of the antrum occurs late but carries a poor prognosis.
Diagnosis
The diagnosis of intraoral carcinoma is
primarily clinical, and a high index of suspicion is necessary for all those
clinicians seeing and treating patients with oral symptoms. A careful and
detailed history with particular attention to recording the dates of the onset
of particular signs and symptoms precedes the clinical examination. All areas
of the oral mucosa are carefully inspected and any suspicious lesion is palpated
for texture, tethering to adjacent structures and induration of underlying
tissue.