Question Write short note on carcinoma of Jaws.
Or
Describe etiology, clinical and radiographic features of squamous cell carcinoma invading the jaws.
Or
Write in detail about etiology, clinical features and radiographic features of squamous cell carcinoma.
Or
Write short note on radiographic features of squamous cell carcinoma of alveolar mucosa.
Or
Write short note on oral squamous cell carcinoma.
Answer. Squamous cell carcinoma is the most common malignant epithelial tissue neoplasm of the oral cavity.
- It represents 90% of all malignant tumors occurring in oral cavity.
- It is also called “Epidermoid carcinoma” or “Epithelioma”.
Oral Cancer Etiology
- Tobacco usage: Tobacco in both smokeless and smoking form leads to oral cancer. Smokeless tobacco consists of various potential carcinogens such as nitrosamine, polycyclic hydrocarbons, polonium and the metabolites of these constituents which lead to oral cancer. Smoking tobacco consists of carbon monoxide which causes oral cancer.
- Alcohol: Alcohol of all form dehydrates the mucosa and increases the mucosal permeability as well as effects of carcinogens on mucosa which cause oral cancer.
- Actinic radiation: This is the minor etiological factor for lip cancer. It occurs in fair people who are in outdoor occupation.
- Familial and genetic: It has little predisposition for the oral cancer. More common in blacks as compared to whites.
- Orodental factors: These are common in patients with poor oral hygiene, faulty restoration, sharp teeth, ill fitting dentures and syphilitic glossitis.
- Vitamin A deficiency: It leads to the excessive keratinization of oral mucosa, so its deficiency leads to oral carcinoma.
- Immunity: Declining immunity with age is increasing incidence for oral cancer. It can occur in immunosuppressed patients. HIV/AIDS patients are at increased risk.
- Syphilis: Oral cancer is seen in tertiary stage of oral cancer. In treating syphilis, arsenic and heavy metals are used which are the potential carcinogens.
- Diet deficiency: Nutritional deficiency can cause oral cancer.
- Ionizing radiation: As long term radiotherapy is given to the patient, it can cause carcinoma of buccal mucosa.
- Trauma: Factors such as chronic cheek biting, faulty denture use can act as co-carcinogens.
- Virus: Human papilloma virus and HIV can cause oral cancer.
- Various intraoral lesions:
- Chronic ulcer and fissure: It causes carcinoma of lip
- Oral lichen planus: It can turn into carcinoma if not treated.
- Candidiasis: It is the precursor of oral carcinoma
- Leukoplakia: Nodular leukoplakia has highest rate of conversion into oral cancer.
- OSMF and oral melanosis: It turns into oral cancer.
- Discoid lupus erythematosus: It causes carcinoma of lip
Carcinoma of Jaws Clinical Features
- It is more common in males as compared to females with ratio of 2:1.
- It occurs from 50 to 60 years of age.
- Most commonly involved are the posterior and lateral borders of tongue, lower lip and less frequently the floor of mouth, palate, alveolar mucosa and buccal mucosa.
- Patient complaints of presence of mass in the mouth. Small lesion is asymptomatic while the large lesion may cause some pain or paresthesia and swelling.
- Patients complain of persistent ulcer in the oral cavity.
- Clinical appearance of a carcinomatous ulcer is of irregular shape induration and raised-everted edges.
- Lesion have broad base and are dome-like or nodular. On palpation the base is firm.
- Surface of the lesion may range from granular to pebbly to deeply creviced. In some of the areas surface can be entirely necrotic and consists of ragged whitish gray appearance.
- Color of the lesion is either completely red or red surface may be sprinkled with white necrotic or keratin area.
- Superficial and deep cervical nodes are commonly affected. Lymph nodes become enlarged, firm and tender on palpation. Fixation of lymph nodes occurs to adjacent tissues later.
- Primary tumor is fixed to the underlying tissues.
Carcinoma of Floor of Mouth
- It occurs at the anterior portion of floor of mouth.
- An indurated ulcer is seen of varying size over the one side of midline.
- This carcinoma invade the deeper structures and even extend in sub – maxillary and sublingual glands.
- Movements of tongue are restricted.
Carcinoma of Buccal Mucosa
- This mainly occurs opposite to third molar and is often painful.
- Tumor appears as small nodule, enlarges and form wart like growth which undergo ulceration.
- There is presence of induration and infiltration to deep tissues and this extend to muscle of neck, alveolar mucosa and ultimately in the bone.
- It may also show verrucous or exophytic growth
Carcinoma of Labial Mucosa
- Involvement of lower labial mucosa is very common.
- Initially there is presence of swelling, soreness and ulceration.
- Advanced lesion can be ulcerative – infiltrative type and shows exophytic growth.
Carcinoma of Palate
- It is common in females as compared to the males.
- It present as poorly defined ulcerated painful lesion over one side of midline.
- Lesion is exophytic, consists of broad base and the nodular surface.
- It frequently crosses the midline and can extend laterally to include tonsillar pillars and the uvula.
Carcinoma of Jaws Radiographic Features
- Tumor is seen along the complete border of mandible or can be restricted to small area.
- It may erode into the underlying bone in any direction, producing a radiolucency that is polymorphous and irregular in outline.
- Sclerosis in underlying osseous structures (likely from secondary inflammatory disease) may be seen in association with erosions from surface carcinoma. These erosions appear semicircular or saucer shaped. The border may appear smooth without a cortex, indicating erosion rather than invasion.
- Invasion occurs in more than 50% of the cases, and is characterized by an ill-defined, non-corticated border. The periphery will appear to have bays of bone destruction which into the bone appearing as finger-like extensions preceding a zone of osseous destruction.
- If a pathological fracture occurs, then borders show sharpened thin bone ends with displacement of the segments.
- The adjacent soft tissue mass may be seen as a faintly increased density in the radiograph, standing above the general level of the bone.
- The squamous cell carcinoma in jaw lesions appears totally radiolucent, with occasional small islands of residual normal trabecular bone.
- The periodontal ligament space is widened, with loss of lamina dura, which is evidence of invasion of bone around the involved teeth. The teeth appear to float in a mass of radiolucent soft tissue bereft of any bony support, floating or hanging teeth. In extensive tumors, this soft tissue mass may grow with the teeth in it as “passengers”, so the teeth are grossly displaced from their normal position.
- The tumor may grow along the inferior alveolar canal and through the mental foramen, resulting in increased width and loss of cortical boundary of the canal.
- It may invade adjacent structures such as, floor of the nasal cavity, maxillary antrum, buccal or lingual mandibular plates by destruction of the cortical boundaries.
- The posterior aspect of the maxilla may also be affected. Inferior border of the mandible may be thinned or destroyed, with occurrence of a pathological fracture.
Carcinoma of Jaws Diagnosis
- Clinical diagnosis: Presence of ulcerative growth with indurated base.34 Mastering the BDS IVth Year-I (Last 25 Years Solved Questions)
- Radiological diagnosis: Presence of ill-defined radiolucency with infiltrative margin.
- Laboratory diagnosis: Incisional biopsy is done which show dysplastic features along with the rupture of basement membrane. Dysplastic cells are seen infiltrating in connective tissue. Histologically, it can be graded as well differentiated, moderately differentiated and poorly differentiated.
Differential Diagnosis – Clinical carcinoma of Jaws
- Aphthous ulcer: It should heal in one or two weeks after the removal of mechanical agent.
- Basal cell carcinoma: It shows slow development and main etiological factor is sunlight.
- Primary syphilitic ulcer: Pain is absent, ulcer is indurated, it is reddish brown with copper color halo.
- Malignant salivary gland tumor: Seen in women, present in posterior hard palate, it shows dome shaped appearance.
- Verrucous carcinoma: It slow growing and is associated with tobacco, it is papillomatous and white.
- Pyogenic granuloma: It is soft to firm on palpation and bleed very easily.
Radiological
- Osteomyelitis: It produces periosteal reaction.
- Osteoradionecrosis: History of radiation therapy is present.
- Periodontitis: Margins here are smooth and well defined and this is generalized.
- Papillon Lefevre syndrome: It shows areas of sequestration.
Carcinoma of Jaws Management
- Oral cancer is treated via surgery and radiation.
- Primary tumor is excised with 1.5 cm margins for T1N0M0 lesions and for T2N0M0 and more advanced cases, treating the neck prophylactically with either an in continuity functional neck dissection or radiotherapy in dose of 5000 to 6500 cGy is recommended if incisional biopsy show greater than 3mm depth of invasion.
- For nodal invasion disease of N1, functional neck dissection is recommended for nodal disease of N2 or N3 modified radical neck dissection is preferred by post operative radiotherapy from 5000 to 6500 cGy.
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