Dott.re Giuseppe Spinelli

Mouth cancer

MOUTH CANCER OR CANCER OF THE ORAL CAVITY

Oncologic Surgery

Introduction to mouth tumors

Mouth cancer is a neoplasm originating from the mucosa of the lining of the mouth (lips, tongue, cheek, palate, gingiva, ecc.) or from the bones (Jaw Tumors). It can be called malignant neoplasm, carcinoma, cancer o tumor. 90% of tumors of the mouth are represented by squamous cell carcinoma, which has the potential to metastasize lymphatic to the laterocervical lymph nodes and more rarely to the blood via the lung, liver, bone and brain. A neoformation of the oral cavity that persists for more than 3 weeks should suggest its neoplastic nature.

EPIDEMIOLOGY OF MOUTH CANCER

Mouth cancer or oral cavity cancer is the 6th most common malignant tumor worldwide, casi cases occur in developing countries where cancer of the oral cavity is even the 3rd most common tumor. In some parts of India the cancer of the mouth but especially the tumor of the tongue can also represent 50% of the diagnosed tumors. In the more developed countries it is rarer, still remaining 8th in the ranking of the most frequent neoplasms. However the classification varies a lot according to the various countries, for example in the areas of the north of France it appears to be the most common form of cancer in men.

In Italy the incidence of mouth cancer is average and is 8.44 new cases per 100,000 male inhabitants and 2.22 for women. In industrial areas this neoplasm has a higher incidence. Mouth cancer affects males more frequently than females (on average 2:1).

MOUTH TUMOR RISK FACTORS

Tobacco and alcohol are the most important risk factors to consider for mouth cancer. Heavy tobacco smokers are 20 times more likely than the rest of the population; those who consume alcohol have a greater risk than 5 times and those who take them both have a greater risk than 50 times. Betel and chewing tobacco are important risk factors for cancer of the mouth in people from specific geographical areas (for example, chewing betel in Southeast Asia).

A diet low in fresh fruit and vegetables is certainly responsible for the formation of squamous cell carcinoma of the mouth. The microtrauma resulting from the presence of excessively mobile dental prostheses and the presence of pathological dental elements represent an additional risk factor: the chronic irritative action associated with the inflammation present in these patients may be the basis of the development of tumors of the mouth.

The pre-cancers of the oral cavity are considered alterations of the oral mucosa that predispose the patient who is affected to develop a tumor of the mouth. They are distinguished as obligatory and non-precancerous. A precancerous alteration of the mucosa is defined as definitely evolving into a carcinoma. Infectious agents such as Candida albicans and viruses (herpes virus and papillomavirus) may be implicated in some cases. Human papillomaviruses (HPVs) are often implicated in oropharyngeal tumors. HPV-related cancers tend to be more frequent in younger patients, in the mouth, and usually have a better prognosis.

PRESENTATION OF MOUTH TUMOR

Many tumors of the mouth and some tumors of the tongue arise on an apparently normal mucosa, but many are preceded by clinically evident precancerous lesions: erythroplakia (red spot), leukoplakia (white spot), spotted leukoplakia (red and white spot), or warty leukoplakia.

LEUKOPLACKIA

Lesion with irregular margins, whitish on the right lingual margin.

ERYTHROPLAKIA

Erythematous lesion on the right lingual margin.

The tumor of the mouth and especially the tumor of the tongue arises 17 times more frequently in relation to erythroplachia compared to leukoplakias; however, leukoplakias are much more common. Physical examination should keep in mind that the most common sites of cancer of the mouth include the lower lip, the lateral margin of the tongue, and the oral floor; however all areas must be examined. After inspection it is important to proceed with palpation to detect any hardening and / or fixation of deeper tissues.

The clinical aspect of the tumor of the mouth or of the tumor of the tongue is highly variable but more commonly it is manifested as an ulceration with irregular, raised and hard edges with a fleshy, irregular and easy bleeding bottom. In the initial phase, oral cavity cancer may not be painful, then painful crises, cranial nerve deficiency (altered sensitivity to lips, tongue) may occur, depending on the site there may also be difficulties in speaking, swallowing and ultimately breathing .

Mouth cancer can lead to an increase in the size of the cervical lymph nodes caused by infections, reactive hyperplasia secondary to the tumor, or metastatic disease. Increased consistency and poor lymph node mobility are clinical evidence of laterocervical metastatic disease. Occasionally, a pathological lymph node is detected in the absence of any obvious primary tumor.

DIAGNOSIS OF MOUTH TUMOR

Once a suspected neoformation / ulceration of the oral cavity has been identified by the trusted dentist or general practitioner, the surgeon must confirm the diagnosis by biopsy and subsequent histological examination.

At the maxillo-facial surgery SOD of the University Hospital of Careggi, Florence, diagnosis and staging of the neoplasm are made within 7 days of the patient’s presentation, while the surgery is performed within 2 weeks.

Dysplasia is an alteration of the normal mucosal structure, mild, medium and severe. The more the mucosal structure is altered, the greater the chances of transformation into a cancer. The important thing is to be aware of the fact that individual ulcers, red spots, or white spots (especially if they persist longer than 3 weeks) can be manifestations of malignancy.

The biopsy of the tumor of the mouth, of the tongue and also of the jaw tumor is performed, when possible, under local anesthesia by removing one or more fragments of the suspicious area bordering the healthy mucosa. The biopsy must be large enough to include enough suspect tissue and even a portion of apparently normal tissue. The fragment taken is sent to be analyzed at the pathological anatomy laboratory.

Subsequently it is fundamental to frame the performance status (the general conditions of the patient, or how the patient looks before the surgery) of the patient through blood tests. The operability of the mouth tumor depends on the local extension and the presence of locoregional or distant metastases.

This is possible through imaging techniques such as:

  • TC and RMN with and without contrast of the primary site including the entire head and neck region.
  • PET with fluorodeoxyglucose 18 to identify the possible presence of metastases.
  • TC the chest, indicated because the lungs are the most common site of metastasis.
  • Ultrasonography of the abdomen to rule out possible involvement of the liver.

At the end of all these tests it is possible to define the nature, classification and staging of cancer of the mouth and in particular of the tumor of the tongue.

Staging defines the dimensions of the tumor of the mouth (T expressed in cm), the involvement of the laterocervical lymph nodes (N expressed in cm, number and homo / bilateral) and the presence of distant metastases (positive or negative M). Based on these parameters, a stage ranging from 0 to IV with various sub-levels is assigned to the neoplasm.

The patient’s life expectancy depends on the stage, which in turn is derived from the TNM classification. The increasing size of the mouth tumor corresponds to an increase in the stage, however the positivity of N and M are the most important prognostic factors able to move the stage towards the IV (a, b, c) regardless of the size of T.

TUMOR THERAPY

THE ORAL CAVITY

Treatment of cancer of the mouth, cancer of the tongue and jaw cancer is multidisciplinary; the surgeon, the oncologist, the radiotherapist, the pathologist and the radiologist are the most important figures.

The goal of the surgery is to remove the primary tumor along with a margin of clinically healthy tissue (about 1 cm) to ensure complete removal of the malignant tissue. The reconstructive phase must be associated with the demolishing phase. The tracheotomy is a fundamental phase of surgical treatment, if indicated. The lymph nodes of the neck constitute the first and main route of dissemination of neoplasms of the oral cavity and must be examined during the planning of the surgical procedure.

The removal of the laterocervical lymph nodes (emptying), in a tumor of the mouth or in a tumor of the tongue, can be done for a prophylactic purpose (if the size of the tumor,> 2cm, is such as to suggest a microscopic involvement of the lymph nodes), or for therapeutic purposes (if there are clinical or radiographic signs of nodal involvement). There are 3 types of laterocervical emptying: radical emptying, functional emptying, selective emptying. These differ in the sacrifice or preservation of laterocervical noble structures (the internal jugular vein, the sternocleidomastoid muscle and the accessory nerve) and for the different lymph node stations involved.

The radiotherapy can be used as a complementary treatment to the surgical act or it can be used alone for the treatment of some forms of tumors (oropharyngeal) or in cases where the surgery is contraindicated (poor health conditions, extension of the disease) . Radiation therapy can be performed both on the tumor and on the neck; on both sites it has the function of “sterilizing” the surgical field as a function of the histological result (positive resection margins, involvement of one or more lymph node stations).

Globally the local healing of carcinomas of the oral cavity can be obtained today with a fairly high frequency (60-65%). Obviously the percentages vary depending on the location and extent of the disease, from 95% for small lip carcinomas to 30% of extended tumors of the tongue and retromolar trigone. Loco-regional healing varies according to the presence or absence of lymph node metastases and their extension.

RECONSTRUCTION AFTER CANCER OF THE MOUTH

Cancer of the mouth once removed leaves an empty space (gap) that must be reconstructed. The reconstruction must be studied to measure for the patient, in addition to the missing anatomical portions, the surgeon must take into consideration the general state of health and the patient’s ability to sustain a long surgical intervention.

For the reconstruction of the tissues, grafts, local flaps, pedunculated or free can be used. They can be composed of various types of tissue: skin, adipose tissue, muscle and bone combined together. By grafting we mean a portion of tissue separated from its own vascular component, its survival depends on the condition of the contiguous tissues to where it is placed (receiving bed).

By local flap we mean a portion of tissue with a random vascular component that ensures its nourishment; the pedunculated flap has its own vascular axis, the free flap is considered a true transplant taken by the patient himself (autologous) with a specific vascular peduncle that needs to be sutured to the laterocervical vessels.

Clinical cases
Case 1 - Lip tumor ONCOLOGICAL SURGERY - Attention, contains images of intervention

Squamous cell carcinoma right lower lip – removal of the tumor and reconstruction with webster bernard flap

Swelling at the level of the right maxillary fornix with mobility of the posterior dental elements to the canine.

Osteoaddensing lesion with total subversion of the right hemimascellar structure.

Right paralateronasal access flap with median labiotomy and exposure of the osteosarcoma that completely affects the right hemimascellar.

Excision of the neoformation, right hemimaxillectomy with preservation of the frame of the ipsilateral orbital floor.

Caso 2 - Mouth tumor ONCOLOGICAL SURGERY - Attention, contains images of intervention

Squamous cell verruciform carcinoma – excision of neoformation and cervical lateral voiding – temporalis muscle flap

Hemipital hard left hemipalar carcinoma with verruciform aspect the lesion affects the alveolus but also extends on the superior gingival fornix.

Preparation of the temporal muscle that will be rotated at the level of the oral cavity to reconstruct the defect.

The temporal muscle flap before being rotated in the oral cavity.

Images at the end of the operation with the muscle sutured to the mucous membrane of the oral cavity.

Intraoral post-operative result with flap remaration.

Post-operative result.

Caso 3 - Mouth tumor ONCOLOGICAL SURGERY - Attention, contains images of intervention

Carcinoma squamocellulare regione geniena sinistra

Preoperative

Preoperative

Neoplasm infiltrating the mucosa and left genital musculature.

Imaging (TC, RMN, PET) negative for laterocervical and distant metastases.

Neoformazione excision with intraoral access and incision of Jager. Ipsilateral supomoheoid lymph node emptying.

Neoformazione excision with intraoral access and incision of Jager. Ipsilateral supomoheoid lymph node emptying.

Neoformazione excision with intraoral access and incision of Jager. Ipsilateral supomoheoid lymph node emptying.

Reconstruction with fasciocutaneous free flap of forearm.

Reconstruction with fasciocutaneous free flap of forearm.

Remote control after surgery and adjuvant radiotherapy.
Post-operative result.

For more completeness see also:

Tongue tumor

Jaw tumor

Carcinoma Oral Cavity