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Oral Squamous Cell Carcinoma

by Bradley A. Schiff, MD

Oral squamous cell carcinoma affects about 30,000 people in the US each year. Over 95% smoke tobacco, drink alcohol, or both. Early, curable lesions are rarely symptomatic; thus, preventing fatal disease requires early detection by screening. Treatment is with surgery, radiation, or both although surgery plays a larger role in the treatment of most oral cavity cancer. The overall 5-yr survival rate (all sites and stages combined) is > 50%.

Oral cancer refers to cancer occurring between the vermilion border of the lips and the junction of the hard and soft palates or the posterior one third of the tongue.

In the US, 3% of cancers in men and 2% in women are oral squamous cell carcinomas, most of which occur after age 50. As with most head and neck sites, squamous cell carcinoma is the most common oral cancer.

The chief risk factors for oral squamous cell carcinoma are smoking (especially > 2 packs/day) and alcohol use. Risk increases dramatically when alcohol use exceeds 6 oz of distilled liquor, 15 oz of wine, or 36 oz of beer/day. The combination of heavy smoking and alcohol abuse is estimated to raise the risk 100-fold in women and 38-fold in men. Squamous cell carcinoma of the tongue may also result from any chronic irritation, such as dental caries, overuse of mouthwash, chewing tobacco, or the use of betel quid. Oral human papillomavirus (HPV), typically acquired via oral-genital contact, may have a role in the etiology of some oral cancers; however, the role of HPV is not as clearly defined in oral cancer as it is in oropharyngeal cancer.

About 40% of intraoral squamous cell carcinomas begin on the floor of the mouth or on the lateral and ventral surfaces of the tongue. About 38% of all oral squamous cell carcinomas occur on the lower lip; these are usually solar-related cancers on the external surface.

Symptoms and Signs

Oral lesions are asymptomatic initially, highlighting the need for oral screening. Most dental professionals carefully examine the oral cavity and oropharynx during routine care and may do a brush biopsy of abnormal areas. The lesions may appear as areas of erythroplakia or leukoplakia and may be exophytic or ulcerated. Cancers are often indurated and firm with a rolled border. As the lesions increase in size, pain, dysarthria, and dysphagia may result.

Diagnosis

  • Biopsy

  • Endoscopy to detect second primary cancer

  • Chest x-ray and CT of head and neck

Any suspicious areas should be biopsied. Incisional or brush biopsy can be done depending on the surgeon's preference. Direct laryngoscopy and esophagoscopy are done in all patients with oral cavity cancer to exclude a simultaneous second primary cancer. Head and neck CT usually is done and a chest x-ray is done; however, as in most sites in the head and neck, PET/CT has begun to play a larger role in the evaluation of patients with oral cavity cancer.

Prognosis

If carcinoma of the tongue is localized (no lymph node involvement), 5-yr survival is > 50%. For localized carcinoma of the floor of the mouth, 5-yr survival is 65%. Lymph node metastasis decreases survival rate by about 50%. Metastases reach the regional lymph nodes first and later the lungs.

For lower lip lesions, 5-yr survival is 90%, and metastases are rare. Carcinoma of the upper lip tends to be more aggressive and metastatic.

Treatment

  • Surgery or radiation therapy

Surgery and radiation therapy are the treatments of choice. (See also the National Cancer Institute’s summary Lip and Oral Cavity Cancer (PDQ®): Treatment .)

For tongue lesions, surgery is usually the initial treatment, particularly for early-stage disease. Selective neck dissection is indicated if the risk of nodal disease exceeds 15 to 20%. Although there is no firm consensus, neck dissections are typically done for T2 (see Table: Staging of Head and Neck Cancer) lesions (greatest dimension 2 to 4 cm) and most T1 lesions with a depth of invasion about ≥ 4 mm. Routine surgical reconstruction is the key to reducing postoperative oral disabilities; procedures range from local tissue flaps to free tissue transfers. Speech and swallowing therapy may be required after significant resections. Radiation therapy is an alternative treatment. Chemotherapy is not used routinely as primary therapy but is recommended as adjuvant therapy along with radiation in patients with advanced nodal disease.

Treatment of squamous cell carcinoma of the lip is surgical excision with reconstruction to maximize postoperative function. When large areas of the lip exhibit premalignant change, the lip can be surgically shaved, or a laser can remove all affected mucosa. Thereafter, appropriate sunscreen application is recommended.

Key Points

  • The chief risk factors for oral squamous cell carcinoma are heavy smoking and alcohol use.

  • Oral cancer is sometimes asymptomatic initially, so oral screening (typically by dental professionals) is useful for early diagnosis.

  • Do direct laryngoscopy and esophagoscopy to exclude a simultaneous second primary cancer.

  • Once cancer is confirmed, do head and neck CT and a chest x-ray or PET/CT.

  • Initial treatment is usually surgical.

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