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Oral Squamous Cell Carcinoma

By

Bradley A. Schiff

, MD, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine

Last full review/revision Oct 2019| Content last modified Oct 2019
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Topic Resources

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. Over 95% of people with oral squamous cell carcinoma 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-year survival rate (all sites and stages combined) is > 50%.

Oral squamous cell carcinoma affects about 34,000 people in the US each year. 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)

  • 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, HPV is identified in oral cancer much less often than 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.

Manifestations of Oral Squamous Cell Carcinoma

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. (See table Staging of Lip and Oral Cancer.)

Table
icon

Staging of Lip and Oral Cancer

Stage

Tumor (Maximum Penetration)*

Regional Lymph Node Metastasis†

Distant Metastasis‡

I

T1

N0

M0

II

T2

N0

M0

III

T3 or

N0

M0

T1–3

N1

M0

IVA

T1–3

N2

M0

T4a

N0–2

M0

IVB

T4b

Any N

M0

Any T

N3

M0

IVC

Any T

Any N

M1

* Definition of Primary Tumor (T)

T1

Tumor ≤ 2 cm with DOI (depth of invasion, not tumor thickness) ≤ 5 mm

T2

Tumor ≤ 2 cm with DOI > 5 mm OR tumor > 2 cm and ≤ 4 cm with DOI ≤ 10 mm

T3

Tumor > 2 cm and ≤4 cm with DOI > 10 mm OR tumor > 4 cm with DOI ≤ 10 mm

T4a

Moderately advanced local disease

Lip: Tumor invades through cortical bone or involves the inferior alveolar nerve, floor of mouth, or skin of face (eg, chin or nose)

Oral cavity: Tumor > 4 cm with DOI > 10 mm OR tumor invades adjacent structures only (eg, through cortical bone of the mandible or maxilla, or involves the maxillary sinus or skin of the face)

Note: Superficial erosion of bone/tooth socket (alone) by a gingival primary is not sufficient to classify a tumor as T4.

T4b

Very advanced local disease

Tumor invades masticator space, pterygoid plates, or skull base and/or encases internal carotid artery

† Definition of Regional Lymph Node (N)

N1

Metastasis in a single ipsilateral node, ≤ 3 cm and no extranodal extension

N2

Metastasis in single ipsilateral node > 3 cm but ≤ 6 cm and no extranodal extension; OR in multiple ipsilateral nodes ≤ 6 cm and no extranodal extension; OR in bilateral or contralateral nodes ≤ 6 cm and no extranodal extension

N3

Metastasis in a node > 6 cm and no extranodal extension; OR in any nodes and extranodal extension

‡ Definition of Distant Metastasis (M)

M0

No distant metastasis

M1

Distant metastasis

Data from  Amin MB, Edge S, Greene F, Byrd DR, et al: American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 8th edition. New York, Springer, 2017; AJCC Cancer Staging Form Supplement, 2018. For a comparison of the 7th and 8th edition, see Cramer JD, Reddy A, Ferris RL, et al: Comparison of the seventh and eighth edition American Joint Committee on Cancer oral cavity staging systems. Laryngoscope, 128(10):2351-2360, 2018. doi: 10.1002/lary.27205.

Data from  Amin MB, Edge S, Greene F, Byrd DR, et al: American Joint Committee on Cancer (AJCC) Cancer Staging Manual, 8th edition. New York, Springer, 2017.

Prognosis

If carcinoma of the tongue is localized (no lymph node involvement), 5-year survival is > 75%. For localized carcinoma of the floor of the mouth, 5-year survival is 75%. Lymph node metastasis decreases survival rate by about half. Metastases reach the regional lymph nodes first and later the lungs.

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

Treatment

  • Surgery, with postoperative radiation or chemoradiation as needed

For most oral cavity cancers, surgery is the initial treatment of choice. Radiation or chemoradiation is added postoperatively if disease is more advanced or has high-risk features. (See also the National Cancer Institute’s summary Lip and Oral Cavity Cancer Treatment.)

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 any lesion with a depth of invasion > about 3.5 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. Mohs surgery can be used. 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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