Oral Cancer

Oral cancer accounts for 4% of all cancer deaths or approximately 8,000 people in the United States each year. This is twice as many cancer-related deaths as cervical cancer and more than melanoma, Hodgkin’s lymphoma and leukemia, brain, stomach, thyroid, ovarian, kidney, pancreas or esophageal cancer. Oral cancer is the 8th most common cancer in men and the 12th most common in women. There are 30,000 new cases per year in the USA.

Squamous cell carcinoma can be detected with self-exam of the oral cavity by looking for abnormalities of the lining of the oral cavity. An exam by your dentist at regular intervals is also important because dental professionals are experienced in oral anatomy. The earliest signs of squamous cell carcinoma are tiny white patches, reddish areas and ulcers on the mucosa (wet skin of the mouth). When squamous cell carcinoma is detected early it is 80% curable but when it is detected late it is only 20% curable. That is why even small lesions should be tested.

Testing usually consists of a biopsy in which a small amount of tissue is taken. Sometimes a brush biopsy (Oral CDX) can be done.

Scalpel biopsy (Scalpel biopsy) is the gold-standard for pathologic testing however because it yields the most information. It can be done under local anesthesia or anesthesia of your choice. Usually, a small incision is made, a piece of tissue is taken, and then the site is sutured with resorbable sutures. The specimen is sent to a pathologist who is specially trained in oral diseases. In approximately ten days the results are returned to the office and our doctors personally review them with you and discuss any needed follow-up.

When a patient is found to have oral cancer their treatment is handled by a team approach. Initially, the patient will have further testing to establish the extent of the disease including distant spread (metastasis). This establishes the tumor stage. Each type of cancer has its own staging protocol. For squamous cell carcinoma (SCCa) the stage is determined by the TNM system.

TNM System for Squamous Cell Carcinoma (SCCa)

T = Tumor size Tx Cannot assess 1° tumor T0 No evidence of 1° tumor Tis Carcinoma in situ T1 <2cm T2 2-4cm T3 >4cm T4 Invades adjacent structures

N = Lymph Nodes Nx Cannot assess N0 No lymph node metastasis N1 Single ipsilateral <3cm node N2 (3 subgroups below) N2a Single ipsilateral 3-6cm N2b Multiple ipsilateral <6cm N2c Bilateral or contralateral <6cm N3 >6cm

M = Metastasis Mx cannot assess distant metastasis M0 no distant metastasis M1 distant metastasis

Stage Grouping

Once the T, N, and M categories have been assigned, this information is combined by a process called stage grouping to assign an overall stage of 0, I, II, III, or IV.

Stage 0	Tis, N0, M0	The cancer is “in situ”. It has not yet penetrated to a deeper layer of oral or oropharyngeal tissue and has not spread to lymph nodes or distant sites.
Stage I	T1, N0, M0	The tumor is 2 cm (about 3/4inch) or smaller and has not spread to lymph nodes or distant sites.
Stage II	T2, N0, M0	The tumor is larger than 2 cm, but smaller than 4 cm, and has not spread to lymph nodes or distant sites.
Stage III	T3, N0, M0 or T1, N1, M0 or T2, N1 M0 or T3, N1, M0	The tumor is larger than 4 cm; or it is any size and has spread to one lymph node, on the same side of the head or neck as the primary tumor, which is smaller than 3 cm, and it hasn’t spread to distant sites.
Stage IVA	T4, N0, M0 or T4, N1, M0 or Any T, N2, M0	The tumor is of any size but invades adjacent structures and may or may not have spread to one lymph node, on the same side of the head or neck as primary tumor, which is smaller than 3 cm; or it is of any size and has spread to lymph nodes larger than 3 cm or to lymph nodes on both sides of the neck and it hasn’t spread to distant sites. The lymph nodes are smaller than 6 cm.
Stage IVB	Any T, N3, M0	The tumor is of any size and has spread to lymph nodes larger than 6 cm but it hasn’t spread to distant sites.
Stage IVC	Any T, Any N, M1	The tumor is of any size, may or may not have spread to lymph nodes, but it has spread to distant sites.

Relative 5-year survival by stage

These survival numbers are more specific because they take into account the stage of cancer, not just whether it has or hasn’t spread anywhere. (AJCC Cancer Staging Manual 6th Ed)

Lip Stage	5-year survival	Oral Cavity  Stage	5-year survival	Oropharynx  Stage	5-year survival
Stage I	83%	Stage I	83%	Stage I	83%
Stage II	73%	Stage II	73%	Stage II	73%
Stage III	62%	Stage III	62%	Stage III	62%
Stage IV	47%	Stage IV	47%	Stage IV	47%

Recurrent squamous cell carcinoma: This is not an actual stage in the TNM system. Recurrent disease means that cancer has come back (recurred) after treatment has taken place. Recurrent oral cancer may return in the oral cavity (local recurrence) or in another part of the body (distant recurrence).

A radiologist oncologist (cancer specialist) will be consulted and depending on the type and extent of surgery a “head and neck” surgeon may be involved.

Each type of cancer responds differently to radiation therapy and chemotherapy. Chemotherapy has many different regimens. Squamous cell carcinoma which accounts for 90% of oral and pharyngeal cancers responds best to radiation. Treatment for squamous cell carcinoma usually consists of radiation therapy and surgery.

Radiation:

In addition to surgery, radiation therapy and sometimes chemotherapy is used to treat tumors of the head and neck. For squamous cell carcinoma, radiation is often used as an adjunct to surgery. Preparations must be made prior to radiation therapy. Radiation to the head and neck region can cause permanent xerostomia (dry mouth) due to its effect on the salivary glands. It also causes decreased blood flow through the soft tissues and bone. These two effects are important because pre and post radiation care is shaped by it.

Pre-radiation care involves a dentist or dental specialist examining the health of all the teeth. Any questionable teeth that are not essential should be considered for extraction six-weeks before radiation therapy. In the case of cancer, aggressive removal of teeth is the conservative route. Post-radiation care for the remaining teeth includes at home fluoride treatments using custom trays, increased home care and quarterly instead of biannual dental visits.

Oral Cancer Pictures and Case Studies

Caries susceptibility is greatly increased due to the loss of the saliva’s protecting factors. This puts the patient at increased risk for tooth loss due to deep caries.

Radiation therapy diminishes the blood flow in the jaws and makes future extractions problematic. A condition known as osteoradionecrosis can occur in the jaw bone around infected teeth or after simply extracting a tooth from an irradiated jaw (jaw that has had radiation). This condition is similar to osteomyelitis and results in the death of, or infection of, bone tissue itself.

Osteoradionecrosis is difficult to treat and may require surgical debridement, hyperbaric oxygen therapy, and long term IV antibiotics. For these reasons early removal of questionable teeth and excellent care for the remaining teeth is imperative.

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WHY Reynolds oral and facial surgery?

Reynolds Oral and Facial Surgery is one of the best oral and facial surgery teams around. With more than 20 years of experience and extensive training, we know what it takes to make sure your procedure runs smoothly. Dr. Reynolds and Dr. Gresehover have a keen eye for detail and strive to make sure to answer any questions you may have. Our team understands that medical procedures can be very nerve-racking experiences which is why we make sure you are comfortable and have the best experience possible. We also invest heavily in the most advanced surgical technology available ensuring you get the best results possible. 

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