P4- ORAL PATHOLOGY

SQUAMOUS CELL CARCINOMA

-

Epithelial malignancy
Squamous cell differentiation
Flattened polyhedral, round, ovoid
epithelial cells
Intracellular/ extracellular keratinization
Intercellular bridges

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MALIGNANCY
Tumor:
-

New growth, mass

Malignant/ benign
Not Normal in the area

Cancer:
-

Unknown etiology
With predisposing factors

Benign Tumor:
Clinical signs & symptoms; Lesions are:
-

Fixed, sessile/ pedunculated

Slow growing
Asymptomatic
May become malignant

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CARCINOMA VS. SARCOMA
-

Different locations
Different features

2.
-

EMBRYONAL REST THEORY

Cells are left forms growth
Remnant sometimes become malignant
DURING GROWTH

3. HUMORAL THEORY
- 4 Humors:
1) Blood
2) Phlegm
3) Yellow bile
4) Black bile
- Balanced = healthy
4. CANCER CELL THEORY
- Improved: Embryonal Rest theory
- Cancer cells:
o Renew & sustain organs & tissues
- Anti cancer therapies
o Shrink tumors
o But if it doesnt kill the cancer stem
cell tumor will grow back
5. POST FETAL THEORY
- Remnants of epithelial or CT develop to
new growth
- Alterations between epithelial & CT
- AFTER GROWTH
6. HEREDITY
- Genes to develop malignancy
7. CO-CARCINOGENESIS THEORY
Initiation Phase
-

Initiating agent that cause neoplastic

formation
Instantaneous effect (will just appear)
Irreversible changes

CARCINOMA

Promotion Phase

Epidermoid
Epithelial in origin

SARCOMA
-

Mesodermal
Mesenchymal in origin

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THEORIES OF MALIGNANCY
1. VIRCHOW CHRONIC IRRITATION
THEORY
- Continuous/ constant irritation to normal
tissue
- Ex:
o Ill fitting denture
o Cheek biting

Non specific agents (Ex. Chronic irritants)

Action is prolonged
Effect is reversible

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PREDISPOSING FACTORS
1. CHEMICAL AGENTS
- Strong acids
- Ex: Asbestos can cause injury to the cell
change in morphology or mutation can
result in malignancy
o Chemist; Factory workers
2. TOBACCO
- Time-dose relationship meaning:
CUMULATIVE
- Smoke, smokeless, reverse-smoking
- Mix it with other agents
o Betel nut, lime (acids)

Poor hygiene, poor nutrition, poor

immunity Lower chance to fight

3. PHYSICAL AGENTS
- Sunlight: UV
- Know carcinogen:
o BCCA: deeper
o SCCA: superficial
- Cumulative sunlight exposure
- Radiation alters cells
4. ALCOHOL
- Absinthe, ethanol
- Ethanol & tobacco
o Risk: Head & neck 100-fold
- Alcohol-containing mouthwash although
not really proven
5. AGE
- Risk increases with age. Why?
o Immune system compromised
6. NUTRITIONAL STATUS
- Increase risk if you lack Vit. A, D & E
- Fe deficiency:
o Plummer-Vinson Syndrome
o Affects middle aged women
o Painful red tongue
o Mucosal atrophy &dysphagia
7. PREVIOUS RADIATION & CHRONIC
IRRITATION
- Mechanical trauma
- Ex: Ill fitting dentures
8.
-

BACTERIA/ VIRUSES/ FUNGI

Increase risk if untreated
Immunocompromised patient
TreponemaPallidum
EBV, HSV, HPV, cytomegalovirus
Candida albicans

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5S IN ORAL MALIGNANCY
1.
2.
3.
4.
5.

Smoking
Spicy food
Spirits
Syphilis/ Sunlight
Sepsis

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CLINICAL FEATURES
LIPS
-

25-30%
50-70 yrs old; M > F
Lower lip > Upper lip? Exposure to
sunlight

Vermillion, chronic non healing ulcers or

exophytic growths
Metastasis Local
submental&submandibular
Tx: Excise (Pre-op:
tanggalinnayungngipin)

TONGUE
-

25-40%
6th, 7th& 8th decade; M > F
45% post lateral border
25% post 1/3 or base of tongue
o Late detection. Why? Asymptomatic.
Rare dorsum or on tip of tongue
Asymptomatic
Indurated, non healing ulcer
Exophytic or endophytic pattern
Leukoplakia/ erythroplakia

FLOOR OF THE MOUTH

-

15-20% (2nd most common)

Older male smoker & drinkers
Painless, indurated, non healing ulcer
White or red patch
Cells infiltrate soft tissues causing
immobility of tongue (Invasion of tumor
cells)
Metastasis Submandibular lymph
nodes (Multiple organ metastasis)

BUCCAL MUCOSA & GINGIVA

-

10%, associated with smokeless tobacco

7th decade, Men
White patch, ulcer, exophytic lesion
Verrucous CA Broad based, wart like,
slow growing
Well differentiated, rare metastasis
Good prognosis

PALATE
-

10& Soft > hard palate

Older men
Soft: Faucial tissues (tonsils); 10-20%
Hard: Rare SCCA, common adeno CA
Asymptomatic red/ white plaques, ulcer,
keratotic masses
Metastasis cervical nodes
Commonly encountered in countries like
India. WHY?
o Spices & smokeless tobacco

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NEOPLASMS
1. SCCA IN SITU
- Does not go beyond the basement
membrane; Does not invade
2. INVASIVE SCCA

- Breaks in the BM & spreads

3. SPINDLE CELL CA
- Similar to smooth cells showing a change
in morphology

6. PAPILLARY SCCA

7. MUCOEPIDERMOID SCCA
- Duct like structures
- Tx: Maxillectomy (Fabricate: Obturator)
4.
-

BASALOID SCCA
Base of tongue;
Basaloid pattern of tumor cells
Squamous cell differentiation
o (Islands)

8. NASOPHARYNGEAL SCCA
- Replicating

5.
-

VERRUCOUS SCCA
Very well differentiated
More hyperplastic than neoplastic
Invasive nature with broad, pushing
margins
o Like fingers = HARD TO REMOVE;
remove the block (whole)

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EARLY SIGNS & SYMPTOMS
1.
2.
3.
4.
5.

Painless lump/ mass

Sore throat that does not heal for weeks
Progressive change in color
Fast growing
Chronic/ progressive thickening of lips/
membrane
6. Unexplained bleeding/ discharge

7. Difficulty in opening the mouth

- Especially saNaso SCCA kasilumalakina
tumor
8. Sudden appearance of swelling of the
neck
9. Dysphagia, hoarseness, cough
10. Unexplained numbness of lips

What to do when not sure?

o Check history
o Eradicate DD
o BIOPSY

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HISTOLOGIC FEATURES

CLASSIFICATION
More undifferentiated, more malignant
1. Grade 1
- 75-100% well differentiated
2. Grade 2
- 50-75%
3. Grade 3
- 25-50%
4. Grade 4
- 0-25% (More malignant) Poorly
differentiated: Highly aggressive
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TREATMENT
1.
2.
3.
-

1.
2.
3.
4.
5.

Keratinizing SCCA
Non-keratinizing SCCA
Moderately/ well differentiated
Keratin pearls
Inflammatory cells: Lymphocytes,
Plasma, Macrophage
6. Spindle shaped cells
(#5 & 6: Chronic in nature;
pag may Neutrophils = Acute)
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Surgery
Chemotherapy
Radiation
Effective on less differentiated cells
40-70 Gy lymphomas
60-70 SCCA
Side effects:
o Pain
o Xerostomia
o Loss of taste
o Dysguesia

*Last: Palliative treatment

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SIDE EFFECTS OF RADIOTHERAPY
1.
2.
3.
4.
5.
6.
7.

Mucosal ulcers
Pain
Dysguesia/ hypoguesia
Dermatitis
Candidiasis
Erythema
Alopecia (low)

DIFFERENTIAL DIAGNOSIS

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1. Ulcers (Non healing)

2. Clinical TB, syphilis, deep fungal
infections (oral infections)
3. Palate: Midline granuloma& necrotizing
sialometaplasia
4. Chronic trauma from factitial injuries may
also mimic SCCA

PROGNOSIS
-

Dependent on histologic subtype (grade)

& clinical extent (stage)
Age, gender, general health, immune
system

If SCCA metastasize: 5 years survival

rate is cut in half (25-50% 20%)
Secondary primary lesion 10% (1-2 years
after) Recurrence in another location

EX: less than 2cm tumor with no node & no

metastasis
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STAGES

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CLASSIFICATION
T (Tumor)
1.
2.
3.
4.

T1:<2cm
T2: 2-4cm
T3:>4cm
T4: Invades in adjacent area (Metastasis)

N (Node)
1.
2.
3.
4.

N0: None
N1:Ipsilateral (same side)
N2:Contralateral/ bilateral
N3: Fixed

M (Metastasis)
1. M0: None
2. M1: Distant M

1. Stage 1
- T1N0M0
2. Stage 2
- T2N0M0
3.
-

Stage 3
T1N1M0
T2N1M0
T3N0M0
T3N1M0

4.
-

Stage 4
T1N2M0
T1N3M0
T2N2M0
T2N3M0
T3N2M0
T3N3M0
T4N0M0