ORAL SQUAMOUS CELL

CARCINOMA (OSCC)

Hà Nội, 12/2013
 Definition
 An invasive epithelial neoplasm with varying degrees of
squamous differentiation and a propensity to early and
extensive lymph node metastases, occurring
predominantly in alcohol and tobacco-using adults in the
5th and 6th decades of life.
WHO classification of tumours of
the oral cavity and oropharynx
 Epidemiology
 Oral cancer accounts for 2%–4% of all cancer
cases.
 Oral cancer: affecting any region of the oral
cavity, pharyngeal regions and salivary Glands
 Oral cavity: buccal mucosa, upper and lower
gingiva, hard palate, anterior two-thirds of the
tongue, and the floor of mouth
 Oral squamous cell carcinoma (OSCC):
represents 90% of all oral neoplasms
 Percentages of morbidity and mortality
 Males: 6.6/100,000 and 3.1/100,000
 Females: 2.9/100,000 and 1.4/100,000
 Age: 18 to 44 years
 5-year survival: 40-50%.
 RISK FACTORS
 Tobacco smoking: 75% of all cases of oral cancer,
 Tobacco/Alcohol: carries a six-fold risk
 Tobacco + alcohol: fifteen-fold risk
 Betel quid chewing, Areca nut.
 Older males.
 The inadequate immune response: HIV infection, B cell
Hodgkin lymphoma, organ transplantations and
immunosuppressive therapy
 Human Papilloma Virus (HPV): HPV16
 Viral protein E6 binds to p53 causing its breakdown
 Viral protein E7 reacts with retinoblastoma protein
(pRb), a tumor suppressor protein, inhibiting its
function. incontrollable cellular proliferation +
disturbances of apoptosis
 Epstein-Barr Virus  malignant transformation of B cells
 Hepatitis C Virus (HCV)
 CLINICAL FEATURES
 POTENTIALLY MALIGNANT DISORDERS
 Erythroplakia
 Leukoplakias, particularly:
 Erythroleukoplakia (nodular or verrucous)
 Actinic cheilitis
 Lichen planus (mainly the erosive and atrophic type)
 Submucous fibrosis
 Dyskeratosis congenita
 Discoid lupus erythematosus
 LIP
 The most common OSCCs
 Loss of superficial tissue, erosion,
ulcers and occasionally exophytic
shaped lesions, keratotic, verrucous
, tumorous or “skin horn” aspect
 "lip on balcony”
 A significant atrophy of the vermillion
area with scales form keratosis can
often be observed.
 Cracking, ulceration: actinic cheilitis.
 Develops slowly to the corner of the
mouth or to the gingiva.
 Metastatic lymph nodes: submental
and submandibular
 Tongue
 Lateral border of the tongue and
ventral surface: ulcerated forms,
 Dorsum: lichen planus,
leukoplakia
 Evolve towards the ventral side ,
the floor of the mouth: horse
shoeshaped region
 Lymphadenopathy: suprahyoid,
submaxillary, carotid,
lateropharyngeal nodes,
contralateral nodes
 Gum and alveolar ridge
 Associate with periodontal
disease
 Red or/and white spot slightly
vegetant
 Invade the bones  loosening of
teeth
 Metastatic lymph nodes:
submental, submandibular,
carotid regions, bilateral
metastases
 Posterior zone: invade the floor of
the mouth, masticatory muscles.
 Floor of the mouth

 Mainly in the anterior area

 Red and/or white spots,
plaque or nodular, ulcerated
lesions, later indurated at
palpation
 Tongue´s mobility impaired.
 Invading the floor of the
mouth muscles
 the submental, submaxillary
and cervical nodes
 Buccal mucosa
 Developing on previous
lesions.
 Anterior: Leukoplasiform,
erythroplastic
 Posterior: traumatic lesions,
lichen planus.
 The posterior third:
differentiated histopathologic
 The anterior third:
Undifferentiated histological
types - worse prognosis
 Lymph nodes
Mobile, painless nodes volumes increase, fix to surrounding
tissue
Union for International Cancer Control (UICC) :
 Level I: submandibular and submaxillary nodes.
 Level II: upper jugular nodes.
 Level III: jugular media.
 Level IV: lower jugular.
 Level V: posterior triangle
 Level VI: lymph nodes in the central compartment, which
extends from the suprasternal notch to the hyoid bone.
 Level VII: lymph nodes located in the upper
mediastinum, below the suprasternal notch
TNM system
Five year survival rates, according to OSCC stage
at the moment of diagnosis
Histopathology
 Histopathology
Grade 1 – Well differentiated
 Histopathology
Grade 2 - Moderately differentiated
 Histopathology
Grade 3 – Poorly differentiated
 Treatment Process
 Pre oncologic treatment oral preparation:
The first step of the treatment should be a panoramic X-Ray in
order to have a global vision.
Criteria for pre-radiotherapy tooth extractions (15-20 days
before radiation treatment and 5-10 days before
Chemotherapy)
 Caries (nonrestorable).
 Active periapical disease (symptomatic teeth).
 Moderate to severe periodontal disease (with mobility grade
2 and 3).
 Furcation lesions of grade II and III, periodontal pocket < 4
mm.
 Endo-periodontal processes.
 Lack of opposing teeth, compromised hygiene.
 Extensive periapical lesions (if not chronic or well localized).
 Partial impaction or incomplete eruption
 Treatment Process
Surgery or radiation therapy for early or localized
disease
Stages I-II:
 Primary treatment for oropharyngeal cancers is
surgical resection or definitive radiation therapy
 Surgery is the preferred approach except for some
patients who may have early lip, retromolar trigone,
and soft palate cancers
 Radiation therapy is preferred for patients who may not
be able to tolerate surgery
 The radiation dose depends on tumor size. For early
stage disease, doses of 66-74 Gy (2.0 Gy/fraction;
daily Monday-Friday in 7wk)
 Treatment Process
Chemotherapy with radiation therapy for locally advanced
Stages III-IVB
 Surgery should be considered for locally advanced disease; however,
definitive radiation therapy, concurrent chemoradiation, and induction
therapy are alternative options for patients who are not candidates for
surgery
 Concurrent chemoradiation therapy is the current standard of care for
patients with locally advanced squamous cell carcinoma of the head and
neck
 Chemotherapy is given for the duration of radiation therapy unless
otherwise stated; definitive radiation doses used are 66-74 Gy (2.0
Gy/fraction; daily Monday-Friday in 7wk)
 Conventional fractionation for concurrent chemoradiation is ≥ 70 Gy (2.0
Gy/fraction)
 Postoperative radiation dose is 60-66 Gy (2.0 Gy/fraction); preferred
interval between resection and postoperative radiation therapy is ≤ 6wk
 The decision to treat the patient with concurrent chemoradiation therapy
rather than surgery, radiation, or chemotherapy individually should be
made by a multidisciplinary tumor board (including a medical oncologist,
a radiation therapist, and surgeon)
 Treatment Process
Induction chemotherapy for locally advanced disease
Stages III-IVB:
 Induction chemotherapy is typically given to patients with stage III-IVB
disease in order to shrink a primary tumor to reduce its bulkiness in
preparation for future surgery or radiation therapy
 Decision to treat the patient with induction chemotherapy rather than
concurrent chemoradiation or surgery, radiation, or chemotherapy alone
should be made by a multidisciplinary tumor board (including a medical
oncologist, a radiation therapist, and an ENT surgeon)
 Treatment Process
First-line chemotherapy for metastatic or recurrent disease
Stage IVC:
 Treatment recommendations include the use of single-agent or
combination chemotherapy
 Platinum-based chemotherapy regimens are preferred if these agents
can be tolerated by the patient; if they cannot be tolerated, single
agents have been used in this setting
 Below are first-line chemotherapy options for metastatic disease or
recurrent squamous head and neck cancers (after surgery and/or
radiation)
Second- and third-line chemotherapy for metastatic or recurrent
disease
Stage IVC:
 Second-line chemotherapy is given after disease progression or
recurrence following completion of first-line therapy
 Third-line therapies are given after disease progression or recurrence
following completion of first-line and second-line therapies
 Second- and third-line regimens are similar to regimens used as first-
line therapy but usually offer lower response rates and survival benefits
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