Oral cancer: Clinical features

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Oral Oncology 46 (2010) 414–417

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Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology


Oral cancer: Clinical features Jose Bagan a,*, Gracia Sarrion b, Yolanda Jimenez b a b

Valencia University, Department of Stomatology, University General Hospital, Valencia, Spain Valencia University, Spain

a r t i c l e

i n f o

Article history: Available online 18 April 2010 Keyword: Oral cancer

s u m m a r y Oral squamous cell carcinoma (OSCC) is a well-known malignancy that accounts for more than 90% of all oral cancers. In this article we will perform a brief review of its clinical characteristics and the differential diagnosis. Regarding symptoms, pain is the most frequent presentation and the tongue and the floor of the mouth have the highest occurrence. OSCC in its initial stages shows an erytholeukoplastic area without symptoms but in advanced stages there are ulcers and lumps with irregular margins which are rigid to touch. The different diagnosis should be established with other oral malignant diseases such as lymphomas, sarcomas and metastasis, which have rapid growth rates as opposed to the typical OSCC. Ó 2010 Elsevier Ltd. All rights reserved.

Introduction Oral squamous cell carcinoma (OSCC) is a well-known malignancy which accounts for more than 90% of all oral cancers.1 The overall 5-year survival rate in OSCC has not significantly increased in the last few years. The overall and disease-free survival rates are 56% and 58%, respectively.2 The most important task is to establish an early diagnosis at the first stages of the disease.3 Symptoms Pain is a common symptom in oral cancer patients, representing 30–40% of their main complaints. There were 12 different descriptions of pain; pain was related to TNM staging in the tongue and the tongue/mouth floor.4 Although pain is the main symptom, it usually arises only when the lesions have reached a remarkable size, and is the time when the patient requests medical assistance. Thus, early carcinomas often go unnoticed because they are asymptomatic.5 In later and larger lesions, symptoms may vary from mild discomfort to severe pain, especially on the tongue. Other symptoms include ear pain, bleeding, mobility of teeth, problems in breathing, difficulty in speech, dysphagia and problems using prosthesis, trismus, and paraesthesia.6 In some locations, such as the tongue or the floor of the mouth, pain can arise early on. In the case of OSCC of the tongue, the tongue’s movement against the teeth causing more discomfort. In con* Corresponding author. Address: Hospital General Universitario, Servicio de Estomatología, Avda/Tres Cruces s/n, 46014 Valencia, Spain. Tel.: +34 96 1972127; fax: +34 96 394 18 54. E-mail address: [email protected] (J. Bagan). 1368-8375/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2010.03.009

trast, carcinomas of the lip and buccal mucosa only show intense pain at advanced stages.7 Occasionally patients may present with cervical lymphadenopathy without any other symptoms. In terminal stages, patients may develop skin fistulas, bleeding, severe anaemia and cachexia.8 Jainkittivong et al.9 found that swelling and/or pain were the first signs or symptoms in the 342 (52.6%) OSCC patients studied. Other authors reported that the main symptoms were ulceration and swelling10, followed by pain, bleeding, decreased mobility of the tongue, dysphagia and paraesthesia. Gorsky et al.11 reported a series of patients with OSCC of the tongue, finding that the main symptom was pain on the tongue (66.5%), while 29% had a lump on the tongue. Symptoms such as ear pain, voice changes, dysphagia, and cervical tumours were more common in tumours at the tongue base. Location OSCC may appear in any location, although there are certain areas in which it is more commonly found. The most common locations are the tongue and the floor of the mouth12–16, mainly in Western countries; it occurs in over 50% of cases. Other areas of involvement are the buccal mucosa, retromolar area, gingiva, soft palate and, less frequently, the back of the tongue and hard palate. The lip is involved more frequently in some geographic areas.6 Hirata et al.12 in their study of 478 carcinomas of the oral cavity performed between 1947 and 1970 found that, excluding the lip, 40% of tumours were located on the tongue and 33% on the floor of the mouth. Oliver et al.13 in a review of 92 cases, found that the lateral and ventral surfaces of the tongue were the most frequent locations, followed by the floor of the mouth. The lateral

J. Bagan et al. / Oral Oncology 46 (2010) 414–417

border of the tongue and the floor of the mouth, with extension to the soft palate and tonsillar is the area of highest risk of developing cancer.14,15


Advanced stages The classic features of oral malignancy include ulceration, nodularity and fixation to underlying tissues.21,24–26

Clinical presentation Ulceration The clinical presentation of OSSC is so characteristic in advanced stages that there is usually clear suspicion of malignancy.17 In contrast, it is quite possible in early stages to make the wrong diagnosis.18 It is always necessary to establish the diagnosis by a biopsy and histopathological examination19,20, because the clinical characteristics alone are insufficient. A clinician should always make a thorough clinical examination of the oral mucosa and mainly of those sites that are especially predisposed, such as the sides of the tongue and the floor of the mouth. Together with the oral cavity it is recommended to palpate the lymphoid tissue of the neck (cervical lymph nodes) to look for neck masses which can represent metastases.21 OSCC lesions have a variable size and can range from a few millimetres to several centimetres in the more advanced cases. The initial lesions are usually asymptomatic as they are small. Mashberg et al.14 reported a series of 102 asymptomatic OSCCs where 17% of the lesions were smaller than 2 cm (T1). They also found a relationship between the size of the lesions and ulceration, bleeding, and lymphadenopathy. Other authors such as Brandizzi et al.16 in their 274 OSCC cases, found 29% under 2 cm, 46% between 2 and 4 cm and 18% with lesions greater than 4 cm. Martínez-Conde et al.22 in a retrospective study of 40 patients with OSCC in stage I and II found that the average diameter of the lesion was 2.6 cm. Vallecillo Capilla et al.23 reported on 216 patients with oral squamous cell carcinoma studied over a period of five years. They found that the factors most associated with mortality were: location in the gingiva, in the trigone, large size (T3–T4), and lymph node involvement (N2a–N2b).

This is one of the most common and best-known types of OSCC. The ulceration has an irregular floor and margins, and is elevated and hard on palpation. When the lesion is large the patient often has severe pain, radiating from the lesion to the ipsilateral ear (Figs. 2–4). Lump In these advanced stages, exophytic tumours with warty surfaces, poorly defined boundaries, and hard to palpation may be seen (Fig. 5). Less common presentations OSCC may manifest with paraesthesia or numbness of the chin. Others manifest with delayed healing after a dental extraction, or sometimes a lump with abnormal supplying blood vessels, dysphagia or weight loss.21 These advanced cases can be associated with neck metastases, seen as cervical lymph node enlargement, especially if there is hardness in a lymph node or fixation. Occasionally (about 5%), a cervical lymph node enlargement is detected in the absence of any obvious primary tumour – when the likely site for the

Initial stages It is very important to establish an early diagnosis in OSCC, and it must be suspected in patients with single oral lesions persisting for more than 3 weeks. The clinical presentation of these early malignant lesions is usually in the form of an erytholeukoplastic lesion.14 It consists of red or red and white areas with a slight roughness and is well-demarcated. (Fig. 1) The elasticity of the soft tissue changes to a harder sensation on palpation (‘‘induration”). There is often no pain, but there may be some discomfort.

Figure 2 Oral squamous cell carcinoma on the gingiva.

Figure 1 Erythroplastic lesion, a carcinoma, on the lateral border of the tongue.

Figure 3 Oral squamous cell carcinoma on the alveolar ridge.


J. Bagan et al. / Oral Oncology 46 (2010) 414–417

tients who attended their first consultation in a department of head and neck surgery. The time elapsed from the first appointment to the treatment was 27.9 days for males and 40.6 days for females. In late stages this rate of survival is much lower. In a study by Brandizzi et al.16 on 274 patients with primary oral carcinoma, the survival rate of this population was 80% at 12 months, 60% at 24 months, 46% at 36 months, 40% at 48 months, and 39% at 60 months. The tumour locations with the worst prognosis were the floor of the mouth and the tongue, with survival rates of 19% and 27%, respectively. Sixty-five percent of the oral carcinomas evaluated were diagnosed at advanced stages (III and IV). They concluded that the low survival rate obtained was mainly due to the large number of oral cancer cases that were diagnosed at advanced stages. Figure 4 Ulcerated tumour on the lateral border of the tongue.

Conflicts of interest statement None of the authors has any financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.


Figure 5 Tumour in the floor of the mouth.

primary (in order of predilection) is the tongue base, tonsil or nasopharynx.21 Diagnosis The clinical characteristics of OSCC are so typical in advanced stages that it is easy to establish the clinical diagnosis but one must always take a biopsy to confirm the diagnosis.27 OSCC in advanced stages should be distinguished from other malignancies such as lymphoma, metastases and sarcomas. In the early stages of the malignancy an incorrect clinical diagnosis is more likely to be made.28 Among malignant lesions, lymphoma ranks second only to squamous cell carcinoma in frequency of occurrence in the head and neck.29 The upper jaw, mandible, palate, vestibule and gingiva are, respectively, the most common locations. Swelling, ulceration, and radiographic destruction of bone are the most frequent signs.30,31 Metastatic tumours in the oral region are uncommon but may occur in the oral soft tissues or in the jawbones. In the jawbones most patients complain of swelling, pain and paraesthesia which develop in a relatively short period. Early manifestation of gingival metastases may resemble a hyperplastic or reactive lesion.32 Oral and maxillofacial sarcomas are present at any age and have a rapid growth with extensive and ulcerated tumours.33 Importance of early diagnosis Early diagnosis is the most important factor for improving patient survival, rates as high as 80–90% on these first stages can be achieved. Early diagnosis also minimizes the extent of surgery required. In order to analyse the delay for diagnosis and treatment of oral cancer in a public hospital, Abdo et al.34 studied 180 pa-

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