Oral squamous-cell carcinoma

Oral squamous-cell carcinoma is the most frequent type of oral cancer, affecting predominantly more males aged between 50 and 70 years. The main, predisposing and known factors are tobacco (cigarettes, cigars, betel, chewing tobacco) and alcohol. Other factors can include: pre-existing lesions (potentially malignant disorders – erythroleukoplakia, leuokoplakia, lichenoid dysplasia), chronic trauma (e.g. from ill-fitting dentures, chipped or fractured teeth or malocclusion), bacterial/viral and/or fungal infections, nutritional deficiencies, poor oral hygiene, exposure to ultraviolet radiation, immunodeficiency, genetic factors and systemic syndromes (e.g. dyskeratosis congenita, Fanconi anaemia and xeroderma pigmentosum).
The clinical appearance of squamous-cell carcinoma can vary considerably: from exophytic lesions (neoformation) with a white-rosy/white-red and warty appearance to endophytic lesions (e.g. ulcer) with a crateriform appearance, with hard and raised borders, without excluding possibly flat (patch or papula) and red (e.g. erythroplakia) lesions. Associated symptoms include: pain, spontaneous blood loss, loose teeth, paresthesia, dysgeusia but occasionally the lesions can be totally asymptomatic. Often the medical history and symptomology are accompanied by a submandibular and/or cervical lymphoadenomegalia.
The most common location of these lesions is: the lower lip (particularly in patients who have excessively exposed themselves to the sun), the tongue, floor of the mouth, hard palate, the retromolar region and buccal mucosa.
A rare variant of squamous cell carcinoma is verrucous carcinoma, characterised by different clinical behaviour although the same risk factors as squamous cell carcinoma can be taken into consideration. Clinically, it presents as a slowly-growing neoformation which is exophytic in nature, especially on the lip, the hard palate, the tongue or buccal mucosa. Verrucous carcinoma can become locally aggressive if left untreated, but absent are local or distant metastases. Microscopically, this tumour was described by Ackerman in 1948. It is characterised by a predominant proliferation of the keratinized epithelium, which is well-defined. There is minimal atypia; verrucous carcinoma is associated with an intense, inflammatory and chronic infiltrate.
All suspect lesions which do not heal 2 weeks after the removal of potential causal factors should always be subject to biopsy and histo-cytopathological examination. When the latter confirms the presence of squamous-cell carcinoma, a complete diagnostic pathway can be confirmed by identifying the pathological stage, according to the international TNM system. The latter is assessed by making use of investigative tools, such as an ultrasound examination of the neck (to establish possible lymph node involvement), CT scan or MNR (to ascertain the extent of the tumour and surrounding tissue) with or without radiocontrast agents. The treatment strategy of a patient with a diagnosis of squamous-cell carcinoma of the head and neck will depend on various factors, such as: the location of the tumour, the TNM stage, age of the patient and their general state of health.
Therapy will include surgery (a resectioning of the tumour mass and morpho-functional reconstruction of the affected area), radiotherapy, chemotherapy or a combination of these treatments. Very often a diagnosis of squamous-cell carcinoma is made late when the neoplasm has invaded the surrounding tissue or even spread to secondary organs (lymph nodes, lung, bone, liver and cerebral metastases); it is precisely for this reason that the survival rate of more than 5 years is very low. Early diagnosis is, therefore, vital.