SQUAMOUS CELL CARCINOMAIt is the eighth most common cancer in males and

the fifteenth most common in femalesApproximately 94% of all oral malignancies are squamous cell carcinomaAs with so many carcinomas, the risk of intraoral cancer increases with increasing age, especially for males

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CLINICAL FEATURES

most often older men who have been aware of an alteration in anoral cancer site for 4 to 8 months before seeking professional helpOral squamous cell carcinoma has a varied clinical presentation, including:♦ Exophytic (mass-forming; fungating, papillary,verruciform)♦ Endophytic (invasive, burrowing, ulcerated)♦ Leukoplakic (white patch)♦ Erythroplakic (red patch)♦ Erythroleukoplakic (combined red-and-whitepatch)

Destruction of underlying bone, when present, may be painful or completely painless, and it appears on radiographs as a "moth-eaten" radiolucency with ill-defined or ragged margins (an appearance similar to osteomyelitis)

Lip vermilion carcinomaIntraoral carcinomaCarcinoma of the tongueCarcinoma of the oral floorGingival and alveolar carcinomasOropharyngeal carcinoma

Squamous cell carcinoma. An exophytic lesion of the posterior lateral tongue demonstrates surface nodularity and

minimal surface keratin production. It is painless and indurated

Squamous cell carcinoma An exophytic buccal

lesion shows a roughened and irregular surface with areas of

erythemaadmixed with small areas of white

keratosis. Surface ulcerationis eviden

Squamous cell carcinoma .A posterior lateral

tongue lesion is exophytic but also demonstrates extensive surfaceulceration and nodularity. Such

lesions are sometimesreferred to as "fungating" carcinomas

Squamous cell carcinoma An ulcerated or

endophytic lesion of the hard palate demonstrates rolled borders

and a necrotic ulcer bed. This cancer was painless, although it had

partially destroyed underlying palatal bone

Squamous cell carcinomaBone involvement is

characterized by an irregular, "moth-eaten" radiolucency with

ragged margins—an appearance similar to that of osteomyelitis

Squamous cell carcinomaSmall, crusted ulcer of

the lower lip vermilion

Squamous cell carcinomaUlcerated mass of

the lower lip vermilion

Squamous cell carcinomaPatient neglect can

result in extensive involvement, even in a readily visible site such

as the lip vermilion. This ulcerating lesion of the lower lip had

been present for more than 1 year before diagnosis

Squamous cell carcinomaUlcerated lesion with

surrounding leukoplakia on the posterior lateral and ventral

tongue.

Squamous cell carcinomaUlcerated, exophytic

mass of the posterior lateral border of the tongue

Squamous cell carcinomaOral floor lesions are

typically ulcerated or present as an admixed red-and-white,

pebbled-surface change

Squamous cell carcinomaAn exophytic lesion with

an irregular and pebbled surface has a linear indentation along its

facial aspect resulting from pressure from the patient's lower

denture. Underlying alveolar bone was extensively destroyed

Squamous cell carcinoma Large fungating

tumor of the maxillary alveolar ridge and hard palate

Squamous cell carcinomaAn innocuous pebbledsurface

change of the attached and marginal gingiva was interpreted

as an inflammatory change until multifocal white keratoses

occurred.

Squamous cell carcinoma. Large, ulcerated

lesion of the right lateral soft palate

Metastasis

The metastatic spread of oral squamous cell carcinoma is largely through the lymphatics to the ipsilateral cervical lymph nodesA cervical lymph node that contains a metastatic deposit of carcinoma is usually firm to stony hard, nontender, and enlargedThe most common sites of distant metastasis are the lungs, liver, and bones

Staging

Tumor size and the extent of metastatic spread of oralsquamous cell carcinoma are the best indicators of thepatient's prognosisQuantifying these clinical parameters is called staging the diseaseTNM

HISTOPATHOLOGIC FEATURESSquamous cell carcinoma arises from dysplastic surfaceepithelium and is characterized histopathologically by invasive islands and cords of malignant squamous epithelial cellsInvasion is represented by irregular extension of lesional epithelium through the basement membrane and into subepithelial connective tissueIndividual squamous cells and sheets or islands of cells are seen to be thriving as independent entities within the connective tissues, without attachment to the surface epithelium

Histopathologic evaluation of the degree to which these tumors resemble their parent tissue (squamous epithelium) and produce their normal product (keratin) is called gradingLesions are graded on a three-point (grades Ito III) or a four-point (grades Ito IV) scale

To a certain extent, the grading of squamous cell carcinomais a subjective process, depending on the area of the tumor sampled and the individual pathologist's criteriafor evaluation. Moreover, clinical staging seems to correlate much better with the prognosis than microscopic grading

Treatmt and prognosisSurgical exisionRadiotherapychemotherapy

VERRUCOUS CARCINOMA (SNUFF DIPPER'SCANCER; ACKERMAN'S TUMOR)

Verrucous carcinoma is a low-grade variant of oral squamous cell carcinomaReported first by Ackerman in 1948 as a spit tobacco-associated malignancyTypically in the area where the tobacco is habitually Placed

Clinical Features:men older than 55 years of agemandibular vestibule, the buccal mucosa, and the hard PalateThe lesion appears as a diffuse, well-demarcated,painless, thick plaque with papillary or verruciform surfaceLesions are typically white but also may appear erythematous or pinkVerrucous carcinoma is a lesion that may develop from the highriskprecancer, proliferative verrucous leukoplakia (PVL)

HISTOPATHOLOGIC FEATURES

wide and elongated rete ridges that appear to "push" into the underlying connective tissueParakeratin typically fills the numerous clefts or crypts (parakeratin plugs) between the surface projectionsThe lesional epithelial cells generally show a normal maturation pattern with no significant degree of cellular atypiaThere is frequently an intense infiltrate of chronic inflammatory cells in the subjacent connectiveTissue aAdequate sampling also is important because as many as 20% of these lesions have a routine squamous cell carcinoma developing concurrently within the verrucous carcinoma

TREATMENT AND PROGNOSIS

Because metastasis is an extremely rare event in verrucouscarcinoma, the treatment of choice is surgicalExcision without radical neck dissection

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