08 • Clinical risk


Professor Stephen Porter offers advice on recognising the signs of this increasingly common disease


SPOTTING ORAL T


HERE have been alarming trends around oral cancer in the UK in recent years. The number of cases has increased by almost a quarter, with the majority being oral squamous cell carcinoma (OSCC). Over the next 20 years cases are expected to rise by a third, with predicted mortality rates of 38 per cent.


Historically, most people in the UK have developed OSCC as a result of smoking or alcohol. In the last 20 to 30 years there has been a steady increase in the numbers of individuals who have developed OSCC due to infection by oncogenic (cancer causing) types of human papillomavirus (HPV). The carcinoma due to HPV is most likely to be in the posterior tongue and/or upper pharynx. Patients with HPV-driven oropharyngeal cancer do not have the traditional risk factors and tend to be male, aged under 50 and have a much better outcome than those who have similar cancer driven by tobacco and/or alcohol. This article considers the key aspects of the initial recognition


of possible OSCC and disease that may predispose to, or precede, such cancer.


Clinical features of likely oral cancer OSCC can give rise to a range of different features but perhaps the most typical is a solitary ulcer without an obvious local cause. Tumours tend to arise on the lateral border of the tongue or the floor of the mouth (Figures 1 and 2 above right) but can be anywhere within the mouth. The ulceration is often deep, has a rolled margin and the surrounding mucosa may be white to red in colour. There can be necrosis of the tissues and the ulcer can be fixed to underlying structures. Oral cancer can give rise to swellings that are usually firm and the overlying mucosa can be abnormal – for example, speckled. Enlargement of lymph nodes in the neck is not always evident and the absence of this, despite the presence of a solitary ulcer/lump in the mouth, should not rule out a mouth cancer diagnosis. Pain is the most likely symptom of oral cancer. Others include


The easiest aide memoire for diagnosis of all mouth cancers remains a solitary lesion that has no obvious local or likely infectious cause.


Clinical features of potentially malignant disease Oral cancer is usually preceded by a variety of clinically apparent lesions which have cells displaying atypia, collectively termed oral epithelial dysplasia. As with oral cancer, most of these lesions are solitary. Such disease comprises the following:


Leukoplakia These are solitary white patches that can arise on any surface of the mouth (but typically the buccal mucosa and floor of mouth) and are not likely to be caused by local trauma. Lesions can be sub-classified into homogeneous, when there is a uniform whiteness throughout the lesion (Fig. 3), and non-homogeneous, when there are elements of redness, background erythema (Fig. 4) and/or raised areas (verrucous leukoplakias). The majority of isolated white patches do not contain oral epithelial dysplasia but the more non-homogeneous the lesion the higher the risk of malignant transformation.


“Assume all solitary persistent lesions without an obvious cause are suspicious”


Erythroplakia These isolated red patches of the oral mucosa or gingivae arise in the absence of a local cause (e.g. trauma or clinically evident candidal infection). Such lesions are rare but usually represent areas of severe oral epithelial dysplasia or carcinoma-in-situ. These can be an early manifestation of OSCC, so any patient with an isolated red patch that is not due to local trauma warrants immediate biopsy or referral to an appropriate centre.


paraesthesia or anaesthesia of the lip or, less commonly, the tongue, loss of taste sensation, limited mobility of the tongue, or sudden onset of tooth mobility in one area of the mouth (e.g. if the tumour is on the gum.) Late features of cancer can include unexplained weight loss and anaemia.


Other potentially malignant disorders Oral epithelial dysplasia and carcinoma-in-situ (when all layers of the epithelium have cellular atypia) can arise in a number of pre-existing oral disorders. The most common is oral lichen planus (OLP). This typically manifests as bilateral white patches affecting the buccal mucosae, gingivae and/or dorsum of tongue. The white patches (Fig. 5) are usually painless however, areas of erosion (erosive OLP) and ulceration (ulcerative OLP; Fig. 6) can give rise to painful symptoms. About one per cent or more of patients with OLP will develop clinically apparent


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