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Dr. sumer yadav
MCh – plastic surgery
The buccal mucosa includes the mucosal
surfaces of the cheek and lips from the line of
contact of the opposing lips to th...
The muscle of the cheek is the buccinator
muscle.
The buccal fat pad is superficial to the fascia
covering the buccinato...
The lips and cheeks function together as
an oral sphincter propelling food into the
oral cavity.
If the facial nerve is ...
After carcinoma of the lip, oral tongue, floor of
the mouth, and lower gum, carcinoma of the
buccal mucosa is the fifth c...
Carcinomas of the buccal mucosa often occur
in association with pre-existing leukoplakia
and tend to have multiple primar...
 Leukoplakia - A chronic white
mucosal macule which cannot
be scraped off, cannot be
given another specific
diagnostic na...
 Erythroplakia is the clinical
diagnostic term - A chronic
red mucosal macule which
cannot be given another
specific diag...
4.5 – 7.5 % progress to oral cancer
 Clinically, there are three distinct types: exophytic,
ulcerative, and verrucous.
 The patient may present with pain or...
Symptoms Signs Associates
Ulcer Ulceration/growth Leukoplakia
Burning sensation Induration SMF
Mild irritation Ankyloglosi...
Infiltrating lesions of the buccal mucosa can
invade the buccinator muscle, extend to the
buccal fat pad, and invade the ...
 Lymph node metastasis occurs in approximately
9% to 31% of the patients during the course of
the disease.
 The submandi...
 >90 % Squamous cell carcinomas
 Spectrum of diseases from benign
lesions like leukoplakia, lichen planus,
SMF to verruc...
 History & Clinical examination , including head &
neck examination
 Clinical staging
 Assessment of performance & nutr...
Investigations to determine the extent of the
disease
OPG/ Dental occlusal view
CT Scan / MRI for extent of disease
USG...
Routine Investigations
CXR
Routine blood counts
Blood chemistry profile
Urinalysis
Stage Grouping
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N0, N1 M0
Stage IV A T1, T2,...
 Stage I – IV A : Curative
 Stage IV B-C : Palliative
The aim of treatment:
 Cure
 Loco regional control
 Preservatio...
Tumor factors
 Primary site
 Size
 Proximity to bone
 Status of cervical nodes
 Tumor pathology ( histological type, ...
 Primary
 Surgery : wide excision +/- marginal
mandibulectomy
 Radiotherapy : Radical external RT/
Brachytherapy
 Node...
Surgery + Post op RT or CT-RT
Primary
Surgery : Composite resection of the buccal
mucosa with mandible or upper alveolu...
Management is controversial
Perceived risk that the tumor may become more
aggressive if it recurs after RT.
Many tumors...
 Used as single modality in early disease (Stage I &
II )
 Combined with post operative adjuvant
radiotherapy in advance...
 Treatment time is shorter.
 The risk of immediate and late radiation sequel
are avoided.
 Irradiation is reserved for ...
 Modified neck dissection is sufficient treatment
for the ipsilateral neck for patients with N1
without PNE.
 Radiation ...
 RND : superficial & deep cervical fascia with its enclosed
LN (level I-V) is removed in continuity of SCM, omohyoid
musc...
 Marginal mandibulectomy: partial-thickness (marginal)
mandibular resection
 Segmental Mandibulectomy
For small lesions ...
MARGINAL MANDIBULECTOMY SEGMENTAL
MANDIBULECTOMY
Gross pathology
1. Morphology
2. Location & extent of the tumor / lesion
3. Tumor dimensions
4. Distance from various marg...
5. Lymphovascular invasion
6. Bone / Cartilage / Skin / Soft tissue involvement
7. Margins of excision, submucosal spread,...
 Unresectable Disease
Primary disease
 Adequate surgical clearance is not achievable
 Extensive Infra Temporal Fossa in...
 Better functional and cosmetic outcome
 Elective irradiation of the lymph nodes can be included with
little added morbi...
 Accessible lesions
 Small (preferably < 3cm ) tumors
 Well defined borders
 Lesion away from bone
 Superficial lesio...
Primary:
Advanced primary – T3 or T4
Close or positive margins of excision
Depth of invasion
High grade tumor
LVI & P...
 T1 and T2 lesions
 Ipsilateral field arrangement that includes the
primary lesion and the level I and II lymph
nodes.
...
T3 and T4 lesions
Patients with significant tumor extension
toward the midline are treated with parallel
opposed fields ...
 Doses of 66 Gy in 2-Gy fractions for positive
margins.
 60 Gy in 2-Gy fractions or 59.4 to 63 Gy in 1.8-Gy
fractions to...
 Interstitial implants with iridium wires or seeds
in nylon ribbons can be considered for
treatment of early, small lesio...
The buccal mucosa tolerates high-dose RT
with a low risk of late complications.
Trismus may develop if the muscles of
ma...
Cisplatin
- Used in NACT (T4b and N3 cases)
- Used in CTRT
The FOM is a horseshoe-shaped area that
is confined peripherally by the inner aspect
(lingual surface) of the mandible.
...
 Sublingual gland
and its duct.
 The deep part of
the submandibular
gland and its duct.
 Lingual frenum
 Deep lingual
...
 The inferior surface of the tongue is covered with a thin
transparent mucous membrane through which one can see the
unde...
 Superior and
inferior genial
tubercles.
 Mylohyoid line.
 Sublingual fossa.
 Submandibular
fossa.
Description :
The lesion usually presents as a smooth,
movable, solitary , asymptomatic, round,
or as a circumscribed intr...
Description :
Cavernous hemangiomas are composed of large,
irregular, deep dermal and subcutaneous blood-
filled channels ...
Description :
Cystic hygromas are abnormal growths
that usually appear on a baby’s neck or
head. They consist of one or mo...
Description :
A lipoma can usually be diagnosed by its
appearance alone. They present as slow growing
asymptomatic lesions...
Description :
Neurofibroma is an uncommon benign tumor of the oral
cavity derived from the cells that constitute the nerve...
Description :
Pleomorphic adenoma is a benign salivary gland tumor
that exhibits wide cytomorphologic and architectural
di...
Neurilemmoma
Description :
Schwannomas are usually solitary
lesions; however, some are seen as
multiple lesions as part of...
Description :
The clinical course is characterized by an initial period of slow
and indolent growth that is usually asympt...
Description :
ES is a poorly differentiated neuroectodermal tumor with
small, round and blue cells. Swelling, pain, increa...
Description :
Oral melanomas arise silently, with few symptoms until progression has
occurred. Most people do not inspect ...
Description :
The most common presentation of cancer of the floor of the mouth is a
painless inflamed superficial ulcer wi...
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
Carcinoma buccal mucosa
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Carcinoma buccal mucosa

  1. 1. Dr. sumer yadav MCh – plastic surgery
  2. 2. The buccal mucosa includes the mucosal surfaces of the cheek and lips from the line of contact of the opposing lips to the pterygomandibular raphe posteriorly. This extends to the line of attachment of the mucosa of the upper and lower alveolar ridge superiorly and inferiorly.
  3. 3. The muscle of the cheek is the buccinator muscle. The buccal fat pad is superficial to the fascia covering the buccinator muscle and gives the cheeks a rounded contour. Branches of the maxillary and mandibular nerves (cranial nerves V2 and V3) provide sensory innervation to the skin, the cheek, and the mucous membranes lining the cheeks. The facial nerve (cranial nerve VII) provides motor innervation to the muscles of the cheeks and lips.
  4. 4. The lips and cheeks function together as an oral sphincter propelling food into the oral cavity. If the facial nerve is paralyzed, food tends to accumulate within the cheek along the affected side so that saliva and food dribble out of the corner of the mouth.
  5. 5. After carcinoma of the lip, oral tongue, floor of the mouth, and lower gum, carcinoma of the buccal mucosa is the fifth common carcinoma of the oral cavity. It usually occurs in the sixth and seventh decades of life, and is more prevalent in men than in women. Tobacco and betel nut chewing appear to play an important role in the cause of these tumors.[
  6. 6. Carcinomas of the buccal mucosa often occur in association with pre-existing leukoplakia and tend to have multiple primary sites and recurrence. Excision of the oral leukoplakia may reduce the subsequent development of carcinoma. These tumors usually arise in the area adjacent to the lower molars along the occlusal line of the teeth.
  7. 7.  Leukoplakia - A chronic white mucosal macule which cannot be scraped off, cannot be given another specific diagnostic name, and does not disappear with removal of potential etiologic factors (excepting tobacco).  4-18% progress to invasive carcinoma
  8. 8.  Erythroplakia is the clinical diagnostic term - A chronic red mucosal macule which cannot be given another specific diagnostic name and cannot be attributed to traumatic, vascular or inflammatory causes, i.e. it is a diagnosis of exclusion.  Higher risk of cancer development (~ 30%)
  9. 9. 4.5 – 7.5 % progress to oral cancer
  10. 10.  Clinically, there are three distinct types: exophytic, ulcerative, and verrucous.  The patient may present with pain or bleeding, trismus, or cervical lymphadenopathy.  Posterior extension may result in involvement of the lingual or dental nerves, which may cause ear pain.  Extension behind the pterygomandibular raphe into the pterygoid muscles or into the buccinator and masseter muscles may cause trismus.  In advanced stages, the tumor may destroy the entire cheek and invade the adjacent bones and the neck. Infection is common and mastication becomes difficult. Death usually occurs as a result of poor nutrition and general debilitation
  11. 11. Symptoms Signs Associates Ulcer Ulceration/growth Leukoplakia Burning sensation Induration SMF Mild irritation Ankyloglosia eythroplakia Pain Bleeding ulcer Earache Trismus Bleeding Parotid enlargement
  12. 12. Infiltrating lesions of the buccal mucosa can invade the buccinator muscle, extend to the buccal fat pad, and invade the subcutaneous tissue. Carcinomas of the buccal mucosa frequently spread by direct invasion into the gingivobuccal sulcus, the upper and lower alveolar ridges, the hard palate, the maxilla, and the mandible.
  13. 13.  Lymph node metastasis occurs in approximately 9% to 31% of the patients during the course of the disease.  The submandibular lymph nodes are most frequently involved; involvement of the upper cervical and the parotid lymph nodes is less common. The risk of subclinical disease is 16%.  Distant metastases are rare, as patients often die of uncontrolled local disease before distant metastases are manifested clinically.
  14. 14.  >90 % Squamous cell carcinomas  Spectrum of diseases from benign lesions like leukoplakia, lichen planus, SMF to verrucous carcinoma to well differentiated squamous carcinoma  Malignant Minor salivary gland tumors such as Adenoid cystic, Adenocarcinoma, Mucoepidermiod carcinoma (< 10%) are uncommon  Malignant Melanoma, Lymphoma, sarcoma occur rarely.
  15. 15.  History & Clinical examination , including head & neck examination  Clinical staging  Assessment of performance & nutritional status  Investigations for histological diagnosis – Punch Biopsy
  16. 16. Investigations to determine the extent of the disease OPG/ Dental occlusal view CT Scan / MRI for extent of disease USG for N0 neck in select cases
  17. 17. Routine Investigations CXR Routine blood counts Blood chemistry profile Urinalysis
  18. 18. Stage Grouping Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 N1 M0 T3 N0, N1 M0 Stage IV A T1, T2, T3 N2 M0 T4a N0, N1, N2 M0 Stage IV B Any T N3 M0 T4b Any N M0 Stage IV C Any T Any N M1 sumeryadav2004@gmail.com
  19. 19.  Stage I – IV A : Curative  Stage IV B-C : Palliative The aim of treatment:  Cure  Loco regional control  Preservation of anatomy & function  Reasonable cosmesis  Quality of life
  20. 20. Tumor factors  Primary site  Size  Proximity to bone  Status of cervical nodes  Tumor pathology ( histological type, grade, & depth of invasion) Patient factors  Age  General medical conditions  Tolerance of treatment  Acceptance of expected sequelae of therapy  Socioeconomic considerations
  21. 21.  Primary  Surgery : wide excision +/- marginal mandibulectomy  Radiotherapy : Radical external RT/ Brachytherapy  Nodes  N0 : Observe or SOHD ( if cheek flap raised , USG suspicious, thick tumor or poor follow up expected) followed by Frozen section, if positive nodes, MND is required.  N+ : MND/RND  Post op RT as per guidelines
  22. 22. Surgery + Post op RT or CT-RT Primary Surgery : Composite resection of the buccal mucosa with mandible or upper alveolus or overlying skin with reconstruction Nodes N0 : SOHD followed by FS, if positive nodes, MND required. N+ : MND/ RND
  23. 23. Management is controversial Perceived risk that the tumor may become more aggressive if it recurs after RT. Many tumors that recur after treatment are biologically more aggressive. Therefore, it is reasonable to treat these lesions with irradiation if surgery is not feasible. Wang reported a series of patients with verrucous carcinoma treated with RT; the results were comparable to those for patients treated for squamous cell carcinoma.
  24. 24.  Used as single modality in early disease (Stage I & II )  Combined with post operative adjuvant radiotherapy in advanced disease(Stage III & IV)  Wide excision of tumor in all dimensions with adequate margins & appropriate neck dissection essential for locoregional control of disease
  25. 25.  Treatment time is shorter.  The risk of immediate and late radiation sequel are avoided.  Irradiation is reserved for recurrence, which may not be resectable.  Pathological assessment, accurate staging. Disadvantage: functional & cosmetic impairment, increased morbidity when bilateral neck is addressed.
  26. 26.  Modified neck dissection is sufficient treatment for the ipsilateral neck for patients with N1 without PNE.  Radiation therapy is added for  N1 with PNE/LVI  N2,N3 stages, for control of contra lateral subclinical disease  For invasion through the capsule of the node,  For multiple positive nodes
  27. 27.  RND : superficial & deep cervical fascia with its enclosed LN (level I-V) is removed in continuity of SCM, omohyoid muscle, internal & external jugular veins, spinal accessory N & submandibular gland  MND : is finding more acceptance & preference to RND in managing N0 neck because of severe morbidity related to RND such as, shoulder dysfunction, poor cosmesis, facial edema (level I-V LN)  SOHND : least morbid, provides most satisfactory sampling of the LN at the level I, II, III which are greatest risk  Extended SOHND : level I-IV LN dissection
  28. 28.  Marginal mandibulectomy: partial-thickness (marginal) mandibular resection  Segmental Mandibulectomy For small lesions with minimal bone invasion, a short section of mandible is removed in continuity with the tumor (e.g., removal of the mandible from the angle to the mental foramen).  Hemimandibulectomy - Removal of the mandible symphysis to the condyle on one side. - Major cosmetic and functional loss - Reconstruction is performed with a composite osteomyocutaneous flap
  29. 29. MARGINAL MANDIBULECTOMY SEGMENTAL MANDIBULECTOMY
  30. 30. Gross pathology 1. Morphology 2. Location & extent of the tumor / lesion 3. Tumor dimensions 4. Distance from various margins of excision 5. Nodal dissection Microscopy 1. Histologic type 2. Grade 3. Extent of disease including depth of infiltration 4. Perineural invasion
  31. 31. 5. Lymphovascular invasion 6. Bone / Cartilage / Skin / Soft tissue involvement 7. Margins of excision, submucosal spread, In – situ changes 8. Nodal status – no. & size of nodes, perinodal extension & level of nodes 9. Status of cut margins Miscellaneous features 1. In RND/ MND status of internal jugular vein 2. Presence of predisposing factors - leukoplakia, SMF 3. Dysplasia/ in situ elements
  32. 32.  Unresectable Disease Primary disease  Adequate surgical clearance is not achievable  Extensive Infra Temporal Fossa involvement  Extensive involvement of base skull  Extensive soft tissue disease – skin edema / ulceration Nodal disease  Clinically fixed nodes  Infiltration of Internal / Common carotid artery  Extensive infiltration of prevertebral muscles
  33. 33.  Better functional and cosmetic outcome  Elective irradiation of the lymph nodes can be included with little added morbidity, whereas the surgeon must either observe the neck or proceed with an elective neck dissection (sometimes bilateral depending on the primary site),  The surgical salvage of irradiation failure is probably more likely than the salvage of a surgical failure.  The risk of postoperative complications is avoided
  34. 34.  Accessible lesions  Small (preferably < 3cm ) tumors  Well defined borders  Lesion away from bone  Superficial lesions  Tumors of the anterior two thirds of the buccal mucosa without involvement of gingiva are ideally suited for brachytherapy alone.
  35. 35. Primary: Advanced primary – T3 or T4 Close or positive margins of excision Depth of invasion High grade tumor LVI & PNI Nodes: Bulky nodal disease N2/N3 Extra nodal extension Multiple level involvement
  36. 36.  T1 and T2 lesions  Ipsilateral field arrangement that includes the primary lesion and the level I and II lymph nodes.  The anterior and superior borders of the field should be at least 2 cm from the borders of the primary tumor. The posterior border should be at the posterior aspect of the spinous processes if the nodes are to be irradiated.  Inferior border is at the thyroid notch.
  37. 37. T3 and T4 lesions Patients with significant tumor extension toward the midline are treated with parallel opposed fields weighted 3 : 2 toward the side of the lesion. The low neck is treated with an anterior field with a 6-MV x-ray beam to 50 Gy in 25 fractions once daily
  38. 38.  Doses of 66 Gy in 2-Gy fractions for positive margins.  60 Gy in 2-Gy fractions or 59.4 to 63 Gy in 1.8-Gy fractions to high-risk regions.  54 Gy in 1.8-Gy fractions for low-risk regions.  An LAN is often used, treated to either 50 Gy in 2- Gy fractions or 50.4 Gy in 1.8-Gy fractions.
  39. 39.  Interstitial implants with iridium wires or seeds in nylon ribbons can be considered for treatment of early, small lesions that have not invaded the buccogingival sulcus, the gingiva, or bone.  Usually a minimum tumor dose of 60 to 70 Gy in 5 to 8 days is delivered through a single-plane or double-plane implant on the thickness of the lesion.
  40. 40. The buccal mucosa tolerates high-dose RT with a low risk of late complications. Trismus may develop if the muscles of mastication receive high doses of irradiation.
  41. 41. Cisplatin - Used in NACT (T4b and N3 cases) - Used in CTRT
  42. 42. The FOM is a horseshoe-shaped area that is confined peripherally by the inner aspect (lingual surface) of the mandible.   sublingual/ranine veins are visible. The frenulum is a mucosal fold that extends along the midline between the openings of the submandibular ducts .
  43. 43.  Sublingual gland and its duct.  The deep part of the submandibular gland and its duct.  Lingual frenum  Deep lingual artery and veins.  Lingual nerve.
  44. 44.  The inferior surface of the tongue is covered with a thin transparent mucous membrane through which one can see the underlying veins  A sublingual caruncle (papilla) - opening of the submandibular duct 1- frenulum, 2- lingual vein, dashed-circle- sublingual gland. Arrow- Wharton's duct opening,
  45. 45.  Superior and inferior genial tubercles.  Mylohyoid line.  Sublingual fossa.  Submandibular fossa.
  46. 46. Description : The lesion usually presents as a smooth, movable, solitary , asymptomatic, round, or as a circumscribed intramuscular mass. DD: granular cell tumor(S-100 positivity ) - salivary gland tumors, namely, acinic cell carcinoma or oncocytoma- rhabdomyosarcoma. Treatment: The treatment of choice for rhabdomyoma is surgical excision.
  47. 47. Description : Cavernous hemangiomas are composed of large, irregular, deep dermal and subcutaneous blood- filled channels that impart a purplish discoloration to the overlying skin. readily blanch with compression, giving them a characteristic "bag of worms" feel. The lesion may expand and darken with crying, when agitated, or when placed in a dependent position. Occlusal Radiographs – Computed Tomography. Etiology : The causes of vasoformative tumors are unknown. One hypothesis postulates that placental cells, such as the trophoblast, may be the cell of origin for hemangiomas. DD:The diagnosis of hemangiomas is straightforward from the history and the clinical examination, and the differential diagnosis is limited. For intraosseous lesions, the differential diagnosis can be more challenging, with the radiographic appearance being similar to that of a giant cell lesion or an ameloblastoma. Treatment: Treatment COMPLETE SURGICAL EXCISON OF THE LESION
  48. 48. Description : Cystic hygromas are abnormal growths that usually appear on a baby’s neck or head. They consist of one or more cysts and tend to grow larger over time. The main symptom of a cystic hygroma is the presence of a soft, spongy lump. This lump most commonly appears on the neck. Radiography : CT Scan DD: Branchial cleft cyst -Thyroglossal duct cyst - Ranula -Goiter -Soft tissue tumors -Neck abscess Treatment: The first step of treatment is surgery.
  49. 49. Description : A lipoma can usually be diagnosed by its appearance alone. They present as slow growing asymptomatic lesions with yellowish color and soft, doughy feel, generally with no gender predilection. X-Ray: No X-ray Picture DD: Other connective tissue lesions such as granular cell tumor, neurofibroma, traumatic fibroma, and salivary gland lesions (mucocele and mixed tumor).- Normal Fat – Well- differentiated Liposarcoma Treatment: Lipomas usually are not treated, because most of them don't hurt or cause problems. It might remove the lipoma if it is painful, gets infected, or bothers the patient.
  50. 50. Description : Neurofibroma is an uncommon benign tumor of the oral cavity derived from the cells that constitute the nerve sheath. Neurofibroma is seen either as a solitary lesion or as part of the generalized syndrome of neurofibromatosis (usually neurofibromatosis type 1 [NF-1], also called von Recklinghausen disease of the skin). Patients usually present with an uninflamed, slowly enlarging, asymptomatic lesion that varies greatly in size from tiny nodules to large pendulous masses. Oral neurofibromas usually present as submucosal, nontender, discrete masses that range in size from a few millimeters to several centimeters. The lesions are typically pedunculated or sessile, usually painless, but occasionally pain or paresthesia is reported due to nerve compression. DD: Granular cell tumor -Fibroma -Scar tissue - Neurilemmoma (schwannoma) -Leiomyoma –Rhabdomyoma. Treatment: Solitary oral neurofibromas are usually treated by surgical excision, depending on the extent and the site.
  51. 51. Description : Pleomorphic adenoma is a benign salivary gland tumor that exhibits wide cytomorphologic and architectural diversity. Pleomorphic adenoma usually presents as a slow-growing, painless mass, which may be present for many years. On gross examination, a pleomorphic adenoma is a single firm, mobile, well-circumscribed mass. Its color may vary from whitish-tan to gray to bluish, and its size may range from a few millimeters to quite large or even giant. Pleomorphic adenomas are irregularly shaped and have a bosselated surface. Computed-tomography (CT) images showed a distinct radiolucent, homogeneous lesion extending anteriorly in the area where the left sublingual gland (sublingual sulcus) normally lies DD: other salivary gland tumors of submandibular/minor salivary glands.- lymphomas, non-neoplastic entities of salivary glands such as ranulas, retention cysts, sialolithiasis, sialadenitis, and cystic lesions of the floor of the mouth such as dermoid cysts. Treatment: Early total surgical resection of the sublingual gland and its neoplastic mass in normal margins for benign tumors is the treatment of choice to avoid recurrences.
  52. 52. Neurilemmoma Description : Schwannomas are usually solitary lesions; however, some are seen as multiple lesions as part of Neurofibromatosis type I. The solitary neurilemoma is a slow growing, encapsulated tumor that typically arises in association with a nerve trunk. As it grows it pushes the nerve aside. Usually the mass is asymptomatic, although tenderness or pain may occur in some instances. DD: Lipoma – Fibroma –Neurofibroma - Rhabdomyoma - Leiomyoma
  53. 53. Description : The clinical course is characterized by an initial period of slow and indolent growth that is usually asymptomatic. In most cases the tumor goes unnoticed until it has invaded local nerves and structures causing varying symptoms depending on location. Thus, most patients will present with locally invasive disease. The tumor is typically a firm, poorly circumscribed, and unencapsulated mass. Tumor size typically averages from 1 to 8 cm in maximum dimension. Tumor size greater than 3 cm has been associated with increased rates of distant metastasis. The cut surface is white to gray-white with a solid appearance. Hemorrhage and necrosis are rare features and should raise the suspicion of high-grade transformation into dedifferentiated ACC. Computed Tomography DD: benign mixed tumor, mucoepidermoid carcinoma and polymorphous low-grade adenocarcinoma (PLGA). Treatment: Surgery
  54. 54. Description : ES is a poorly differentiated neuroectodermal tumor with small, round and blue cells. Swelling, pain, increased CRP, leukocytosis, and elevated temperature may be the first signs of oral ES, occurring also in odontogenic infections . Also there is apical osteolysis, loss of sensibility and loosening of teeth. Axial MRI scan revealing a bone destroying mass of approximately 7 × 8 × 6 cm 3 surrounding the mandible and massively infiltrating the soft tissue of the floor of the mouth and the tongue. Etiology :More than 90% of cases show a characteristic translocation t(11;22)(q24;q12) resulting in the fusion of the EWS and FLI-1 genes. This gene rearrangement causes a fusion product which functions as an oncogenic aberrant transcription factor with structural variability and potentially prognostic impact . Immunoreactivity against FLI-1 and CD 99 can help to confirm the diagnosis Treatment: Treatment of ES should include wide surgical resection and (neo-)adjuvant chemotherapy .
  55. 55. Description : Oral melanomas arise silently, with few symptoms until progression has occurred. Most people do not inspect their oral cavity closely, and melanomas are allowed to progress until significant swelling, tooth mobility, or bleeding causes them to seek care. Pigmented lesions 1.0 mm to 1.0 cm or larger are found. On physical examination, the pigmentation of these lesions varies from dark brown to blue-black ; however, mucosa-colored and white lesions are occasionally noted, and erythema is observed when the lesions are inflamed. Etiology : The cause of oral melanoma or melanoma of any mucosal surface remains unknown. In contrast, cutaneous lesions are linked directly to fair-skinned and blue-eyed persons with a history of blistering sunburns, and the incidence has increased dramatically (approximately 4-6% per year) over the same period. However, mucosal exposure to sunlight is unlikely, and, therefore, cutaneous melanoma and mucosal melanoma are different diseases. DD : Haemangioma -Melanotic macule-Oral mucosal nevi- Amalgam tattoo-Kaposi Sarcoma
  56. 56. Description : The most common presentation of cancer of the floor of the mouth is a painless inflamed superficial ulcer with poorly defined margins. Preexistent or coincident leukoplakia can be observed in adjacent tissues in approximately 20% of cases. The presence of erythroplasia strongly suggests an invasive tumor. A small ulceration or nodular lesion may remain asymptomatic for long periods, so the patient may not seek medical attention. Vague symptoms of soreness in the regional mucosa could be attributed to an aphthous ulcer. In fewer than 50% of cases, the ulcer is localized only to the floor of the mouth on initial presentation. Etiology : Tobacco and alcohol have additive effects on oral cancer. Tobacco includes smokeless tobacco derivatives, such as snuff and betel nut. Some people seem to be more vulnerable than others to the effect of these irritants. The nature of the increased vulnerability may be genetic, familial, or acquired (eg, immunosuppression, syphilis, Plummer-Vinson syndrome, chronic candidiasis). These risk factors and the underlying pathogenesis do not disappear following surgical excision or radiation therapy for the cancer. The organs remain susceptible. DD: Lymphoma – Adenoid cystic carcinoma – Adenocarcinoma – Mucoepidermoid Carcinoma – Liposarcoma –Rabdomyosarcoma – Ranula - Infected Teeth – Radionecrosis of mandibular soft tissues. Treatment : Various therapeutic measures are available for managing localized carcinomas of the oral cavity, including surgical excision, radiation therapy, electrodesiccation, cryotherapy, laser-beam excision, chemotherapy, and a combination of these methods.
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Carcinoma buccal mucosa

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