ORAL CANCER: THE PROBLEM OF EARLY DIAGNOSIS

this 48 year old man has had a growth in his mouth for the past four months this lesion is conspicuously located on the dorsum of the tongue it is a grayish white slightly raised papillary tumor measuring one and a half by one sada meters it is painless and has not interfered with the patient's following or speech upon palpation the lesion is found to be indurated with a slight degree of fixation to the underlying tissues there is no palpable evidence of lymph node involvement this examination performed during a routine dental check-up aroused a suspicion of cancer later confirmed by pathological examination however because this growth was found in a relatively early and localized condition the patient's chances for cure are excellent if this man had not presented himself for a routine dental examination and if his dentist had not recognized the possible malignant nature of this lesion this patient like most others with mouth cancer might have continued to neglect or ignore his disease until it had progressed beyond any hope of cure the recognition of mouth cancer is a responsibility shared by the dental and medical professions in this motion picture six common sites of oral cancer will be discussed the gingiva or gum palate tongue cheek floor of the mouth and lip all of these sites are readily accessible to inspection palpation and biopsy and therefore susceptible of early diagnosis and treatment despite this ready accessibility they breakdown of the oral cancer problem reveals that the majority of these lesions are not recognised at a time when satisfactory treatment can be accomplished in one series studied the five-year cure rates for all patients both early and advanced were gingiva thirty-two percent tongue thirty percent floor of the mouth nineteen palate thirty percent cheek or buccal mucosa 24 and the lip sixty-seven percent taking the picture as a whole the overall five-year cure rate for these anatomic sites was 32 and a half percent roughly one-third the fact that this end result can be greatly improved through the earlier recognition of oral cancer is illustrated by selecting small lesions from the above cases the five-year cure rates for patients from the same series with lesions less than two centimeters in size were gingiva thirty-eight percent tongue 55 floor of the mouth fifty palate 57 cheek 60 and the lip 86 in this series a composite picture for patients with lesions less than two santa meters in size shows an average five-year curate of fifty-seven percent or nearly double the cure rate of oral lesions regardless of size by comparing these two groups it is evident that only by the recognition of mouth cancer in an earlier stage can ultimate improvement in the control of this disease be achieved who is responsible for this earlier recognition as illustrated in this typical case most patients ignore or neglect early oral cancer because it suggests a benign transitory condition which they have safely ignored before many malignant oral lesions can be differentiated from benign conditions only as the result of a thorough clinical and pathological examination whether performed by the dentist or by the physician the technique of an oral examination should be uniform and its purpose identical to detect any abnormality in and about the mouth which may possibly be neoplastic the examination should be preceded by careful and detailed case history however the examiner should bear in mind that a history of no complaint may be misleading and does not do away with the necessity of performing a thorough examination the patient must be seated upright in a good light with adequate exposure of the anatomy in carrying out this examination as a routine office procedure the instruments required are familiar to both the physician and the dentist these are tongue blades or tongue depressors rubber gloves or finger cots and oral mirrors of various sizes with this simple equipment an adequate examination of the oral cavity can be accomplished by a combination of observation inspection and palpation the anatomy of the normal head neck and mouth is symmetrical and the examiner should be alert for any significant or symmetry the lips are inspected first the normal lips in repose or symmetric on the mucosa is soft vermilion in color and clear any deviation from this picture should arouse suspicion of underlying disease there follows a progressive examination with in the mouth itself if dentures are present they should be removed the tongue is protruded and carefully inspected for color texture and symmetry it should be observed for any sign of discomfort or limitation of motion adequate inspection of the tongue requires that it be grasped with gauze and pulled forward to expose its lateral borders with a tongue blade retracting the cheek the lateral borders adjacent to the molar teeth are the most common sites of cancer of this organ the base of the tongue is examined later by mirror and palpating finger one of the most neglected steps in cancer detection and its importance cannot be overemphasized here again an orderly procedure will include all areas of the mouth and will provide the examiner with a maximum opportunity to detect any area of swelling roughness in duration or our symmetry the cardinal signs of suspicion when feeling for cancer moreover palpation will often elicit bleeding in the presence of cancer and this should be watched for an important but frequently neglected step of this examination is inspection of the nasopharynx this can be accomplished readily by depressing the tongue and passing a small mirror gently behind the uvula with adequate care a gag reflex can usually be prevented or the palate may be sprayed with a topical anesthetic the patient is directed to breathe through both mouth and nose this maneuver relaxes the soft palate exposing the nasopharynx to good visualization another frequently overlooked sight of accessible cancer is the base of the tongue and the larynx the early detection of disease in this area is made possible by mirror examination this simple office examination is the only means by which either physician or dentist can inspect the base of the tongue the epiglottis the vocal cords the lateral pharynx and the hypopharynx by warming the mirror fogging is prevented and good visualization is sustained and now deferred until last for the patient's comfort is deep palpation of the mouth this includes the soft palate tonsils tonsillar pillars pharyngeal walls and base of the tongue although inspection and palpation of the oral cavity and it's contiguous structures may revealed no evidence of disease examination of the patient is not complete without reference to the neck for a frequent first sign in oral cancer is a lump in the neck which is in most cases cancer metastatic to a lymph node anatomically there are five major secret re glands in the neck the paired parotid zeeeee the paired submaxillary s and the thyroid gland although these true glands maybe the sites of primary cancer the usual lump in the neck of neoplastic character is due to involvement of the lymph nodes of the neck from a primary focus within the mouth or pharynx for this reason the examiner should be familiar with the principally symmetrical it can conveniently be demonstrated on one side of the neck the principal lymph nodes which the examiner should bear in mind are the submental group which drains the superficial tissues of the lower depth and anterior gingiva least frequently involved by metastatic cancer the submaxillary group which drains the superficial tissues of the cheek buccal mucosa and gums the pre ocular and parotid groups which drain superficial soft parts of the lateral scalp and face the lateral canthus of the eye and the conjunctiva it is noteworthy that cancer of the upper lip frequently metastasizes first to the pre auricular lymph nodes the most common sight of metastasis is to the sub de gas trick node sometimes referred to as the tonsillar nodes actually these are the masternodes because they receive drainage from the entire oral cavity including the lateral pharynx tonsil piriform sinus and larynx this is the most superior group of the internal jugular chain the internal jugular chain lies directly beneath the sternomastoid following the course of the internal jugular vein this group drains all of the deeper structures of the neck including the larynx thyroid gland cervical esophagus and all other nodes previously described the most inferior group of the jugular chain is associated with the thoracic duct on the left and with the lymphatic duct on the right these nodes receive drainage from above and below the clavicle and they lie between the sternal and clavicular heads of each sternomastoid finally there is the posterior cervical or spinal accessory chain this receives drainage mainly from the nasopharynx scout posterior neck and skin as well as overflow from the jugular chain although it may not be necessary for the examiner to memorize the details of the lymphatics of the neck his examination should be sufficiently methodical and broad to include all of these important groups thus by following such a pattern he palpate the submental the submaxillary the parotid and priya rick ulor the superior jugular chain along the course of the sternomastoid including the sub thai gastric nodes above down to the inferior group of the jugular chain best felt by too deeply placed fingers and finally the posterior cervical or spinal accessory chain the examination is repeated on the opposite side of the neck following the same methodical pattern only by adhering to such a routine can the examiner be sure he has felt into the Julie all of the important node bearing areas the normal node is a flattened ovoid somewhat being shaped the abnormal node is globular or spherical normal nodes can be palpated in thin individuals and children by comparing the two sides of the neck simultaneously any enlargement of the nodes on one side can be more readily detected and this enlargement is usually important as a final contribution to the earlier detection of cancer of the mouth and neck the thyroid gland is palpated by displacing it to one side and the other as the patient swallows and now after a 10 minute examination this man can be ruled free from any clinical evidence of oral cancer in this motion picture 6 anatomic sites of oral cancer have been discussed the importance of earlier recognition of this disease has been emphasized and the technique required for this recognition has been Illustrated although cancer of any of these sites can be finally proved only by histologic examination the clinical recognition of early cancer of these sites can usually be made by the gross appearance of the lesion together with its history of onset and particularly its persistence as evident in the selected early cases which follow case number one cancer of the gingiva one month ago this man complained to his dentist that food persistently stuck in his left lower molar teeth a routine occlusal film taken by the dentist revealed an impacted third molar tooth before attempting an extraction diagnosis of syphilis case number seven the lump in the neck a first sign of mouth or pharynx cancer this 54 year old man relates a fairly common and unfortunate series of events three months ago he noted a painless wrestled change overlying the left posterior gum and ascending ramus because of the granular appearance of this lesion its lack of pain and most particularly its in duration the dentist suspected cancer and referred the patient to a surgeon subsequent biopsy proved this to be an epidermoid carcinoma of the gingiva case number 2 cancer of the palate this 57 year old physician has noticed a soft painless submucosal swelling in his hard palate for the past six months which he had ascribed to infection of a minor salivary gland two weeks ago this lesion underwent a degenerative change and appeared as a shallow punched out ulcer with a necrotic base this officer is painless however it failed to respond to any form of local treatment and aroused in the patient himself a suspicion of possible cancer clinical examination have revealed the ulcer base to be firmly fixed to underlying tissue and to have a rolled nodular border this lesion was subsequently identified histologically as an adenocarcinoma of minor salivary gland origin as the patient had suspected case number 3 cancer of the cheek this 57 year old shopkeeper has had leukoplakia of both cheeks for many years he is a moderately heavy smoker the Mazzini is negative and he gives no history of injury to the areas in question in the right cheek there is a zone of diffuse leukoplakia during the past several years this has shown no tendency to undergo any suspicious change and is characteristically soft and superficial to inspection and palpation clinically this may be described as uncomplicated leukoplakia however on the opposite cheek a different clinical picture is found here is a papillary tumour call a flower like in appearance which arises in an area of leukoplakia this lesion occupies an area in the posterior gingival buckle fold and measures approximately 2 x 1 Santa meters it is typically fish ered and bleeds on slight trauma it is mobile over the underlying ascending ramus the clinical picture suggests cancer a suspicion later confirmed by biopsy case number 4 cancer of the tib the patient smokes a pack of cigarettes daily one year ago an area of leukoplakia was excised from the dorsum of the tongue three months ago his dentist noticed a granular change in the mucosa of the central third of the tongue this was painless and did not interfere with speech or deglutition the lesion is irregular and measures about two and a half centimeters in length and one centimeter in width although most lingual cancers occur on a lateral border this lesion was suspected of being malignant on the basis of its onset and duration as well as its firm consistence and fixation noted on palpation the diagnosis was later confirmed by histologic examination case number 5 cancer of the lip this 48 year old elevator operator has noticed a sore on his lower lip for the past two months there is no history of trauma tuberculosis or syphilis the patient has smoked a pipe for many years habitually gripping the stem on the right side of his mouth examination now reveals an area of diffuse leukoplakia inversion which has failed to heal for one month in addition to a suspicious onset and duration this lesion is located on a lateral border of the lower lip a characteristic site for cancers of the lip gentle palpation reveals in duration as well as fixation to the underlying tissues although subsequent biopsy confirmed the diagnosis of cancer this patient did not present any clinical signs of metastasis which in this case are muy carcinoma he was discharged without further study and referred to a cancer clinic as we see him now for the first time the only external finding is residual in duration in the left upper jugular chain at the site of the recent surgical incision in this case there are no symptoms pointing to an internal tumor but with this setting there must be a primary cancer probably on the left side of the mouth or pharynx and the lesion can be quite small here the primary tumor is readily discovered in the left soft palate this is epidermoid carcinoma proven by biopsy discrete granular starting to ulcerate but still painless a perfectly obvious lesion unknown to the patient and not sought for by physician or surgeon this is the primary cancer which should have been found which should have been biopsied and which must be controlled if this patient is to survive removal of the next node contributed little to the diagnosis here and in fact measurably interfered with proper treatment by delay and by scarring of a surgical field where radical dissection might be contemplated when faced with the problem of an unknown mass in the neck we're obviously poma cyst or thyroid adenoma can be excluded open biopsy is a measure of last resort in a series of diagnostic maneuvers which start with a thorough examination of the mouth tonsils base of the tongue larynx such as this tumor on the lateral under surface of the tongue is most conveniently biopsied by and resembles a syphilitic shanker and the Wasserman is positive but no time was lost on dark field studies in the presence of possible cancer there is no substitute for immediate biopsy in this respect it should be remembered that cancer of the tongue is 400 times more common than syphilis in the town and 200 times more common than tuberculosis of this organ in ten to fifteen percent of the cases of tongue cancer there is coexisting syphilis to their complaint this examination must include careful inspection and thorough palpation not only of the oral cavity and pharynx but also of the true glands as well as the lymph nodes of the neck plenty of color texture or symmetry at this time inspection is extended to the posterior pharyngeal wall and the tonsillar areas the same careful scrutiny is now directed to the cheek including the entire buccal mucosa the gingival buckle gutters and the gums there is no substitute for the methodical and painstaking inspection of these tissues early cancer is most commonly seen as a small ulcer with local induration less often as an area of thickening or roughening or as a patch of leukoplakia with or without any obvious ulceration in brief symptoms both subjective and objective may be so slight that the patient may disregard them or be completely unaware of any abnormality for the same reason such early mouth only by these simple methods repeated periodically can the patient with cancer be afforded prompt diagnosis and effective treatment and the patient without cancer be afforded peace of mind