Oral Cancer and Complications of Cancer Therapies _ _____________________________________________
here. When radiotherapy or chemotherapy causes ulcerations anywhere in the oral mucosa, it is because the mitotic sequence of the basal cells has been interrupted. A small membrane beneath the basal cells, called the basement membrane, is what malignant cells perforate to invade the underlying tissue and begin the growth of a malignant lesion [12]. Premalignant Lesions The earliest deviation from normal cellular arrangement is dysplasia. Dysplasia is characterized by atypical cellular forma- tion and arrangement without any malignant transformation. Dysplastic cells can progress to carcinoma in situ, in which actual malignant transformation has occurred to one layer of cells. At this point, there is no invasion into the underlying tissue. The potential for continued growth and metastasis continues to be very high [13]. Both dysplasia and carcinoma in situ can only be diagnosed by histologic analysis. Lesions of varying sizes, shapes, colors, and surface textures cannot be discerned by visual means to possess any of these cellular alterations. Patients with premalignant lesions do not experi- ence symptoms that would prompt them to seek medical or dental care. There is no universal appearance of malignant lesions. It is recommended that an oral lesion of unknown origin that does not heal within two weeks should be submitted for an expedited referral [2]. Patients should be advised that lesions that appear harmless may be malignant, while those that appear aggressive may be benign. Whether benign or malignant, oral lesions span a remarkable array of clinical presentations.
inflammation or hypertrophy. A prominent vascular supply causes erythroplakic lesions to appear red and to bleed eas- ily upon palpation. These lesions occur with less frequency than leukoplakic lesions but have a 91% probability of being dysplastic or malignant [14]. Therefore, it is essential that any erythroplakic lesion is biopsied. Among leukoplakic lesions that have undergone histologic examination, 20% are found to be malignant or premalignant [14]. However, this rate is more than doubled for leukoplakic lesions that are found in the floor of the mouth [14]. Healthcare professionals should perform thorough oral soft tissue exams as these lesions may be difficult to detect and patients are usually asymptomatic. It is also important to remember that lesion color cannot be used as a feature to distinguish a malignant lesion from one that is innocuous.
DIAGNOSTIC PROCEDURES FOR ORAL CANCER
BIOPSIES Ultimately, histologic analysis is the only standard by which an oral lesion can be classified ( Table 2 ) [8]. However, only 25% of intraoral leukoplakic lesions are submitted for histopathic examination via traditional biopsy procedures [15]. Traditional biopsy techniques are either incisional or excisional in nature. Larger lesions that cannot be removed completely usually undergo an incisional biopsy. This procedure features the removal of a small portion of the lesion along with a con- tinuous band of healthy tissue. If a lesion plus some adjacent healthy tissue is small enough to be removed in its entirety, this process is essentially an excisional biopsy. If a general dentist does not provide this service, the patient should be referred to an oral or maxillofacial surgeon or an otolaryngologist. Lesions located on the soft palate or the tonsillar pillar area may be difficult to biopsy due to a strong gag reflex. These patients may need sedation to accomplish the procedure. Correspondence from any specialist to which the patient has been referred should be monitored closely for the diagnosis and the treatment plan. It should not be assumed that the patient will go to the specialist or follow his or her recommen- dations; a follow-up with the patient is necessary. In the event a malignancy is detected, the patient should be made aware of his or her treatment options, and those options should be pursued. Similarly, a patient’s refusal to seek specialty care when it is recommended should be documented in the chart for medicolegal reasons. The patient should clearly be informed that the risks of refusing a biopsy procedure may allow for the formation of a malignant lesion that is capable of metastasizing with possible fatal consequences. Ideally, the patient should sign this informed refusal with at least two staff members witnessing it. Legal counsel may be necessary to prepare the appropriate forms.
The National Guideline Alliance recommends considering an urgent referral (for an appointment within two weeks) for
assessment for possible oral cancer by a dentist in people who have either a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. (https://www.nice.org.uk/guidance/ng12. Last accessed December 20, 2024.) Level of Evidence : Expert Opinion/Consensus Statement Leukoplakic and Erythroplakic Lesions The surface appearance of oral lesions may be flat, raised, smooth, ulcerated, invasive, pedunculated, or velvety, among many other descriptions. Some lesions may share two or more of these characteristics and may occur anywhere in the mouth. Leukoplakic (white) lesions are much more common than their erythroplakic (red) counterparts. Clinically, the latter group of lesions is more difficult to see amidst oral mucous membranes of a similar color, especially in areas of tissue
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