Carcinoma of the mouth and lips [s8]common in India

Carcinoma of the mouth is one of the commonest malignant tumours in India. It is a disease of the poor, of both sexes, and may be due to: (1) Chewing ''pan' (betel leaf) with tobacco and slaked lime, and keeping the chewed ''cud' in the mouth. (2) Reverse or ''chutta' smoking. (3) Smoking cheap ''bidis' (rolled tobacco leaves). And, (4) poor oral hygiene. Pan masala (spiced betel nut) is the latest fad in India, and is likely to add to the incidence of cancer of the mouth. This is an entirely self- inflicted disease, and is potentially completely preventable by health education.

The patient, who is usually elderly, presents with: (1) A painless mass. (2) An area of thickening or induration, (3) an ulcer. (4) A sore throat or dysphagia (late). And, (5) inability to open his mouth (trismus). Because the disease is painless, poor patients are usually unaware of the danger and present late. Yet the mouth is easily accessible, and if only health workers, especially junior ones, would examine the mouths of their patients more often, this carcinoma would be diagnosed earlier.

Carcinoma can occur anywhere on a patient's lips, or inside his mouth. It most commonly involves his buccal mucosa, but it may involve any part of his tongue, the floor of his mouth, his alveolus, or his hard palate. It commonly occurs in his gingivobuccal groove[md]where he keeps his ''cud'.

There are several kinds of tumour: (1) Squamous cell carcinomas (95%). A few of these are slow-growing, cauliflower like, ''verrucous carcinomas' with a good prognosis. (2) Adenocarcinomas arising from ectopic salivary glands (5%). (3) Sarcomas (rare). Most tumours spread to the lymph nodes on the same side, and blood-stream spread is rare. His prognosis depends the extent of his local disease, and whether or not he has cervical metastases.

Precancerous lesions occur as: (1) leukoplakia (dyskeratosis), (2) erythroplakia (leukoplakia interspersed with reddish spots), (3) white vascular bands of submucous fibrosis, (4) chronic dental ulcers. Black-pigmented spots are harmless.

Surgery and/or radiotherapy gives excellent results, in early cases. In late ones radiotherapy reduces bleeding, discharge, and smell, and is useful palliation. If the buccal mucosa is involved, radiation is enough; but if bone is involved, resection is also necessary. Resection of the jaw is not described here, but if carcinoma of the mouth is common in your area it is well worth learning and is not too difficult.

Fig. 32-9 MALIGNANT TUMOURS OF THE MOUTH. A, a carcinoma of the labio-gingival sulcus. B, an early carcinoma of the lip. C, a mixed tumour of the palate. D, carcinoma of the side of the tongue. E, a carcinoma of the palate starting to ulcerate. F, leucoplakia of the tongue; this is a precancerous condition. B, to F, adapted from drawings by Frank Netter, with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).

CARCINOMA OF THE MOUTH [s7]AND LIPS EXAMINATION. Encourage your junior health workers to examine their patients' mouths. Any ulcer or lump in the mouth, which does not respond to treatment in 2 weeks, should be suspected of being carcinomatous, and biopsied. Feel for enlarged nodes in the patient's neck.

SPECIAL TESTS. Confirm the diagnosis with a punch or incision biopsy. X-ray his mandible, or maxilla, to detect local infiltration. X-ray his chest.

STAGING. This is the UICC method. T[,1] nodes [lt]2 cm. T[,2] nodes 2 to 4 cm. T[,3] nodes [mt]4 cm. T[,4] infiltration of skin, muscle and bone. N[,0] no nodes felt. N[,1] mobile ipsilateral nodes. N[,2] bilateral nodes. N[,3] fixed nodes. M[,0] no systemic metastases. M[,1] systemic metastases.

Stage One T[,1] N[,0] M[,0] Curable

Stage Two T[,2] N[,0] M[,0] Curable

Stage Three T[,3] N[,0] M[,0], or T[,1],,, T[,2] or T[,3],,, N[,1] M[,0] Curable

Stage Four T[,4] N[,0] M [,0] occasionally curable. All further lesions are incurable.

MANAGEMENT. You can only treat these patients in the earliest stages.

If he has a lesion of less than 1 cm on his lips or tongue, excise it with a margin of at least 1 cm. Refer all other patients for chemotherapy, followed by radiotherapy and/or surgery. If no radiotherapy is available, and he has a carcinoma of his tongue, refer him for a partial glossectomy, perhaps with chemotherapy. Verrucous carcinoma is best treated by surgery only, because radiotherapy causes it to become a rapidly growing anaplastic lesion.

If he has cancer of his mouth, and you can feel nodes in his neck when he presents, he is probably incurable.

If, (1) his primary is potentially curable by radiotherapy (first choice) or surgery, and (2) his nodes are mobile, and (3) he has no distant metastases, skilled surgery has about a 25% chance of cure.

If nodes appear months or years after the primary has been treated, [f10]and are still mobile, radical dissection has a 30[nd]50% chance of cure.

Node biopsy probably has no place. His nodes may be enlarged by infection. If in doubt, try antibiotics for a few days, and see if they become smaller.

CHEMOTHERAPY is not curative, but there is a 20% response rate to twice weekly intravenous methotrexate at 40 mg/m['2], with little further benefit from multidose regimes, or more expensive drugs.

Fig. 32-10 SALIVARY GLAND TUMOURS. A, an inoperable adenoid cystic carcinoma of the left parotid, with extensive ulceration and secondaries in the patient's cervical lymph nodes. B, a large pleomorphic adenoma, which has grown slowly over 20 years. After Adekeye and Robertson, with the kind permission of the editor of Tropical Doctor.