Causes of Buccal Cancer

As with most cancers, doctors can’t tell you with certainty what causes buccal cancer. It’s a combination of genetic predisposition and factors in your environment.

• Tobacco:This is by far the most common factor contributing to buccal cancer. Smoking cigarettes, cigars or pipes and using chewing tobacco greatly increase your chance of getting any oral cancer.
• Alcohol:Drinking excessive amounts of alcohol is also strongly associated with getting oral squamous cell cancers. Moreover, if you both smoke and drink heavily, the risk more than doubles.
• Betel nut: This is the seed of the areca tree. It is often chewed by people from Southeast Asia and is known to cause oral cancer.

Other factors that can increase your chance of getting oral cancer include:

• Marijuana
• Bad dental hygiene
• Viruses
• Food and nutrition
• Genetic factors

Signs and Symptoms of Buccal Cancer

For cancers in the mouth, you, your dentist or your general doctor can see or feel something abnormal in most cases. This is different from cancers in other parts of the head and neck, which can remain hidden for some time.

Symptoms to watch for include:

• Painful sores in the mouth: Most commonly, an oral cancer will start as a painful sore in the mouth. In some cases, a dentist or dental hygienist will see a sore in the mouth that you didn’t even realise was there. In general, a patch or sore in the mouth that doesn’t heal after a few weeks should be evaluated in more detail by a specialist.
• A patch in the mouth: A red patch (erythroplakia) in the mouth that lasts for more than a few weeks is more likely to be cancer than a white patch. However, any lesion that doesn’t go away needs to be biopsied to determine whether it is cancer. The topic of white patches in the mouth (leukoplakia) and dysplasia (abnormal cells that are not cancer) can get complicated, and you should discuss this with a specialist.
• Recurrent bleeding from the mouth: This can happen when the cancer makes a hole in some part of the mouth (this is called an ulcer) or if cancer cells are accidently rubbed off while brushing your teeth or eating certain foods.
• Bad breath: In rare circumstances, when cancer cells start to become necrotic, the dead cells can lead to a bad smell from the mouth. This is called halitosis.

In some cases, a dentist or oral surgeon will see something in the mouth, remove it and a week later get the report that it is a cancer.

• If a lesion was removed and later found to be cancer: In this case, you should still see a specialist in head and neck cancers because it is important to review the pathology in detail to see if any more treatment is needed. Some questions to review are:
  • What type of cancer was it?
  • How big was it?
  • How deeply did it invade?
  • Was it completely removed with a rim of normal tissue around it? (This is known as having “clear margins.”)

In rare cases, the first sign of an oral cancer could be a lump in the neck.

 A lump in the neck: This means that the tumour has spread to the lymph nodes in the neck. This is less common for oral cancers than other types of cancers in the head and neck because the primary cancer is usually the main problem.

A more thorough list of possible symptoms from buccal cancer include:

• Loose teeth or dentures that don’t fit correctly: This happens if the tumour gets into the tooth sockets or the bones in which the teeth are rooted.
• Difficulty opening the mouth: This can happen if the cancer gets into any of the muscles that help to open and close the mouth. This is called trismus.
• Numbness (for example in the lower teeth or lower lip/chin area): This means that the cancer cells have gotten into nerves that allow you to feel. The main nerve responsible for this when dealing with oral cancer runs just inside the lower jawbone, and a branch even runs in the middle of the jawbone and comes out under the skin of your chin.
• Pain or difficulty with swallowing: This can happen when tumours get large and either get in the way of eating or involve the muscles and nerves of swallowing.

But don’t jump to any conclusions. You could have one or more of these symptoms but NOT have an oral cancer. There are several non-cancerous causes of the same symptoms. That’s why you need to see a specialist.

What to Expect at Your Doctor’s Visit?

 Step 1: History

First, your head and neck specialist will take a thorough history of your health and address any specific concerns you may have.

Your doctor might ask questions such as:

• How long has the problem been there?
• Is it getting worse, better or staying the same?
• Does it come and go?
• Have you tried anything to make it better?
• Is it painful?
• Do you have numbness or tingling anywhere in your face or mouth?
• Do you have any lumps or bumps in your neck?
• Are you losing weight?
• Do you have any other medical conditions?
• Have you had any surgeries in the past?
• What medications do you take? And do you have any allergies?
• Have you ever been exposed to radiation in the head and neck?
• What do you (or did you) do for a living?
• Do you have a family history of cancer?

Step 2: Physical Exam

Next, your doctor will examine you. Typically, if you’re seeing a specialist in head and neck disorders, you will get a thorough physical examination focused on the area of concern. Your doctor will see how wide you can open your mouth and then look and feel inside your mouth. The doctor is likely to feel around very thoroughly, especially against the bone. Knowing whether the tumour is fixed to the bone will be an important part of treatment and reconstructive recommendations.

You should also expect the doctor to:

• Feel your neck thoroughly and carefully to check for any lumps or bumps
• Look inside your ears
• Look inside the front of your nose
• Check your cranial nerves by asking you to move your face, stick your tongue out, lift your shoulders, follow his or her fingers around with your eyes, do some simple hearing tests and test your sense of touch all over your face

Your doctor might even put a camera in through your nose to look at the back of your throat and your vocal cords.

Step 3: Reviewing Tests

After getting your history and performing a physical exam, your doctor will review any imaging, laboratory work and pathology results you may have already had. Be sure to bring all of these with you to your appointment. Bring actual discs of any scans you’ve had, as well as any reports of those scans. If you are seeing a head and neck cancer specialist after a lesion was removed by a non-cancer specialist, you need a thorough review of the pathology to discuss whether additional treatment is necessary. Try to obtain the actual glass slides that were prepared by the pathologist with the specimen taken during your biopsy procedure so your doctor can conduct a complete review. You might need more tissue removed or further treatment.

Step 4: Recommendations

Finally, your doctor will make recommendations about your next steps. This will likely include reviewing some of the studies you’ve already had done or ordering more tests. Once your doctor has all the necessary information, you should be given a preliminary stage and discuss treatment plans.

If the tumour is very large and is putting your breathing at risk, your doctor might recommend you undergo a tracheotomy, which is a breathing tube placed into the front part of your neck directly into your windpipe.

Also, if you are having difficulty getting enough nutrition by mouth because of a tumour, your doctor might recommend a feeding tube. This will help ensure that you are able to undergo the treatment that you will need to beat the cancer.

Diagnosing Buccal Cancer

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like most cancers in the head and neck, this will include some combination of biopsy and imaging tests, which is the term that doctors use to refer to X-rays, MRIs, CT scans, etc.

If you came to a specialist after having something small removed from your mouth and found it was cancer only afterwards, your doctor might skip some of the tests and jump to close follow-up or additional treatment. Be sure to bring all the reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumours that are easily evaluated on physical examination (especially those in the front of the mouth), imaging might not be necessary. For larger tumours, or tumours in locations in the mouth that are difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumour location and possible spread to regional lymph nodes. An important reason to get a scan for oral cavity tumours is to see if there is any evidence of spread into the jawbones. Spread into the jawbones will influence what treatment your doctor recommends for you.

For oral cancers, if imaging is required, your doctor will most likely start with a computed tomography (CT) scan with contrast. Other tests might include magnetic resonance imaging (MRI) and/or a positron emission tomography (PET) scan.

Other tests might include jaw X-rays (Panorex), Dentascans or Cone Beam CT scans. These can help determine the extent of tumour invasion into the jawbones from the cancer.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your mouth (or a mass in your neck).

Fortunately, almost all tumours in the mouth can be biopsied in the office with a little numbing medicine (either a spray or a tiny injection or both). Just keep your mouth open and stay still. It will only take a few seconds to do the biopsy. After a piece of the lesion is removed, you will probably apply pressure with a bit of gauze to stop any tiny amount of bleeding that will result from the biopsy. The bleeding usually stops after a few minutes, or your doctor might dab it with a chemical to stop the bleeding.

In some cases, your doctor might take you to the operating room to perform a surgical biopsy.

The most common ways to do a biopsy inside the mouth include:

• Incisional oral biopsy: This is a biopsy in which your doctor will take a piece of the suspicious lesion without removing it all. He or she must be sure to get deep enough to make a good diagnosis.
• Punch biopsy:This is just another way to perform an incisional biopsy. Your doctor will use a tool called a punch forceps, which makes a quick snip to remove a piece of the suspicious area in your mouth.
• Excisional oral biopsy: In this technique, the whole area of concern is removed. Typically, if the diagnosis is unknown, it is better to do an incisional biopsy to find out what the diagnosis is and then determine how much normal tissue needs to be removed around the lesion.
• Brush biopsy: This is often used by dentists, and they basically rub a few cells off the surface of a suspicious lesion. This is not ideal for diagnosing oral cancer because it doesn’t get into deeper layers of tissue. However, it can give some information and lead to a diagnosis of cancer.

The biopsy report is extremely important. Sometimes a doctor or dentist who cares and wants to help you will remove something that looks abnormal and send it off to a pathologist; unfortunately, the pathology report may be missing some important information, such as the grade of tumour, how deep it goes, whether it is endophytic, exophytic or ulcerated and whether there is a rim of normal tissue around the cancer. All these factors need to be evaluated either after a biopsy or after a more definitive removal of the cancer. Ask your doctor about the CAP Protocols, a standard way for pathology doctors to report results of their analysis.

Neck biopsy

If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck:

• Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumour and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. Several “passes” might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

DIFFERENT TYPES OF FINE NEEDLE ASPIRATION BIOPSIES

 Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumour rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.⁷

 Open neck biopsy: An open biopsy involves making an incision over the tumour and removing a piece or all the tumour to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumour is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.

 Sentinel lymph node biopsy (SLNB): A sentinel lymph node biopsy is a new type of lymph node biopsy being used for some cancers of the head and neck. They are mainly used in skin cancers, such as melanomas and Merkel cell cancers, but some doctors are using them in oral cancers as well.

Cancer cells spread from a tumour to regional lymph nodes by traveling through a channel of lymph and making a stop in the first lymph node along the way—the sentinel node. In SNLB, special techniques are used to figure out where that first lymph node is located. Then, that lymph node is removed and analysed. If there is cancer in that lymph node, then the rest of the lymph nodes in the region are removed. If there is no cancer in that lymph node, then your doctor will closely watch the area but save you from undergoing additional treatment that might not be necessary.

For oral cancer, the advantages and disadvantages of SLNB are not very clear and are still being studied.

Determining the Type of Buccal Cancer

Only after a pathologist analyses some cells or actual pieces of tissue from the lesion will your doctor be able to tell you if you have cancer. Your doctor and pathologist should specialise in oral cancers because some benign (non-cancerous) lesions can look like cancer on a small biopsy.

If you do have cancer, it will probably be squamous cell carcinoma.

Squamous cell carcinoma: This is a cancer that starts from abnormal cells on the surface layer of the lips or mouth lining. More than 85 percent of mouth cancers are squamous cell carcinomas.

Other epidermoid cancers (meaning cancers that start from the lining of the mouth) include:

• Carcinoma in situ (also called severe dysplasia):This is really an early stage of squamous cell carcinoma. It is called carcinoma in situ when there are cancerous cells on the tissue lining the oral cavity, but they have not invaded past the outermost layer of tissue. These should be removed completely, before they start invading (penetrating more deeply).
• Verrucous carcinoma: This is a type of squamous cell carcinoma that has a better prognosis because it is less likely to spread. It should be treated as any other squamous cell carcinoma.

But there are other cancers that can start in the mouth, which include:

• Salivary gland cancers:There are minor salivary glands located under the lining of the mouth. Therefore, cancers in this region can be glandular malignancies referred to as adenocarcinomas, including mucoepidermoid carcinomas, and adenoid cystic carcinomas. In rare instances, salivary gland cancers may grow inside the bone itself.
• Lymphoma: The mouth also has lymphoid cells under the surface. Therefore, lymphoma could in rare cases appear as a lump in the mouth.
• Mucosal melanoma: These cancers come from skin cells (melanocytes) that give skin its colour. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat.
• Kaposi’s sarcoma: This cancerous tumour is usually associated with AIDS. While it usually presents on the skin, it can be found with a similar appearance in the mouth. It looks like a purple lesion in the mouth filled with blood vessels.
• Osteogenic sarcoma (also called osteosarcoma):This is a type of bone cancer that typically begins in the long bones of the arms and legs, though it can also occur very rarely in the jaw. It is the most common type of bone cancer among children and adolescents.

Determining the Stage of the Cancer

The final step before discussing treatment options is a determination of the stage of the cancer. With all cancers of the head and neck, in Australia it is mandatory for doctors to use the AJCC Cancer Staging Manual (7th Ed) to determine the stage based on three factors.

At first, you will be given a clinical stage based on all of the available information.

Clinical staging (cTNM) is determined from any information your doctor might have about how extensive the cancer is BEFORE starting any treatment. Stage is determined based on your doctor’s physical exam, imaging studies, laboratory work and biopsies. Classification of clinical stage is described using the lower-case prefix c (e.g., cT, cN, cM).

If there is surgical removal of the cancer as part of your treatment, a pathologist will analyse the tumour and any lymph nodes that may have been removed. You will then be assigned a pathologic stage.

Pathological staging (pTNM) provides more data. Classification of pathology stage is described using the lower-case prefix p (e.g., pT, pN, pM). This may or may not differ from the clinical stage.

There are also several other lower-case prefixes that might be used in the staging of your cancer.

The subscript y (yTNM) is used to assign a cancer stage after some sort of medical, systemic or radiation treatment is given (post-therapy or Postneoadjuvant stage). It is typically combined with either a clinical or pathologic stage. For example, ycT2N0M0 indicates that after some sort of non-surgical therapy, the new clinical stage is T2N0M0.

The subscript r (rTNM) is used when the tumour has recurred after some period in which it was gone.

This is called Retreatment Classification Stage. Your doctor will use all the available information to assign you a retreatment stage.

T stage: the main tumour mass

Based on a physical examination and review of any imaging, your doctor should be able to give you a T stage that falls within one of the following categories.

 N stage: spread of cancer to the lymph nodes in the neck

Next, your doctor will use all the available information and assign you an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

 M stage: spread of cancer outside the head and neck

Finally, based on an assessment on the entire body, you will be assigned an M stage.

 Your cancer stages

After TNM staging, your doctor can assign a cancer stage based on the following chart.

 Your clinical stage

Once the diagnostic tests are completed, before deciding what type of treatment you are going to undergo, you should be given a clinical stage that will look like the example below.

 * The lower-case subscript c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to your doctor before starting treatment.

After surgery, you should get a pathological stage of your tumour. It will look almost like the clinical stage you received before starting treatment, but notice the “p” that indicates the stage group is based on an analysis of the entire tumour, with or without lymph nodes, under a microscope by a pathologist. In many cases, the pathological stage will be the same as the clinical stage, but sometimes it will change. You should consider the pathological stage to be a more accurate assessment of your tumour at the time you start treatment.

After surgery, and after the pathologist has evaluated all the tumour that was removed, you should be given a pathological stage that looks something like this:

* The lower-case subscript p indicates that this is a PATHOLOGICAL STAGE, the stage assigned after tumour removal and confirmation of cancer by a pathologist.

Deciding on a Treatment Plan 

Before starting treatment, your doctor will make sure that the following steps are completed.

 Pre-treatment evaluation

• A full history and physical examination, including a complete head and neck exam (mirror and fibreoptic exam if needed)
• An evaluation by the members of a head and neck cancer team
• A biopsy to confirm a diagnosis of cancer
• Evaluation of the lungs to check for spread, if needed
• Imaging of the primary tumour and the neck with CT and/or MRI
• Maybe a PET-CT for advanced cancers
• A dental evaluation, with or without jaw X-rays, when necessary
• Examination under anaesthesia with endoscopy if necessary
• Nutrition, swallowing and speech therapy when necessary
• Pre-treatment medical clearance and optimisation of medical conditions

Then, your doctor will recommend a course of treatment for you, depending on several factors.

Depending on whether the cancer has spread or not, there are three general therapeutic options to consider:

• Surgical removal(with or without reconstruction)
• Radiation (a few different types)
• Medications (chemotherapy and biologic medications

Surgery is the recommended treatment when possible in almost all cases of oral cancer. Also, if a positive margin (rim of tissue around the tumour that should be normal tissue but has cancer cells in it) is found after removal of the cancer, all efforts should be made to re-resect and get to negative margins (rim of normal tissue around the tumour).

The treatment recommendations for oral cancers do not really vary by sub-site, though there are certain subtle differences for lip cancer. The surgery your doctor recommends does vary depending on the location of the cancer as well as the stage. You should have an extensive discussion with your care team about different surgeries that might be required for your cancer.

Also, the reconstruction that your doctor recommends will change depending on what is removed.

Below are the recommended treatment options for oral cancer, depending on your T and N stages.

Determining Your Prognosis

Your prognosis is a prediction of the outcome of your disease. What is the risk of succumbing to the cancer or the risk of its coming back? These are the big questions on most people’s minds after receiving a diagnosis of oral cancer. In general, doctors know there are several characteristics of the tumour that can tell you something about your chances of being cured.

The following aspects of the cancer may affect your prognosis.

It is very difficult to discuss prognosis without understanding all the details of your cancer, and this is a conversation you’re better off having in person with your doctor. To give you a percentage chance of cure is difficult because cancer research looks at all sorts of different types of cancers and may include patients from long ago.

What to Expect After Treatment is Completed?

Once you have made it through treatment, you need to have close follow-up with your doctor.  This follow-up plan is recommended after being treated for an oral cancer:

• Visit your head and neck specialist on a regular schedule (or earlier if you have any concerning symptoms). This allows your doctor to examine you for any signs that the cancer has come back.
  • For the first year, you should go every one to three months.
  • For the second year, you should go every two to six months.
  • For the third to fifth year, you should go every four to eight months.
  • After five years, you can start going every year.
• Your doctor may request imaging. If something suspicious comes up, you might need another biopsy.
• Check your thyroid function every six to twelve months if you have had radiation to the neck area.
• Get help with a therapist as needed for difficulties with speaking, hearing and swallowing.
• See a specialist about appropriate nutrition and diet.
• Alert your doctor if you experience any signs of depression
• Stop smoking and stop drinking; counselling may help.
• See a dentist.

*This page is supported by the following sources:

Cohen, E. E., LaMonte, S. J., Erb, N. L., Beckman, K. L., Sadeghi, N. , Hutcheson, K. A., Stubblefield, M. D., Abbott, D. M., Fisher, P. S., Stein, K. D., Lyman, G. H. and Pratt‐Chapman, M. L. (2016), American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA: A Cancer Journal for Clinicians, 66: 203-239. doi:10.3322/caac.21343