Clinical Case Discussion: Buccal Carcinoma (Oral Cavity Cancer)
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🦷 Clinical Case Discussion: Carcinoma of Buccal Mucosa
Today, we'll have a clinical case discussion on a very common ENT presentation: Carcinoma of Buccal Mucosa - Oral Cavity cancer.
This case discussion format will be helpful for both undergraduates and postgraduates.
We'll go through the patient's history, discuss how history guides us to a provisional diagnosis, cover the clinical examination findings and their significance, summarize the case, arrive at a provisional diagnosis, and outline the management plan.
👤 Patient Profile
- Age: 65 years
- Sex: Male
- Occupation: Farmer
- Residence: Hyderabad
🗣️ Chief Complaint
- Ulcer in the inner aspect of the right cheek since 4 months
📜 History of Present Illness
- Patient was apparently asymptomatic 4 months back
- Developed an ulcer on the inner aspect of right cheek
- Insidious onset, rapidly progressive
- Initial size: 1 × 1 cm
- Present size: 2 × 3 cm
- Initially painless, pain started since last 2 months
- Associated with loss of appetite
What are the differential diagnosis of ulcer in Buccal mucosa?
What does Rapidly progressive VS Gradually progressive increase in size of buccal ulcer indicate?
What does late onset of pain in buccal cancer indicate?
❌ Relevant Negative History (with Clinical Significance)
| Negative History Point | Clinical Significance |
|---|---|
| No bleeding from lesion | Suggests absence of surface necrosis, friable or highly vascular tumor |
| No difficulty in opening mouth (trismus) | No involvement of muscles of mastication, masticator space, or temporomandibular joint |
| No history of trauma / sharp tooth | Rules out traumatic ulcer as a cause |
| No halitosis | Indicates minimal necrosis and absence of secondary anaerobic infection |
| No difficulty in chewing or speech | Suggests buccinator, tongue, and masticator space are not involved |
| No excessive salivation / drooling | Oral competence intact; no significant mucosal irritation or dysphagia |
| No recurrent ulcers / red or white patches | No evidence of pre-existing premalignant lesion (leukoplakia / erythroplakia) |
| No loosening of teeth | Suggests no alveolar process or mandibular bone invasion |
| No prior radiation exposure | Excludes radiation-induced second primary malignancy |
| No difficulty in tongue protrusion | Indicates tongue muscles, floor of mouth, and pterygomandibular space not involved |
| No dysphagia | No posterior extension to retromolar trigone, oropharynx, or soft palate |
| No neck swelling | Clinically node-negative neck (N0) |
| No weight loss | Suggests early or localized disease; cachexia unlikely |
| No ear or nasal complaints | No referred otalgia (V3 involvement) or nasopharyngeal extension |
| No cough, hemoptysis, breathlessness | Lung metastasis unlikely |
| No bone pain, abdominal pain, jaundice | No evidence of distant metastasis to bone or liver |
What is Trismus? What is it's clinical importance?
Name the muscles of mastication.
What are the sites of Distant metastasis in oral cavity cancer? What is the most common site amongst these?
🕰️ Past History
- No previous surgeries
- No drug allergies
- No family history of malignancy
👤 Personal & Addiction History
- Decreased appetite for last 3 months
🚬 Addiction History
- Bidi smoking: 8/day for 40 years
- Betel quid chewing: 4/day for 45 years
- Keeps quid in right gingivobuccal sulcus
What are the carcinogens found in tobacco?
What is the mechanism of action of carcinogenesis by Tobacco?
What are the carcinogens found in quid contributing to oral cancer?
🦷 Local Examination (Oral Cavity)
Inspection
- Single ulceroproliferative growth
- Size: 2 × 3 cm
- Site: Right buccal mucosa
- Extent:
- Anterior: 0.5 cm from oral commissure
- Posterior: up to first molar
- Superior: 3 cm from upper gingivobuccal sulcus
- Inferior: 2 cm from lower gingivobuccal sulcus
- Averted (rolled) edges
- Irregular margins
- Floor covered with slough
Palpation
- Tenderness present
- Induration extending 0.5 cm beyond visible margins
- Base: firm, non-mobile
- Not fixed to mandible
- Does not bleed on touch
🧠 Interpretation of Examination Findings
Ulceroproliferative Growth
- Indicates squamous cell carcinoma
Everted / Rolled Edges
- Due to peripheral tumor proliferation with central necrosis
Induration
- Hallmark of malignancy
- Indicates submucosal tumor spread
- Determines true tumor extent and surgical margins
No Fixation to Mandible
- Suggests no bone invasion
- Rules out T4 disease
What is Edge of ulcer? What is Margin of ulcer?
What are the Types of Edges of Ulcer? What is the mechanism behind each one of them? Give examples of each type.
What is Floor of ulcer? What is Base of ulcer?
What is Induration? What is the Pathology behind Induration? What is it's clinical significance?
🆚 Benign vs Malignant Ulcer
| Feature | Benign | Malignant |
|---|---|---|
| Edges | Sloping | Rolled / everted |
| Margins | Regular | Irregular |
| Floor | Clean | Slough, necrotic |
| Base | Soft, mobile | Hard, indurated |
| Pain | Painful early | Painless early |
| Bleeding | Rare | Common |
| Induration | Absent | Present |
What are the Key Clinical Hallmarks of Malignant Ulcer?
What is Field Cancerization? What is it's Clinical Implications?
What is Synchronous VS Metachronous Tumors? What is Warren and Gates criteria?
📝 Case Summary
- 65-year-old male
- Chronic smoker and quid chewer
- Rapidly progressive ulcer in right buccal mucosa
- Ulceroproliferative lesion with:
- Rolled edges
- Induration
- Slough-covered floor
- No neck nodes
🩺 Provisional Diagnosis
Carcinoma of right buccal mucosa, Clinical stage:** T2N0MX (Stage II)
What are the points in favour of your diagnosis?
What is the Differential Diagnosis of Buccal carcinoma? What are points in favour and against in each one of them?
What are the Anatomical Boundaries of Buccal Mucosa?
What is the most common site of oral cavity cancer worldwide?
What is the most common site of oral cavity cancer in India?
What is the TNM Staging of Oral Cavity cancer?
What is the difference between Premalignant lesions VS Premalignant disorders? Give examples of each.
What is Leukoplakia & Erythroplakia? Which has the highest malignant potential?
What is Oral Submucous fibrosis? What is the Pathophysiology of Oral Submucous fibrosis?
🏨 Management Plan
Management always consists of two parts: Investigation and Treatment.
🔬 Investigations
-
Incisional biopsy
- From edge of ulcer
-
CECT / MRI
-
OPG
- If mandibular involvement suspected
-
USG neck
- Occult nodes
-
Chest X-ray / CT
- Lung metastasis
-
PET-CT
- Advanced / recurrent disease
What is the purpose of doing CECT?
Which Lymph nodes get involved in buccal carcinoma?
What are the Features suggestive of Nodal malignancy on USG?
What is Broder’s Grading?
🩻 Treatment
1️⃣ Primary Tumor
- Wide local excision
- 1 cm margin
- Depth up to buccinator / periosteum
2️⃣ Reconstruction
- Local flaps (< 3 cm)
- Free flaps (large defects)
3️⃣ Neck
- Elective supraomohyoid neck dissection
- Levels I–III
- Due to 15–20% occult metastasis risk
What surgery is done when there is cortical or medullary invasion of mandible?
Name some local flaps and free flaps used in buccal carcinoma for reconstruction.
Classify Neck Dissection and define each one of them.
What are the different types of Selective Neck Dissection?
What are the Contraindications of Neck Dissection?
What are the Indications of Post op Adjuvant Radiotherapy?
What is Residual Tumor Classification?
📝 All the topics and questions mentioned in this post are explained in detail in my ENT notes - built for exam success and clinical understanding. Get full access by purchasing the notes.