Medication Summary
The goals of pharmacotherapy for oral squamous cell carcinoma (SCC) are to reduce morbidity associated with secondary infection and to prevent complications.
Antiviral agents
Class Summary
Nucleoside analogs are initially phosphorylated by viral thymidine kinase to eventually form a nucleoside triphosphate. These molecules inhibit herpes simplex virus (HSV) polymerase with 30- to 50-times the potency of human alpha-DNA polymerase.
Acyclovir (Zovirax)
Acyclovir inhibits the activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 hours of rash onset. It may prevent recurrent outbreaks.
Famciclovir (Famvir)
Famciclovir is a prodrug that when biotransformed into the active metabolite penciclovir, may inhibit viral DNA synthesis/replication.
Penciclovir (Denavir) topical
Penciclovir is an inhibitor of DNA polymerase in HSV-1 and HSV-2 strains, inhibiting viral replication.
Foscarnet (Foscavir)
Foscarnet is an organic analog of inorganic pyrophosphate that inhibits replication of known herpesviruses, including cytomegalovirus (CMV), HSV-1, and HSV-2. It inhibits viral replication at the pyrophosphate-binding site on virus-specific DNA polymerases. A poor clinical response or persistent viral excretion during therapy may result from viral resistance. Patients who can tolerate foscarnet well may benefit from initiation of maintenance treatment at 120 mg/kg/d early in treatment. Individualize dosing based on renal function status.
Antibiotics
Class Summary
Antimicrobials are not especially effective because the tissues are avascular; therefore, prolonged treatment is necessary.
Tetracycline (Sumycin)
Tetracycline is useful because of selective bone uptake. It treats gram-positive and gram-negative organisms as well as mycoplasmal, chlamydial, and rickettsial infections. It inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Add metronidazole in cases of severe infection or when anaerobes are implicated.
Metronidazole (Flagyl)
Metronidazole is used as an adjunct to tetracycline in cases of severe infection or when anaerobes are implicated. It is an imidazole ring-based antibiotic that is active against various anaerobic bacteria and protozoa. It is used in combination with other antimicrobial agents (except in Clostridium difficile enterocolitis).
Antifungal agents
Class Summary
Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.
Clotrimazole (Lotrimin, Mycelex, Femazole, Gyne-Lotrimin)
Clotrimazole is a broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells. Reevaluate the diagnosis if no clinical improvement is seen after 4 weeks.
Fluconazole (Diflucan)
Fluconazole is a synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P450 and sterol C-14 alpha-demethylation.
-
Oral squamous cell carcinoma in the most common intraoral site, lateral tongue, initially reported as a chronic leukoplakia, which had become ulcerated and indurated at the time diagnosis was confirmed.
-
Oral squamous cell carcinoma in the anterior buccal mucosa arising from a chronic candidal-associated leukoplakia. The lesion slowly developed into an indurated lump in a patient with a history of smoking, who thought it was a traumatic lesion.
-
Cancer developing on the gingiva, misdiagnosed as a pyogenic granuloma.
-
Cervical lymph node metastasis from oral cancer.
-
Oral squamous cell carcinoma on the midlateral border of the tongue. Soft to palpation, it serves to illustrate the importance of the differential diagnosis. It was initially misdiagnosed as an allergic reaction (lichenoid lesion) to amalgam
-
This photo illustrates the importance of a thorough oral examination. Oral squamous cell carcinoma on lateral posterior border of tongue. Notice the ulcer, tender at the time of diagnosis, but not indurated, which was missed by the referral doctor. Oral cancer on the posterior border of the tongue is difficult to see unless the tongue is pulled forward.
-
Advanced oral squamous cell carcinoma presenting as a large, ulcerated lump on the left anterior and midlateral border of the tongue.
Tables
Issue |
|
No Serious Concern |
Concern: Consider Referral to Specialist if Clinician or Patient Concerned, Especially if Multiple Issues Apply |
Serious Concern: Referral to a Specialist |
Historical Features |
Size |
No change |
No reduction in size, even after eliminating trauma to lesion after 10-14 days |
Increasing size, even after eliminating trauma to lesion after 10-14 days |
|
Chronology |
Lesion heals |
No resolution over brief observation period |
Rapid symptom onset Solitary lesion or change in one area of lesion Lesion persisting 2-3 weeks or longer Persistent ulceration Persistent swelling Loosening of a tooth Nonhealing tooth extraction socket |
|
Neurological |
None |
Lack of pain |
Pain Dysphagia Odynophagia Otalgia Numbness/paresthesia Speech or voice change |
|
Weight |
Normal |
No weight loss |
Weight loss |
History |
Lifestyle Habits |
None |
Tobacco consumption mild/moderate Betel quid or khat consumption mild/moderate UV light exposure mild/moderate (lip surface exposure) Late-onset sexual debut (oral sex) Moderate number of lifetime sexual partners |
Tobacco consumption high Betel quid or khat consumption high Alcohol consumption high UV light exposure high Early sexual debut Numerous lifetime sexual partners |
|
Medical History |
Clear |
Deficiencies of iron or vitamins A, C, or E Fanconi anemia High-risk human papillomavirus (HPV) infection Immune defects, including HIV/AIDS or chronic candidosis Medications: Immunosuppressants, antihypertensives Periodontitis, poor hygiene Plummer-Vinson syndrome Scleroderma Xeroderma pigmentosum |
Deficiencies of iron or vitamins A, C, or E Fanconi anemia High-risk HPV infection Immune defects, including HIV/AIDS or chronic candidosis Medications: Immunosuppressants, antihypertensives Periodontitis, poor hygiene Plummer-Vinson syndrome Scleroderma Xeroderma pigmentosum |
Examination and Imaging |
Potentially Malignant Disorder |
None |
Leukoplakia Lichenoid mucositis (unilateral); Oral lichen planus Oral submucous fibrosis |
Erythroplakia Leukoplakia (speckled or verrucous) lichenoid mucositis(unilateral) Oral lichen planus |
|
Lesion Features |
Equivocal |
White patch (leukoplakia) Lichenoid mucositis (unilateral) Oral submucous fibrosis |
Red patch (erythroplakia) Mixed red and white patch (erythroleukoplakia/speckled leukoplakia) Granular surface Rolled, elevated margins Ulceration Induration |
|
Cervical Lymph Nodes |
No enlargement |
Possible enlargement |
Enlarged, firm, fixed, nontender, asymmetric |
|
Imaging |
No abnormality |
Any bone density change |
Poorly defined, uncorticated, irregular radiolucency Lamina dura loss Teeth displaced and/or resorbed Pathological fracture |
Therapies |
Examples |
Adverse effects |
Epidermal growth factor receptor (EGFR) inhibitors (FDA approved) |
Cetuximab |
Ulcers |
EGFR inhibitors |
Panitumumab, erlotinib in combination with gemcitabine |
Ulcers |
Mammalian target of rapamycin (mTOR) inhibitors |
Deforolimus, rapamycin (sirolimus) and temsirolimus |
Ulcers |
Tyrosine kinase inhibitors (TKIs) of platelet-derived growth factor (PDGF) |
Imatinib |
Ulcers, dysgeusia |
TKIs of PDGF and vascular endothelial growth factor (VEGF) |
Sunitinib |
Ulcers, dry mouth, dysgeusia |
Raf multi-kinase inhibitors |
Sorafenib |
Dysgeusia |
