'This ulcer is not healing'
Professor Peter Brennan and colleagues discuss a slowly enlarging, non-healing painless ulcer on the floor of the mouth
A 61-year-old school caretaker who is a lifelong smoker and has a moderate alcohol intake (more than 20 units per week), presents with a six-week history of an enlarging, non-healing ulcer under the tongue. It is painless, but his right neck occasionally swells on eating and is painful. The ulcer occasionally bleeds and he is worried it might be a mouth cancer.
On examination, there is a 1cm firm, indurated ulcer on the floor of the mouth. Neck examination also reveals an enlarged right submandibular gland but no obvious lymphadenopathy. There is a faint smell of alcohol on his breath and he has nicotine-stained fingers.
Oral cancer is the sixth most common cancer worldwide and the commonest cancer in the Indian subcontinent because of betel nut chewing. More than 90% of all oral cancers are squamous cell carcinomas (SCCs), with a crude overall five-year survival rate of approximately 50%. While they are relatively rare compared with other causes of oral ulceration that spontaneously heal (including recurrent aphthous ulceration, painful shallow nicorandil-induced oral ulcers that resolve following drug cessation), malignant oral ulcers do not heal and will progressively enlarge.
Risk factors, including smoking and alcohol, should always be assessed, but HPV-related oropharyngeal carcinomas are becoming increasingly common, often in non-smokers.
These tumours are usually found in the tonsil or tongue base, rather than further forward in the oral cavity, and have a better prognosis than the classic SCC. Having more than five oral sex partners increases the risk of these HPV cancers by 250%.1
An urgent referral should be made for any non-healing solitary ulcer of three weeks’ duration or more in the mouth or oropharynx, particularly if it feels firm and indurated.
Oral cancer is typically painless, at least in the early stages, although occasionally it may bleed, causing concern for patients. Unlike recurrent ulceration (such as aphthae), a malignant ulcer does not heal, progressively enlarges and is firm on palpation.
Ulcers or lumps in the floor of mouth may cause obstruction of the submandibular duct (as in this case). Some floor-of-mouth cancers are diagnosed in this way and present with gland obstruction, the patient (and sometimes the primary care clinician) not having noticed the ulcer under the tongue, so it is always worth looking in the mouth in such cases.
In contrast, traumatic ulcers due to longstanding ill-fitting dentures or sharp teeth are usually painful from the outset and will heal if the cause is removed. If a painful, soft, shallow ulcer appears to be related to the flange of a denture or a sharp tooth, it is not unreasonable to ask the patient to attend their dentist in the first instance to see if this aids healing. However, any firm ulcer noted on examination should always prompt immediate referral to oral and maxillofacial surgery. It is important to examine the neck for lymphadenopathy. This is the single most important prognostic indicator for head and neck carcinoma, with a single-node metastasis reducing five-year survival by up to 50% even if the primary tumour is small.2
There are few investigations that can be arranged in general practice for a suspected oral cancer. Occasionally, oral thrush can complicate the presentation and chronic hyperplastic candidiasis (usually through poor denture hygiene or never removing them) is a premalignant condition. A culture swab for candida would be useful. It is always worth asking patients to remove their dentures in the surgery, as red, inflamed, denture-bearing gums are likely to have chronic candida. Fluconazole and urgent referral are appropriate in these presentations of perceived chronic candidiasis (rather than acute candida, which can be managed in primary care).
A diagnosis is made following an incisional biopsy, which can often be done under local anaesthesia in the oral and maxillofacial surgery department for anterior oral cavity tumours. The neck will always be imaged with cross-sectional scans (CT or MRI) in confirmed cancer cases, and many units also scan the chest too for staging.3
As in this case, the submandibular gland will be seen enlarged on CT but interestingly metastasis to the gland itself does not occur as there are no lymph nodes in the gland structure. Worrying lymph nodes are investigated by ultrasound-guided fine-needle aspiration.
The two potentially curative treatments for oral cancers are surgery and radiotherapy. Chemotherapy also has a role but is not curative in isolation. Some patients will require a combination of treatments. With advances in reconstructive surgery (free flap transfer, lasers and robotic surgery) and organ-sparing radiotherapy techniques such as intensity-modulated radiation therapy, the management of head and neck cancers has become advanced and complex. All patients are discussed in a multidisciplinary team. GPs have a valuable role both in prompt referral and in helping patients to quit smoking and drinking habits. Smoking, in particular, significantly raises the risk of recurrence or a new primary cancer and also a much stormier passage during treatment.
Professor Peter Brennan is a consultant maxillofacial/head and neck surgeon at Queen Alexandra Hospital, Portsmouth;
Mr Arpan Tahim, Mr Karl Payne and Mr Alex Goodson are specialty registrars in oral and maxillofacial surgery at University College Hospital, London
The authors have recently published Important Oral and Maxillofacial Presentations for the Primary Care Clinician’4, which has been sent to every GP practice in the UK free of charge. It contains algorithms for the management of many head and neck conditions including lumps and malignant disease. The book has been written in collaboration with the RCGP. Further copies are available at cost price (£12.50) from Amazon
- D’Souza G, Kreimer A, Viscidi R et al. Case-control study of human papillomavirus and oropharyngeal cancer. N Engl J Med 2007;356:1944-56
- Brennan P, Subramaniam S, Tsioryannis C et al. An update on the latest evidence for managing the clinically negative neck (cN0) in oral squamous cell carcinoma. Oral Dis 2016 Jun 24. doi: 10.1111/odi.12528
- McLeod N, Jess A, Anand R et al. Role of chest CT in staging of oropharyngeal cancer: a systematic review. Head Neck 2009;31:548-55
- Goodson A, Payne K, Tahim A et al. Important Oral and Maxillofacial Presentations for the Primary Care Clinician 2016; Libri Publishing