PATHOLOGY OF ORAL CAVITY.

MANIFESTATIONS OF DISEASES OF THE ORAL CAVITY

-pain- the oral cavity- richly su lie! "ith se#sory #erve e#!i#$s- ai# is a %eature o% all !iseases& i#clu!i#$ !isor!ers o% the teeth -changes of the oral m cosa - such as ulceratio#s& vesicular lesio#s '(listers)& cha#$es i# colour
-ulcers- occur i# *a#y !iseases& i#clu!i#$ i#%ectio#s& aller$y& trau*a& a#! #eo las#s -(listers- i#%ectio#s& such as her es virur& a#! i**u#olo$ic !iseases

-leu+o la+ia- "hite la,ues o# the *ucosa- i# hy er+eratosis& i# !ys lasia

-*ela#i# i$*e#tatio#- -eut.-/e$hers sy#!ro*e-is rare co#$e#ital sy#!ro*e "ith autoso*al !o*i#a#ce& characteri.e! (y *ela#otic i$*e#tatio# o% *ucosal a#! s+i# sur%aces& a#! i#crease! ris+ o% carci#o*a o% a#creas& (reast& lu#$ a#! ovary& i# a!!itio# atie#ts have *ulti le oly s i# s*all i#testi#e a#! colo# A!!iso# !isease -u#co**o# co#!itio# characteri.e! (y *ela#i# i$*e#tatio# o% s+i# a#! *ucosa %ollo"i#$ !estructio# o% the a!re#al corte0& this results i# i#crease! sti*ulatio# o% ituitary $la#!& hi$h level o% ACTH a#! MSH -*ass lesio#s- soli! or cystic

!O!-!"OPLA#TIC $I#OR$"R# OF TH" ORAL %&CO#A 12 Develo *e#tal a#o*alies 32 4hite lesio#s a#! 52 I#%ectio#s 62 -seu!otu*ors
DEVELO-MENTAL ANOMALIES -oral *ucosa is su(7ect to the sa*e ra#$e o% !evelo *e#tal a#o*alies such as s+i#& a#! *ay (e i#volve! i# hea! a#! #ec+ sy#!ro*es& (ut also there are a#o*alies co#%i#e! to the oral *ucosa itsel%

atches

'. For()ce spots- heteroto ic !evelo *e#t o% se(aceous $la#!s i# oral *ucosaro!uce yello" s ots a#! #o!ules *. Pe t+-,eghers s)n(rome- ' eriori%acial le#ti$i#osis)- autoso*al !o*i#a#t co#!itio# "ith #early co* lete e#etra#ce& it is co* ose! o% *ela#ocytic

*acular i$*e#tatio# o% the li s& oral *ucosa& s+i# to$ether "ith i#testi#al oly osis& *ost #u*erous ha*arto*atous oly s i# s*all i#testi#e& the oly s have a lo" *ali$#a#t ote#tial& those i# colo# "ith hi$her ris+ -the atie#ts are i# hi$her ris+ o% *ali$#a#cies at other sites& i#clu!i#$ ovary& uterus a#! (reast -the %acial a!ulthoo! i$*e#tatio# is arou#! li s& eyes a#! #ose a#! *ay !isa ear i#

-*ucosal i$*e#tatio# te#!s to ersist to a!ulthoo!

-. Congenital ep lis- rese#t at (irth as *ass attache! to the $i#$iva& histolo$ically co* ose! o% lar$e $ra#ular cells "ith eosi#o hilic cyto las*& covere! (y strati%ie! hy er lastic s,ua*ous e itheliu*- co* letely (e#i$#
4HITE -ATCHES2 .hite sponge nae/ s- is rare autoso*al !o*i#a#t i#herite! co#!itio#& *ay (e co#$e#ital or !evelo later i# li%e - *ai#ly a%%ects (uccal *ucosa& *ay i#volve li s a#! other oral *ucosa -%a*ily history ca# (e !etecte! i# all cases -histolo$ically8 there is aca#thosis& ara+eratosis& a#! e!e*a "ith hy!ro ic !e$e#eratio# o% the cells i# the stratu* s i#osu*& e itheliu* is #ot !ys lastic& there is #o i#%la**atio#& #o relatio# to tu*or Frictional 0eratosis- is a co**o# cause o% i#traoral "hite atches a#! *ay (e !ue to shar e!$es o% teeth or to chee+ a#! li suc+i#$& it is a res o#se to lo" $ra!e irritatio# *icrosco y *ay sho" aca#thosis or e ithelial atro hy& thic+ layer o% ortho+eratosis a#! ro*i#e#t $ra#ular cell layer& or less co**o#ly hy er ara+eratosis "ith a(se#t $ra#ular cell layer -there is #o si$#i%ica#t !ys lasia& (ut so*eti*es i#%la**atio# o% the u#!erlyi#$ coriu*& #o relatio# to tu*or !evelo *e#t cli#ically- the lesio#s te#! to %or* !i%%use +eratotic la,ues smo0ing relate( 0eratosis- s*o+i#$ ca# result i# i#traoral la,ue %or*atio# -histolo$ically-atro hic or hy er+eratotic e itheliu* "ith atchy i#%la**atio# a#! *ela#i# i$*e#t i# the u#!erlyi#$ coriu*- i$*e#tary i#co#ti#e#ce-release o% *ela#i# %ro* !e*a$e! cells -there is #o si$#i%ica#t !ys lasia -*ay (e see# i# reverse s*o+ers& "ho hol! the (ur#i#$ e#! o% ci$arette i#si!e the *outh& this o#e *ay (e associate! "ith !ys lasia

 ac te oral can(i(osis-oral i#%ectio#s "ith ca#!i!a al(ica#s are co**o#& it %or*s crea*y "hite la,ues "hich ca# (e ru((e! o%% to leave a !ry& re! *ucosa -histolo$ically-loose ara+eratotic la,ues i#%iltrate! (y leu+ocytes 'i#trae ithelial *icroa(scesses) "ith hy hae- !i%%icult to (e see# i# HE stai#e! sectio#s (ut are rea!ily visualise! (y stai#i#$ "ith -AS or silver i* re$#atio# *etho!s& such as 9rocott -"i!e variety o% %actors re!is ose to i#%ectio#& such as !e resse! cellular i**u#ity& a#! i#hi(itio# o% #or*al oral %lora (y (roa! s ectru* a#ti(iotics chronic h)perplastic can(i(osis 1can(i(al le 0opla0ia2 -Ca#!i!a al(ica#s ca# (e rese#t i# ersiste#t& a!here#t "hite la,ues- solitary or *ulti le *icrosco y- sho"s a ara+eratotic la,ue i#%iltrate! (y leu+ocytes& aca#thosis a#! i#%la**atory i#%iltrate i# the coriu*& e itheliu* has elo#$ate! rete ri!$es "ith thi##i#$ o% the su ra a illary e itheliu* $ivi#$ a rese*(la#ce to cuta#eous soriasis& ca#!i!al hy hae ca# (e visuali.e! "ithi# ara+eratotic layer hair) le 0opla0ia- atie#ts i#%ecte! "ith HIV %re,ue#tly !evelo ai#less& "hite la,ues o# the lateral (or!er o% the to#$ue a#! occassio#ally else"here i# the *outh *icrosco y-sho"s irre$ular ara+eratosis "ith or "ithout ca#!i!al hy hae& vacuolate! cell "ith !ar+ y+#otic #uclei ' +oilocytes) i# the stratu* s i#osu*& #o i#%la**atory i#%iltrate i# the coriu*& E stei#-:arr ca si! a#ti$e# ca# (e !etecte! i# the e ithelial cell #uclei -si*ilar lesio#s have (ee# re orte! occasio#ally i# atie#ts receivi#$ i**u#osu ressa#t !ru$s %ollo"i#$ or$a# tra#s la#tatio#s geographic tong e- relatively co**o# i!io athic co#!itio# ty ically characteri.e! (y areas "ith loss o% a illae& *il! chro#ic i#%la**atio# i# coriu*& leu+ocytic *icroa(scesses i# the e i!er*is INFECTIONS- VIRAL& :ACTERIAL AND F;N9AL i#%ectio#s o% the oral *ucosa are co* aratively i#%re,ue#t $ive# the #u*(er o% *icroor$a#is*s rese#t i# the *outh

VIRAL8 -'2 herpes simple3 stomatitis- cause! (y HSV ty e 1- co**o# viral i#%ectio#- usually is su(cli#ical
-i# o#ly %e" er ce#t o% i#%ecte! i#!iviuals& there are *ore severe sy* to*s rese#ti#$ as "i!es rea! $i#$ivosto*atitis& characteri.e! (y *ulti le vesicles a#! ulcers- i# chil!re# a#! you#$ a!ults- syste*ic sy* to*s- li+e %ever are rese#t

-locally severe& ai#%ul& (ut sel%-li*ite! !isease- heali#$ occurs "ithi# t"o "ee+s& recurre#t i#%ectio#s *ay (e associate! "ith a(#or*alities o% cell*e!iate! i**u#ity -HS virus asses u the #erve tru#+s a#! i#%ects the $a#$lia i# acute hase& it re*ai#s i# late#t %or* %or lo#$ ti*e there

-herpes la4ialis-i# so*e atie#ts- attac+s o% reactivatio# o% the i#%ectio# as ai#%ul locali.e! vesicular a#! ulceral lesio# -reactivatio# is al"ays reci itate! (y e0 osure to su#li$ht& %ever& co**o# col!& etc2 -*2 herpangina -is u#co**o# i#%ectio# o% the oral *ucosa (y co0sac+ie virus A& occurs as vesicular lesio# o# the alate --2 aphto s stomatitis- co**o# lesio# characteri.e! (y recurre#t attac+s o% ai#%ul shallo" ulcers o# the oral *ucosa- #o#s eci%ic acute i#%iltrate
- cause is u#+#o"#- #o i#%ectious a$e#t has (ee# i!e#ti%ie!- sel%-li*ite! lesio#

-52 /iral 6arts- viral "arts o% the oral *ucosa rese#t as a lesio# si*ilar to co#!ylo*a accu*i#atu* histolo$ically8 %eatures su$$estive o% viral etiolo$y such as +oilocytosis& #u*erous *itoses& viral i#clusio#s ca# (e rese#t- !etectio# o% H-V DNA se,ue#ces "ithi# the tissue usi#$ i# situ hy!ri!i.atio# tech#i,ue assists i# !ia$#osis- H-V ty e <& 11 a#! 1< "ill (e rese#t 'hu*a# a illo*a virus) :acterial8 '.2 Ac te lcerati/e gingi/itis7
- ai#%ul co#!itio# "ith ulceratio# o% the i#ter!e#tal a illae (et"ee# teeth& the ulcers have irre$ular *ar$i#s a#! are covere! "ith %i(ri#ous e0u!ate -etiolo$y is u#clear& a#! is artly relate to oor oral hy$ie#e -s*ears %ro* ulcers sho" *i0e! o ulatio# o% s irochetes& a#! %usi%or* (acteria

*.2 Actinom)cosis- i#%ectio# o% oral *ucosa (y acti#o*yces rese#ts as s"elli#$ o% the *ucosa& the or$a#is*s are #or*ally rese#t i# the *outh- i#%ectio# is o ortu#istic -.2 T 4erc losis- i#%ectio# o% oral *ucosa (y t(c (acili is #o" u#co**o#& rese#ts "ith tu(erculosis ulcers that are seco#!ary to ul*o#ary tu(erculosis 5.2 #)philis- sy hilitic i#%ectio# o% the oral *ucosa is rare i# this cou#try& the cha#cre o% the ri*ary i#%ect *ay occur o# the li s or i#si!e the *outh& *ucous atches a#! ulcers *ay !evelo i# seco#!ary sta$e& a#! tertiary sy hilis *ay rese#t "ith $u**a i# the to#$ue or alate %u#$al8 -'2 can(i(osis -is cause! (y Ca#!i!a al(ica#s& "hich is rese#t as #or*al co**e#sal o% the *ouths o% a(out o#e-hal% o% the o ulatio#

-cli#ical i#%ectio# o% the oral *ucosa is a# e0a* le o% o ortu#istic i#%ectio#occurs %or e0a* le i# atie#ts "ith i#crease! susce ti(ility '"ith i**u#osu ressio#& i# AIDS& i# #e"(or#s& i# atie#ts receivi#$ a#ti-ca#cer thera y or lo#$-lasti#$ a#ti(iotic thera y& atie#ts "ith !ia(etes *ellitus) *or holo$y8 e!e*a o% the e itheliu*& ulceratio#s& Ca#!i!a ro!uces i#%la**atio#& "hite atches- the (u!!i#$ yeasts a#! seu!ohy hae o% Ca#!i!a ca# (e i!e#ti%ie! i# s*ears a#! (io sy s eci*e#s %ro* the lesio#s

-SE;DOT;MORS AND HY-ER-LASTIC LESIONS OF THE ORAL M;COSA

ep lis - seu!otu*ors o% $i#$iva -these are reactive lesio#s o% $i#$iva& $rosslyoly oi! *asses& *ost co**o# ty es are

-gran lomato s ep lis- p)ogenic gran loma -reactive i#%la**atory roli%eratio# o% #o#s eci%ic $ra#ulatio# tissue
$rossly8 s*all& (ri$ht re! #o!ule "ith ulceratio# o% the *ucosal sur%ace -it occurs ,uite co**o#ly i# re$#a#cy-a#! it resolves s o#ta#eously

-giant cell ep lis -!isti#ctive lesio# o% $i#$iva co* ose! o% *ulti#ucleate! $ia#t cells a#! s i#!le *o#o#uclear cells& $ia#t cell e uli!es te#! to (e hi$hly vasculari.e!& there ca# (e co#si!era(le a*ou#ts o% he*osi!eri#& osseous *eta lasia is rather co**o#
-#ot true #eo las*-*ost li+ely a reactive lesio#& ho"ever& the lesio# te#!s to recur a%ter e0cisio#

-fi4romato s ep lis -co* ose! o% %i(ro(lasts a#! *yo%i(ro(lasts& the lesio#s sho" varia(le !e$ree o% cellularity a#! colla$e#& !ystro hic calci%icatio# *ay occur& osseous *eta lasia is co**o# -osteo%i(ro*atous e ulis
-congenital ep lis- usually see# i# #e"(or# as a oly oi! lesio# i# the a#terior *a0illa& o%te# rotru!e %ro* the *outh as a re!!ish s"elli#$& histolo$ically - the lesio# is co* ose! o% lar$e eosi#o hilic cells "ith $ra#ular cyto las*- the lesio# is e#tirely (e#i$# -fi4ro s h)perplasia =co**o# tu*or-li+e s"elli#$ o% oral *ucosa& these lesio#s are co#si!ere! to (e a res o#se to lo" $ra!e irritatio# - oly oi! s"elli#$s *ay (e sessile a#! e!u#culate! -*icroso ically co#sist o% colla$e# (u#!les a#! *o!erately cellular %i(rous tissue

-papillar) h)perplasia =ty ically see# i# har! !e#ture-relate! & i#!uce! sto*atitits

alate& (elo#$ to s ectru* o%

-generali+e( gingi/al fi4ro s h)perplasia =%a*iliar or !ru$ i#!uce!

-here!itary $i#$ival %i(ro*atosis- rare co#!itio# "ith AD trait& *ay (e associate! "ith hy ertrichosis& #eurolo$ical ro(le*s& such as e ile sy -!ru$-i#!uce! $i#$ival hy ertro hy- see# i# a(out hal% o% atie#ts treate! "ith a#ti-e ile tic !ru$ he#ytoi# %or lo#$ erio!& other !ru$ *ay ro!uce si*ilar- cyclos ori#

-orofacial gran lomatosis = characteri.e! (y chro#ic $ra#ulo*atous i#%la**atio# o% oral *ucosa& the cause is u#+#o"#& !$ a%ter e0clusio# o% Croh#s !isease& t(c a#! sarcoi!osis
-Mel+ersso#-Rose#thal !isease-cheilitis $ra#ulo*atosa&%issure! to#$ue& %acial #erve alsy

PR"CA!C"RO&# CO!$ITIO!# A!$ T&%OR# OF TH" ORAL %&CO#A

-the *ost i* orta#t #eo las* o% the *outh is s,ua*ous cell carci#o*a!es ite the accessi(ility o% the *outh to visual i#s ectio#& *ost oral ca#cers are !etecte! late a#! their ro$#osis is co* ara(le to that o% s,ua*ous cell carci#o*a o% the eso ha$us -other *ali$#a#cies a#! (e#i$# tu*or are rare& e0ce t o% s,ua*ous cell a illo*a& a#! salivary $la#!-!erive! tu*ors o% the oral *ucosa

:ENI9N T;MORS OF ORAL M;COSA

-(e#i$# tu*ors i# the oral cavity *ay arise - %ro* s,ua*ous e itheliu*& %ro* *ese#chy*al tissue& %ro* the *i#or salivary $la#!s -s8 amo s papilloma- are usually s*all& sessile or e!u#culate! lesio#s -tehy are co* ose! o% %i(rovascular core& e0te#sio#s o% "hich are covere! (y aca#thotic strati%ie! s,ua*ous e itheliu*- #o evi!e#ce o% !ys lasia& (ut +oilocytic *eta lasia *ay (e rese#t -*a7ority o% a illo*as are viral i# ori$i#- +oilocytosis is a %eature o% viral i#%ectio#s -+oilocytes- clear cell "ith oly*or hic hy erchro*atic #ucleus ushe! to o#e si!e -there is #o te#!e#cy %or *ali$#a#t cha#$e -fi4roma9 lipoma9 ne rofi4roma- (e#i$# *ese#chy*al tu*ors -gran lar cell t mor- '*yo(lasto*a)- is #ot u#co**o# tu*or o% the s+i# a#! *ucosal sur%aces& they arise articularly i# the *outh& "here the !orsu* o% the to#$ue is a ty ical site&

histolo$ically-stri+i#$ seu!oe ithelio*atous hy er lasia o% the overlyi#$ e itheliu* "ith usually i#cos icuous $ra#ular cell tu*or i# the coriu* 'si*ulates s,ua*ous cell carci#o*a)& the tu*or co#sists o% lar$e cells "ith a(u#!a#t %i#ely $ra#ular cyto las*- these cells "ere o#ce thou$ht to ori$i#ate %ro* *uscle cells& ho"ever !es ite the %act that they see* to %use "ith *uscle& they a ear to (e o% Sch"a## cell ori$i#

ORAL -RE-MALI9NANCIES
-there is a "i!e ra#$e o% *ucosal !isor!ers i# "hich s,ua*ous cell carci#o*a has (ee# sho"# to !evelo *ore easily - pre-malignant lesions- "hich sho" histolo$ically !etacta(le *ucosal cha#$es - pre-malignant con(itions- *ore "i!es rea! or syste*ic !isor!ers a%%ecti#$ oral *ucosa "here ca#cer is statistically *ore li+ely to !evelo althou$h the site is u# re!icta(le - re-*ali$#a#t lesio#s i#clu!e8 %or e0a* le leu+o la+ia& alatal cha#$es associate! "ith s*o+i#$& a#! re-*ali$#a#t co#!itio#s- si!ero e#ic atro hy a#! !ys ha$ia cause! (y iro# !e%icie#cy

LE;>O-LA>IA- this is a ter* (est !e%i#e! cli#ically to !e#ote a "hite atch or la,ue
-accor!i#$ to this !e%i#itio# - hetero$e#ous $rou o% lesio#s a*o#$ "hich e ithelial !ys lasias- have re-*ali$#a#t ote#tial - i# *ost cases leu+o la+ia re rese#ts o#ly si* le hy er+eratosis resulti#$ %ro* chro#ic irritatio#& i# *i#ority o% cases- there is !ys lasia- ersiste#t leu+o la+ia shoul! (e (io sie! "pithelial ()splasia- lesio#s characteri.e! (y !isor!ere! cell *aturatio# a#! roli%eratio# associate! "ith i#crease! ris+ o% ro$ressio# to *ali$a#cy histolo$ically-irre$ular hy er lasia o% cells "ith (asal cell *or holo$y& rete ri!$es sho" a !ro -sha e! co#%i$uratio#& loss o% (oth olarity o% cells a#! #or*al strati%icatio# o% the e itheliu*& #uclear cha#$es& such as i#crease! #uclear-cyto las*ic ratio& hy erchro*atis* a#! leo*or is*& *itoses i# the u er layers o% e ithelliu*& a(#or*al *itoses& i#!ivi!ual cell +erati#isatio# o%te# i# !ee layers '!ys+eratosis or re*ature +erati#isatio#)& a#! loss o% celllular cohesio# -three !e$rees o% !ys lasia ca# (e !isti#$uishe!- *il!& *o!erate& a#! severe

MALI9NANT T;MORS OF ORAL M;COSA '2 Oral s8 amo s cell carcinoma -accou#ts %or over ?@A o% all *ali$#a#t tu*ors o% oral cavity- *ore co**o# i# ol!er *e#
it is i* orta#t to co#si!er the site o% i#volve*e#t -*ost co**o#ly it arises i# the lo"er li '6@A)& lateral *ar$i# o% the to#$ue '3@A)& %loor o% *outh '1BA)i#volve*e#t o% the u er li & alate& $i#$iva a#! to#sillar area is less co**o# -etiolo$ic %actors i#clu!e ci$arette a#! i e s*o+i#$& alcohol& the li is *ore co**o#ly a%%ecte! i# "hite-s+i##e! eo le e0 ose! to rolo#$e! su# li$htarticularly hi$h *ale re!o*i#a#ce -$rossly- the lesio# oral ca#cer *ai#ly rese#ts as a# ulcer& lu* & or re! or "hite

-histolo$ically- *a7ority o% oral ca#cers are "ell or *o!eratelly !i%%ere#tiate! s,ua*ous cell carci#o*as

"ell-!i%%ere#tiate! carci#o*a- is co* ose! o% e ithelial isla#!s "hich rese*(le #or*al strati%ie! s,ua*ous e itheliu*& e0ce t that they are i#va!i#$ the u#!erlyi#$ tissues a#! sho" a(erra#t a(#or*al +erati#i.atio#& there is o%te# a ro*i#e#t +erati# %or*atio# i# the i#%iltrati#$ isla#!s& usually stro#$ host res o#se o% ly* hocytes i# the stro*a& the tu*or *ay (e %ra#+ly !ee ly i#vasive oorly !i%%ere#tiate! carci#o*a- are associate! "ith oorer ro$#osis& +erati# %or*atio# is *i#i*al& *ali$#a#t cells !o #ot e0hi(it !isti#ctio# (et"ee# (asal a#! su ra(asal o ulatio#& *itoses are *ore %re,ue#t& a#! host res o#se is usually less co#s icuous tha# i# (etter !i%%ere#tiate! carci#o*as
- oorly !i%%ere#tiate! carci#o*as are so*eti*es !i%%icult to (e !isti#$uishe! %ro* other *ali$#a#cies& such as hi$h $ra!e ly* ho*as& *ali$#a#t *ela#o*as a#! sarco*as- correct !ia$#osis ca# (e hel e! (y *ea#s o% i**u#ohistoche*istry usi#$ a#ti(o!ies a$ai#st e ithelial *ar+ers 'cyto+erati#)& *ese#chy*al *ar+ers 'vi*e#ti#& !es*i#& acti#)& a#! *ela#o*a *ar+ers& etc - atter#s o% s rea!- *uscle& a!i ose tissue a#! other co##ective tissue te#! to (e i#va!e! rea!ily (y oral ca#cer& salivary $la#! tissue a#! (o#e rovi!e so*e resiste#ce to i#vasio# -ly* h #o!e s rea! is a relatively late %eature o% oral ca#cer- the atter# %ollo"s the *ai# a#ato*ical !rai#a$e ath"ays %ro* the ri*ary site- *ost co**o#ly i#volve! is su(*a#!i(ular ly* h #o!e

ro$#osis a#! treat*e#t 8 !e e#!s o# the sta$e o% the !isease a#! o# the site o% ri*ary tu*or

- co* are! "ith %avoura(le ro$#osis %or li ca#cer- treate! (y sur$ery alo#e or co*(i#atio# o% sur$ery a#! ra!iothera y- %ive-year survival is arou#! C@A -i#traoral ca#cer has oor ro$#osis- B-year survival lo"er tha# 6@A -other si$#i%ica#t a!verse %actor is the si.e o% tu*or at rese#tatio# -ly* h #o!e *etastases& ol! a$e '*ore tha# C@)& a#! !i%%ere#tiatio#- a!verse ro$#ostic %actors oor histolo$ical

*2 /err co s carcinoma- is a varia#t o% oral s,ua*ous cell carci#o*a "ith re!o*i#a#tly e0o hytic $ro"th atter#& "ith *i#i*al i#vasio#&
*icrosco y- sho"s aca#thosis "ith lo" !e$ree o% e ithelial aty ia& the a!va#ci#$ *ar$i# o% the tu*or %or*s ushi#$ *ar$i# rather tha# the %i#$er-li+e i#vasio# o% s,ua*ous cell carci#o*a -it te#!s to have a rather i#!ole#t course "ith *i#i*al i% a#y ca acity %or *etastases- very $oo! ro$#osis- treat*e#t - o#ly sur$ery& ra!iothera y shoul! (e avoi!e!