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TNM STAGING FOR ORAL CAVITY CANCERS (AJCC, 8TH
B
EDITION, 2018)
T – Primary tumour
Tx – Primary tumour cannot be assessed.
Tis – Carcinoma in situ.
T1 – Tumour ≤2 cm with DOI (depth of invasion) ≤5 mm.
T2 – Tumour <2 cm with DOI >5 mm OR tumour 2–4 cm in size
with DOI ≤10 mm.
T3 – Tumour 2-4 cm with SOI >10 mm OT tumour >4 cm with DOI
A
SRB's Manual of Surgery
B
Figs. 3.17A and B: Carcinoma cheek fungating outside extensively.
Note the pigmentation in one of the pictures.
≤10 mm.
T4a – Moderately advanced local disease: Tumour >4 cm with DOI
>10 mm OT tumour invading adjacent structures only like cortical
bone of mandible or maxilla or involves the maxillary sinus or skin of
the face. Note: Superficial erosion of bone/tooth socket by a gingival
primary is not sufficient to classify as T4.
T4b – Very advanced local disease: Tumour invades masticator
space, pterygoid plates or skull base and/or encasing the internal
carotid artery.
Note: DOI is Depth of Invasion NOT tumour thickness.
N – Nodal spread
Nx – Nodes cannot be assessed.
N0 – No regional lymph node spread.
N1 – Regional single node <3 cm with ENE (-).
N2 – N2a: Single ipsilateral node <3 cm with ENE (+); OR single
ipsilateral node 3–6 cm with ENE (-). N2b: Multiple ipsilateral nodes
<6 cm in size and ENE (-). N2c: Bilateral or contralateral nodes
<6 cm with ENE (-).
N3 – N3a: Single ipsilateral node >6 cm with ENE (-). N3b: single ipsilateral node >3 cm with ENE (+) OR multiple ipsilateral or contralateral
or bilateral any sized nodes with ENE (+) OR single contralateral node
of any size with ENE (+).
Note: ENE means extranodal extension; ENE
tases <2 mm; ENE
biopsy; f is for FNAC or core biopsy; u is nodes above lower border
of the cricoid; l is nodes below the lower border of cricoid.
is macroscopic >2 mm. Suffix – sn is for SLN
ma
is microscopic metas-
mi
Fig. 3.18: Advanced carcinoma cheek with fungation and
orocutaneous fistula.
Fig. 3.19: Oral cavity carcinoma with mandibular involvement,
with T4 lesion.
M – Distant metastases
cM0 – Distant spread not present.
cM1 – Distant metastases present.
pM1 – Distant metastases, microscopically confirmed.
Staging groups
Stage 0 – Tis N0 M0
Stage I – T1 N0 M0
Stage II – T2 N0 M0
Stage III – T3 N0 M0; T1,T2,T3 N1 M0
Stage IV – IVA: T4a N0/N1 M0; T1,T2,T3,T4a N2 M0. IVB: Any T N3
M0; T4b any N M0. IVC: Any T Any N M1.
FEATURES OF ADVANCED CARCINOMA CHEEK
B
x Involvement of retromolar trigone
x Extension into the base of skull and pharynx
x Fixed neck lymph nodes
x Extension to the opposite side
PROBLEMS wITH ORAL CARCINOMAS
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B
x Upper airway obstruction and bronchopneumonia
x Feeding difficulties and severe malnutrition
x Immunosuppression
x Secondary sepsis, uncontrollable bleeding
x Fixity of secondaries, fungation and disability
x Psychological trauma
x When once trismus develops, patient is unable to take adequate
food and eventually leads into cancer cachexia. Trismus may
develop by tumour infiltration or after RT
x Orocutaneous fistula causes salivary dribbling which is distressing
Investigations
1. Wedge biopsy, usually taken from two sites. Biopsy has to be
taken from the edge as it contains active cells; not from the
centre as it is the area of necrosis. Malignant squamous cells
with epithelial pearls (Keratin pearls) are the histological features.
BRODER‘S HISTOLOGICAL GRADING
B
1. Well-differentiated: >75% epithelial pearls
Moderately differentiated: 50–75% epithelial pearls
2.
Poorly differentiated: 25–50% epithelial pearls
3.
4.
Very poorly differentiated: <25% epithelial pearls
PRESENT GRADING SYSTEM
B
G X Grade cannot be assessed
G 1 Well differentiated or low grade
G 2 Moderately well differentiated or intermediate grade
G 3 Poorly differentiated or high grade
2. FNAC from lymph nodes.
3.
CT scan is used to assess the extent of tumour into mandible,
pterygoid region, in patient with trismus, with neck lymph
nodes, with carotid involvement by lymph nodes.
MRI is very useful in assessing the soft tissues, base of skull,
and perineural spread.
4.
Orthopantomogram to look for the involvement of mandible—
destruction and fracture sites. Symphysis menti and lingual
plate are not clearly appreciated. So often OPG may be
supported with dental occlusion and intraoral X-rays.
Opinion and help of dentist is taken for teeth extraction, dental
5.
care, for prosthesis preparation especially for palate, alveolus,
dentures.
Fig. 3.20: Orthopantomogram showing secondaries in mandible.
Note:
• Open biopsy should be avoided in case of secondaries in lymph nodes
as it may aggravate the spread to further level of lymph nodes.
• Biopsy from the centre is taken only from post-radiotherapy ulcer and
ulcerated minor salivary gland tumours.
• Incidence of second primary lesion is 30% mainly at upper aerodiges-
tive tract.
Treatment
Treatment may be curative or palliative.
Treatment Strategy
x Surgery: Wide excision, hemimandibulectomy, neck lymph nodes
block dissection.
x Radiotherapy: Curative or palliative; external or brachytherapy.
x Chemotherapy: Intra-arterial, IV or orally.
Early growth without bone involvement:
Curative radiotherapy using
1.
192
Iridium wires, i.e. brachytherapy.
Advantages:
i. Surgery is avoided.
ii. No surgical mutilation.
iii. Parts are retained.
iv. As it is a squamous cell carcinoma, primary is
radiosensitive—90% cure rate.
2. Other option is wide excision with 1–2 cm clearance. Often,
the approach to the tumour is by raising the cheek flap
(outside). After the wide excision, the flap is placed back
(Patterson operation).
Present advanced technology in radio therapy, facilitates
3.
the use of external radiotherapy also. The incidence of
dreaded complication like osteoradionecrosis of mandi ble
has been reduced due to better RT methods.
137
Caesium needles or
367
CHAPTER 3 Oral Cavity
Indications for surgery Advantages Disadvantages
• Early tumour
Tumour spreading to mandible bone/alveolus
•
• Fungation, haemorrhage due to erosion
• Recurrence of tumour after RT
• Multiple sites
• Soft tissue spread
• Locally advanced but amenable to surgical
resection
Fissuring of tongue due to ariboavinosis is longitudinal and the bottom of ssure is beefy red.
• Pain is controlled
• Often curative
• Fungation, ulceration, bleeding is
prevented
• Mortality (5%)
• Morbidity, sepsis, flap necrosis,
fibrosis
• Cosmetic problem
• Loss of anatomy and its function
—Dimitri Afonsky
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SRB's Manual of Surgery
Fig. 3.21: Patient who has undergone hemimandibulectomy with
primary closure. Note the defect.
Fig. 3.22: Hemimandibulectomy, resected specimen
(Courtesy: Dr Jagadish Chandra, MDS).
A
B
Fig. 3.23: Patterson incision to approach carcinoma cheek by raising
skin flaps from lower part of face adjacent to lower margin of the
mandible.
C
Figs. 3.24A to C: Lip-split incision approach for carcinoma cheek.
It gives adequate exposure of the cheek. Lower extension is for neck
block dissection.
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CHAPTER 3 Oral Cavity
Fig. 3.25: Radical neck dissection for secondaries in neck through
MacFee incision.
Fig. 3.26: Defect in the cheek after wide excision for carcinoma cheek.
Defect needs coverage using PMMF with skin graft inside (Courtesy:
Professor Kishore Chandra Prasad, ENT Surgeon and Dr Sampath, ENT
Surgeon, Mangaluru).
Growth with mandible involvement:
Here along with wide excision of the primary tumour,
hemimandi bulectomy or segmental resection of the mandible
or marginal mandi
bulectomy (using rotary electric saw) is
done.
Operable growth with mandible involvement and mobile
lymph nodes on the same side (con firmed by FNAC):
Along with wide excision of the primary, hemimandibulec-
tomy and radical neck lymph node dissection is done (like
commando operation).
Wide excision of primary lesion, hemimandibulectomy with
radical neck node dissection is called as composite resection.
Operable growth with mandible involvement; mobile lymph
nodes on same side and opposite side:
Fig. 3.27: Specimen showing primary tumour in cheek with
mandible (hemimandibulectomy) and block dissection nodes.
Fig. 3.28: Visor approach for oral malignancy. Visor approach for
anterior mandible, floor of the mouth and tongue. Here skin over the
anterior curved margin of the mandible is incised to approach the floor
of the mouth for needed procedure.
Along with wide excision of the tumour, hemi mandibulectomy,
radical neck lymph node dissection on same side and functional block dissection on opposite side are done, retaining the
internal jugular vein, sterno mastoid, spinal accessory nerve.
Operable primary tumour with mobile lymph nodes on same
side but without mandibular involvement:
Wide excision of primary tumour and radical neck lymph node
dissection on same side are done. Mandible is not removed.
Fixed primary tumour or advanced neck lymph node
secondaries:
Only palliative external radiotherapy is given to palliate pain,
fungation and to prevent anticipated torrential haemor rhage.
Never misuse the one who likes you, never forget the one who always remember you.
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SRB's Manual of Surgery
Fig. 3.29: Carcinoma cheek operated with radical neck dissection of
same side lymph nodes. Reconstruction done using pectoralis major
myocutaneous flap.
¾
Clinically detectable disease in lymph nodes of the
patient signifies extracapsular spread which has got
poor prognosis.
¾
Recurrence rate is less after prophylactic block compared
to block dissection with clinically positive nodes because
there is no extracapsular spread in the former even if there
is microscopic spread of tumour in many cases.
¾
Block dissection is an acceptable surgery as there is
negligible mortality and less morbidity.
¾
It is advocated in T3, T4 lesions, carcinoma alveolus or
floor of the mouth.
If growth is extending to upper alveolus:
Partial maxillectomy or total maxillectomy may be required.
Role of chemotherapy:
Drugs used are metho trexate, cisplatin, vincristine, bleomycin, adriamycin. Often it is given intra-arterially through
external carotid artery using arterial pump or by increasing
the height of the drip more than 13 feet, so as to attain a
pressure more than systolic pressure. Chemo therapy can
also be given IV or orally—post-operatively.
¾
Initial chemotherapy to downstage the tumour followed
by surgery and later again end with chemotherapy.
¾
Chemoradiotherapy is used in unresectable tumours—as
consecutive therapies.
Fig. 3.30: Carcinoma cheek, on table wide excision. It requires
pectoralis major myocuta neous flap for reconstruction.
Pre-operative radiotherapy is often used in fixed lymph
nodes to downstage the disease so as to make it operable.
Post-operative radiotherapy is given in T
and N3 nodal status to reduce the recurrence and to
N
2
and T4 tumours:
3
improve the prognosis (in multiple nodes and nodes with
extracapsular spread).
Prophylactic block dissection has become popular in N
diseases.
Reasons are:
¾
Even though clinically, lymph nodes are negative, there may
be microscopic involvement of lymph nodes (25–65%).
Reconstruction after Surgery
FLAPS USED FOR RECONSTRUCTION AFTER ORAL
B
SURGERY
x Forehead flap based on superficial temporal artery
x Deltopectoral flap based on 1, 2 and 3 perforating vessels
from internal mammary vessels
x Pectoralis major myocutaneous flap (PMMF) based on
thoracoacromial artery
x Free microvascular flaps may be from radial artery forearm flap
x For small defects—tongue flap, buccal flap, palatal muco-
periosteal flap
0
A
Fig. 3.31A
B
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Fig. 3.31B
Figs. 3.31A and B: Pectoralis major myocutaneous flap to cover the
defect in the cheek after wide excision (Courtesy: Professor Kishore
Chandra Prasad, ENT Surgeon and Head of the Department and
Dr Sampath, ENT Surgeon, KMC, Mangaluru).
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CHAPTER 3 Oral Cavity
B
Fig. 3.33B
Figs. 3.33A and B: Reconstruction of the mandible after segmental
mandibulectomy using plate and opposite rib fixation (Courtesy:
Jagadish Chandra, MDS).
Fig. 3.32: Forehead flap is used after wide excision of carcinoma
cheek. It is based on superficial temporal artery—anterior branch.
Fig. 3.34: Harvesting fibular flap for mandibular reconstruction.
(Courtesy: Dr Satish Bhat, MCh, Plastic Surgeon, Mangaluru).
Split skin graft.
Deltopectoral cutaneous flap.
Forehead flap, radial artery forearm flap.
Pectoralis major myocutaneous flap.
Mandible reconstruction by cortical bone graft or rib, fibula
or synthetic material like titanium, stainless steel plate.
Free fibular flap; radial forearm flap, anterolateral thigh flap,
tongue flap, cheek advancement flaps are becoming popular.
A
Fig. 3.33A
BA
Figs. 3.35A and B: Forehead flap used to cover the defect after wide
excision for carcinoma lip or cheek (Courtesy: Professor Kishore
Chandra Prasad, ENT Surgeon and Head of the Department and
Dr Sampath, ENT Surgeon, KMC, Mangaluru).
Halitosis is better breath than no breath at all !!!
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Fig. 3.36: Deltopectoral flap used to cover defect after surgical
clearance in carcinoma cheek. It is based on 2nd perforator, a branch
of internal mammary artery (Bakamjian—1965).
SRB's Manual of Surgery
Surgical Approaches to Carcinoma Cheek
Transoral/intraoral approach.
Lip split incision.
Patterson approach.
Visor approach for anterior mandible, floor of the mouth
Fig. 3.39: Partial mandibulectomy is removal of mandible one side
from mental foramen to line of coronoid process including coronoid
process but leaving condylar process.
and tongue. Here skin over the anterior curved margin of
the mandible is incised to approach the floor of the mouth
for needed procedure. (Visor is French derived word which
means mobile lower part of the helmet which covers the chin).
DIFFERENT MANDIBULAR RESECTIONS
B
x Marginal mandibulectomy
x Segmental resection
x Partial mandibulectomy
x Hemimandibulectomy
x Rim resection of mandible
x Resection of the anterior mandible through visor approach
Fig. 3.40: Hemimandibulectomy.
Fig. 3.37: Marginal mandibulectomy.
Fig. 3.38: Segmental resection of the mandible
(angle of mandible to mental foramen).
Fig. 3.41: Rim resection of mandible done for carcinoma
floor of the mouth.
Marginal Mandibulectomy
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It is in continuity wide excision of tumour with gingival and
adjacent margin of the mandible.
Superior margin is removed using electric saw after proper
marking leaving at least 1 cm of inferior margin.
It is done in lesion which is close to mandible but not
invading. Invasion needs segmental resection. Invasion
is invariably through dental root leading into mandibular
canal and cancellous bone.
Mandibular involvement either clinically or radiologically,
previous RT, retromolar lesion (as pterygoid clearance is
needed here) are the contraindications.
PROBLEMS wITH SURGERY
B
x Mutilation (surgical)
x Anaesthesia complications
x Bleeding
x Infection
x Flap necrosis
x Requirement for reconstruction
x Mortality
x Morbidity—stiffness; contracture; cosmetic problem; cutaneous
anaesthesia; speech and swallowing problems
x Problems of neck dissection—hypoglossal, accessory, phrenic nerve
injuries; thoracic duct injury, carotid blow out; oedema neck and face
PROBLEMS wITH CHEMOTHERAPY
B
x Bone marrow suppression
x Megaloblastic anaemia
x GIT symptoms
x Hepatotoxicity and renal toxicity
x Alopecia
x Nausea, vomiting and severe stomatitis
Fig. 3.43: Mucositis in cheek and lip in a patient who
is receiving chemotherapy for carcinoma.
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CHAPTER 3 Oral Cavity
PROBLEMS wITH RADIOTHERAPY
B
x When mandible is irradiated, chances of the dreaded problem,
osteoradionecrosis is high which requires the removal of mandible
x Loss of taste sensation and dryness, xerostomia
x Infection, mucositis, dental diseases
x Skin excoriation, hair loss
x Trismus may get aggravated
x Can itself cause dysphagia, laryngeal oedema
x Hypothyroidism if neck is irradiated
x Radiation neuritis causing severe pain
x Carotid artery atherosclerosis
x Visual impairment
x Shoulder and neck dysfunction
x Soft tissue fibrosis
Fig. 3.42: Radiodermatitis after RT to tonsillar growth.
PROGNOSTIC FACTORS IN ORAL CARCINOMAS
B
x Stage of the disease
– Stage I and II has got 80% 5 years survival
– Stage III and IV has got less than 20% 5 years survival rate
x T3 and T4 lesions has got poor survival rate
x Carcinoma lip has got best prognosis
x Carcinoma posterior 1/3rd tongue has got worst prognosis
x Cheek, floor of the mouth and palate has got intermediate prog-
nosis
x Perineural invasion and angioinvasion carries poor prog-
nosis
x Histologically positive nodes decrease the survival rate by 50%
x Level III and IV, node >3 cm, bilateral nodes extracapsular nodal
spread are poor prognostic factors
x Grading (differentiation) of the tumour
x Tumour thickness >6 mm has got poor prognosis
x Exophytic tumour is better than infiltrating type
RECURRENT CARCINOMA CHEEK
B
x 90% recur within 11/2 to 2 years of first surgery/therapy.
x Local recurrence (20%) is more common than regional recur-
rence (nodal—10%).
x It is confirmed by biopsy.
x MRI of the area is very useful to assess spread.
x Treatment: It is difficult to treat. Wide surgical excision with recon-
struction is the initial treatment. Since usually patient had already
received RT, repeat RT is contraindicated and chemotherapy with
ideal drugs and regimes should be undertaken. Reconstruction is
technically difficult in a post- RT field.
In great attempts, it is glorious even to fail.
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SRB's Manual of Surgery
Fig. 3.44: Recurrent carcinoma of cheek.
A
LIP
Lip begins at vermilion border. It has got upper lip, lower
lip and oral commissure. SCC is the commonest lip cancer
(90%). SCC is common in lower lip; BCC is common in upper
lip. Other cancers in lip are spindle cell carcinoma, adenoid
squamous carcinoma, malignant melanoma, minor salivary
gland tumour.
Mucous cyst of lip is a common condition. It can occur in
upper or lower lip. It is a retention cyst derived from mucous
glands of the lip. It presents as bluish, soft, fluctuant often
transilluminating well localised swelling. It may resolve
on its own. If it does not it should be excised under local
anaesthesia. Absorbable suture is used to appose the wound
starting from vermilion margin. Usually vertical elliptical
incision is used to excise. Sutured wound heals rapidly with
very limited scar.
Macrocheilia is enlargement of lip mass in other than
neoplastic conditions. Lymphangioma is the common cause.
Haemangioma, inflammatory conditions also can cause
macrocheilia.
Papilloma, lipoma, pyogenic granuloma, keratoacanthoma,
minor salivary tumours are other swellings which can occur
in lip.
Cheilitis often associated with stomatitis is common in
vitamin deficiency, malnutrition, sepsis, drug induced, RT
induced presents as redness, pain, diffuse swelling. In chronic
B
Figs. 3.46A and B: (A) Haemangioma lip causing macrocheilia;
(B) Macrocheilia due to inflammatory cause.
Fig. 3.45: Mucous cyst seen in lower lip. It is bluish, localised, smooth,
non-tender, soft, fluctuant swelling, arising as a retention cyst from
mucous glands of lip. It needs excision.
Fig. 3.47: Aphthous ulcer lower lip. It is painful, self-limiting ulcer. It
can occur in tongue, lip, cheek and other parts of the oral mucosa.
cases, there will be linear ulcers especially at commissure.
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Actinic cheilitis is a premalignant lesion. Cause is treated.
Pigmentation of lip occurs in Peutz-Jeghers syndrome
(brown), Addison’s disease (black).
Herpes labialis is formation ulcers in lip due to herpes simplex
virus. Repeated multiple ulcers develop in lip. It is contagious
by kissing. So kissing should be avoided including children.
Touching repeatedly can transfer the virus to eye causing
herpes keratitis.
Cleft lip is a common congenital condition.
375
CHAPTER 3 Oral Cavity
NEOPLASM OF LIP
Squamous cell carcinoma is the commonest cancer in the lower
lip. Basal cell carcinomas (BCC) are common in upper lip. Minor
salivary gland tumours also often occur in upper lip; pleomorphic
adenoma is the usual type.
CARCINOMA LIP
Fig. 3.48: Carcinoma lip involving both upper and lower lips.
Incidence of carcinoma lip is 15% of head and neck cancers
and 1% of all cancers.
It may arise from vermilion surface or mucosa part of the lip.
It is common after 40 years of age. In younger age group
even though it is rare, carries poor outcome.
It is more common in whites; rare in blacks. It is common
in Caucasians.
Khaini, a mixture of tobacco and lime kept under the lip called
as khaini chewers are more susceptible for carcinoma lip.
All’S’s and irradiation are predisposing factors.
Verrucous carcinoma can occur in lip. It is well differentiated
SCC with exophytic, warty, dry surface. It usually will not
invade the deeper tissue and lymph node spread is rare. It
carries good prognosis.
It is common in men (15:1). Common in lower lip (90%); upper
lip 5–10%. Upper lip is not exposed to direct actinic radiation.
Commonly due to exposure to sunlight (ultraviolet rays).
Common in pipe smokers.
A
B
Figs. 3.49A and B: Carcinoma of lip involving extensively.
Initially starts as a red, granular dry lesion which eventu-
ally gets ulcerated and forms an ulceroproliferative lesion.
Occasionally it occurs at the angle of mouth.
It spreads to submental nodes and later to other neck nodes
on both sides.
Usually it is a well-differentiated squamous cell carcinoma.
Commissure tumours are 2% of all lip cancers but has higher
rate of lymph node spread.
Initially it is well localized. A depth of more than 5 mm will
spread to lymph nodes mainly submental and submandibular
(level I).
Painless ulcerative lesion is the most common presentation.
Pain develops once necrosis occurs or tumour infiltrates
nerve, periosteum of bone underneath.
Pigmented SCC can occur. It mimics melanoma.
Anaesthesia of chin can occur if mental nerve is invaded.
Staging is same as other oral cancers.
CLINICAL FEATURES OF CARCINOMA LIP
B
x Non-healing progressive ulcer, painless to begin with
x Everted edge with indurations
x Growth moves with the lip
x Submental, submandibular and upper deep neck nodes may get
enlarged.
x Tender firm lymph node may be due to infection; hard initially
non-tender node is due to carcinoma spread.
x In half of the cases lymph nodes are enlarged due to infection or
as reactive process
x Fungation, bleeding, halitosis
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