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354
Manipal Manual of Surgery
• The dose of RT: 6500–7500 cGy units are required to
eradicate squamous cell carcinoma of head and neck.
It is usually given in the daily dose of 180–200 cGy
units.
• Radiotherapy is given in T1 and T2 lesions as the first
line of treatment and postoperatively in T3 and
T4 lesions after surgery.
Role of Surgery (Key Box 35.7)
• Surgery is done in all stages of oral cancers. It may
be in the form of wide excision or wide excision
with removal of the bone (composite resection).
In advanced stages it may be palliative surgery
such as excision of a fungating, ulcerating, bleeding
mass. Surgery is also done for the lymph nodes in
the form of radical neck dissection (RND), or
modified RND.
• The pectoralis major myocutaneous flap (PMMC
flap): It is the most widely used flap for the reconstruc-
tion of oral cancers.
Fig. 35.7: Management of locally advanced nonmetastatic
disease (III to IVB)
used in CCRT can be high dose cisplatin—100 mg/m
IV for 3 cycles every 21 days concomitantly with RT
(for other dosage, kindly refer to oncology manual).
Side effects include severe mucositis, xerostomia.
Gastrostomy may be necessary for feeding.
Radiotherapy (RT) (Key Box 35.6)
• Irradiation of the oral cancers achieves a cure in about
80–90% of patients. It preserves anatomical part and
also preserves the function.
Key Box 35.6
RT: Advantages
Easy, safe with minimal mortality
Preservation of an organ
Function of the part is preserved
Cure rate is around 80–90%
First line in early cases
RT: Disadvantages
Long stay in the hospital (can also be taken as an
outpatient)
Tumour cure cannot be assessed by pathology
Soft tissue fibrosis resulting in ankylostomia
Adverse effects on skin, loss of hair, mucositis of oral
Section II • General Surgery
cavity, xerostomia, etc.
Indications for Surgery
• Early disease, bulky disease
• Tumour involving mandibular alveolus
• Tumour invading bone
2
• Advanced disease
• Fungating and bleeding lesion
• Radiorecurrence
• Multiple tumours
• Extensive premalignant changes of oropharyngeal
mucosa.
Key Box 35.7
Surgery: Advantages
It removes a fungating, ulcerating, bleeding lesion
It relieves the pain
The specimen is available for histopathological
examination for cancer clearance
80–90% cure is possible
Surgery: Disadvantages
Loss of an organ—total glossectomy
Functional and cosmetic disability
Significant morbidity
Mortality: 8–10%
CARCINOMA OF BUCCAL MUCOSA
Carcinoma of the buccal mucosa is very common in
India due to the habit of keeping tobacco quid in the
cheek pouch (gingivoalveolar sulcus).
Oral Cavity, Odontomes, Lip and Palate
355
Pathological Types
1. A nonhealing ulcer, with slough in the centre of the
lesion.
An exophytic growth, or a proliferative growth—
2.
verrucous carcinoma.
3. An infiltrative lesion slowly involves the adjacent
structures such as tongue, mandible, floor of the
mouth and skin. Skin infiltration results in orocutaneous fistula.
SU20.1: Describe etiopathogenesis of oral cancer
symptoms and signs of oropharyngeal cancer.
Clinical Features
Clinical examination should be thorough—not just
visible oral mucosa but also inside and outside of the
lip, examine gums by pulling away the lips, retromolar
trigone, etc.
• A nonhealing ulcer or cauliflower-like growth.
Verrucous carcinoma is an exophytic growth.
• Edges are everted (Fig. 35.8) with induration at the
base as well as at the edge. Induration clinically
presents as a hard feeling. Pathologically, it is due to
fibrosis, caused by malignancy (carcinomatous
fibrosis). It is a diagnostic feature of squamous cell
carcinoma. Possibly, it is a host reaction indicating
good immunity. Due to fibrosis, some lymphatics get
obliterated. This delays spread of the disease, thereby
improving the prognosis.
• Proliferative lesions are often verrucous carcinoma
Box 35.8).
(Key
Key Box 35.8
Peculiarities of Verrucous Carcinoma
Very slow-growing
Growth is exophytic (than infiltrative)
Rarely spreads by lymphatics
It is a well-differentiated carcinoma
Surgery is the treatment of choice
• Ulcer bleeds on touch. Due to secondary infection
most of the oral cancers are tender to touch
(Fig. 35.9).
• Fixity to the underlying structures such as mandible
may be present.
• Surrounding area may also show induration.
• Evidence of leukoplakia may be present in the oral
cavity.
• Trismus is due to involvement of pterygoid muscles
and masseter. This occurs when carcinoma buccal
mucosa extends into the retromolar trigone. Trismus
can also be due to soft tissue fibrosis caused by
radiation. Once perineural lymphatics are involved,
spread can occur in infratemporal fossa resulting
in trismus (Key Box 35.9).
• Retromolar trigone is triangular space behind the third
molar tooth with base above. It is over the mucous
membrane over the ascending ramus of the mandible.
• Halitosis is very characteristic.
• Assessment of fixity to mandible: Severe pain over
the jaw indicates periostitis.
Key Box 35.9
Trismus
Difficulty in opening the mouth is called trismus. Normal
mouth opening ranges from 35 to 45 mm.
Grades
Grade I: Mouth opening is between 2.5 and 4 cm
Grade II: Between 1 and 2.5 cm
Grade III: Less than 1 cm
Common causes of trismus
1. Temporomandibular joint involvement—such as
ankylosis, dislocation, synovitis, etc.
2. Mandible fractures
3. Pterygoid muscle infiltration by growth in the retromolar region
4. Acute inflammatory lesions in the oral cavity
5. Tetanus and tetany
6. Radiation fibrosis of soft tissues/muscles of mastication
Fig. 35.8: Carcinoma alveolar margin. Look at teeth stains—
everted edge
Fig. 35.9: Carcinoma buccal mucosa infiltrating skin—‘warning’
of fistula
Section II • General Surgery
356
Manipal Manual of Surgery
• Bidigital palpation of mandible is done by examining
with index finger on the outer aspect of the mandible
and the thumb on the under surface of the mandible.
This test
should be done on the opposite side first.
Only then, the thickening of the mandible can be
appreciated.
• Gingival cancers (Fig. 35.10)
Early cases present as
–
mucosal change in
leukoplakia
–
Loosening of tooth may
be a presenting feature.
– Can present as bleeding
and pain
– Bone involvement occurs
early
– Spread to adjacent struc-
tures occurs early.
Fig. 35.10: Carcinoma
buccal mucosa infiltrating
mandible—severe trismus
Also observe tobacco stains
Spread
.
Local spread: Once it
1
involves the entire thickness of the cheek it results
in orocutaneous fistula
(Figs 35.8 and 35.11).
Involvement of mandible
results in sinus (Key Box
35.10).
2. Lymphatic spread: Sub-
mandibular nodes and
upper deep cervical nodes
get enlarged (levels
I and II). In 50% of cases, lymph
Fig. 35.11: Carcinoma cheek
with orocutaneous fistula
node enlargement is due to infection and remaining
50%, it is due to metastasis. Metastatic deposits are
hard in consistency, indurated and with or without
fixity. Significant oedema of face can occur due to
lymphatic spread.
. Blood spread: It is very rare and it occurs late.
3
Key Box 35.10
Carcinoma Buccal Mucosa and Mandible
Direct infiltration by the tumour
Through mandibular canal
Through periodontal membrane
Orthopantomogram or spiral CT can be used for imaging
Loss of central part of mandible results in pouting of
lower lip and continuous drooling of saliva. It is called
Andy Gump deformity
1
Andy Gump was one of the characters in a popular comic strip,
‘The Gumps’ created by Sidney Smith in 1917. The character’s
face seems to end at the upper lip due to ‘absence of mandible’
and is chinless. A statue of this comic character is on display at
Lake Geneva Museum
Section II • General Surgery
1
4. Perineural spread along inferior alveolar nerves may
occur up to the skull base. In such cases frozen section
may be required.
The mandibular canal is close to occlusive surface, in edentulous elderly patients due to decrease in the vertical height of
horizontal ramus, thus facilitating easy spread (Figs 35.11A and B)
of oral cancer to mandible.
Treatment of Carcinoma Buccal Mucosa
It can be classified into early disease and advanced
disease.
Early Disease
Two modalities are given in Key Box 35.11.
I. Surgery
1. A small superficial ulcer (T1, T2) is treated by wide
.
excision followed by split skin graft (SSG).
.
An infiltrative lesion is treated with wide excision
2
followed by a flap reconstruction. Usually, PMMC,
flap (pectoralis major myocutaneous flap) is used.
PMMC flap: This is the most widely used flap now
for head and neck reconstruction. The flap is raised
along with muscle and an island of skin based on
pectoral branch of thoracoacromial artery. It is
tunnelled under the skin of chest wall and neck and
brought to the area of the defect. It has been described
as the ‘workhorse’ for head and neck reconstruction.
• Radial artery based flap is the workhorse of micro-
vascular reconstruction.
Key Box 35.11
Early Carcinoma Buccal Mucosa
T1, T2 lesions—surgery/RT
T1 lesion near commissure—RT
T2—exophytic and superficial—RT
T2—deep—surgery is better
Early disease—no nodes—surgery is better—no other
treatment is necessary
Early disease—positive lymph nodes—same modality
to be used for primary and secondary
II. Radiotherapy
As mentioned earlier, early lesions can be managed with
radiotherapy (RT). The advantage of RT is that it cannot
only cure the disease but also preserve the organ and
its function.
Indications for radiotherapy
(1) Patient not willing for surgery, (2) patient not fit for
surgery, (3) T1 and T2 lesions and (
4) lesion near the
commissure.
Oral Cavity, Odontomes, Lip and Palate
357
Types
1. External radiotherapy: Large total dose of 6000–8000
cGy units are given at the rate of 200 cGy units/day.
2. Interstitial radiotherapy is indicated in infiltrative
small lesions. Caesium 137 or iridium wires are
placed within the tumour. Advantage of this method
is minimal tissue reaction.
Advanced Carcinoma Buccal Mucosa
(Figs 35.12 and 35.13)
Surgery: T3 and T4 lesions require surgery as the main
modality of the treatment followed by postoperative
radiotherapy. Most of the lesions require full thickness
resection leaving behind large defects. Such defects can
be repaired using myocutaneous flap.
Fig. 35.12: Carcinoma cheek
with infiltration into the skin and
mandible—locally advanced.
Good case for composite
resection
When the primary lesion is removed en bloc with mandible
and cervical lymph nodes, it is called composite resection.
Fig. 35.13: Carcinoma
alveolus—excavating ulcer
with slough
trigone. RT followed by surgery
is the ideal choice of treatment
, infiltrating retromolar
Examples of Surgeries
1. Carcinoma buccal mucosa fixed to the mandible:
Wide excision of the growth along with segmental
resection of the man-dible or hemimandi-bulectomy
t
is done depending upon the infiltration of
he
tumour. Very often, whole thickness of the cheek is
lost which is reconstructed by using PMMC flap.
Types of Mandibulectomy
Segmental mandibulectomy (Fig. 35.14)
A.
Indications
• Clinical and radiological involvement of bone
• To obtain wide margins
• To facilitate reconstruction when one has to use
‘bulky’ PMMC flap
• Excision of full thickness of cheek.
B. Marginal mandibulec-
tomy: It can be done
for carcinoma floor of
the mouth or tongue.
This involves removal
of either inner or outer
table of the mandible
or excising the superior
rim of the mandible.
However, in large
lesions, it is better not
to do marginal mandibulectomy.
C. Hemimandibulectomy:
Very advanced lesion
may necessitate removal
of mandible.
Various methods of reconstruction of mandible following
excision
• Soft tissue : PMMC flap
• Soft tissue with bone : 2.4 mm reconstruction allo-
• Nonvascularised bone : Titanium tray and cancellous
graft
s chips from iliac crest
• Vascularised bone grafts : Fibula, iliac crest
Fig. 35.14: Segmental mandi-
bulectomy. (Courtesy: Dr Somshekhar, Head, Department of
Surgical Oncologist, Manipal
Hospital, Bangalore
plastic material plate and
PMMC flap
2. Orocutaneous fistula is treated by wide excision
which refers to removal of the entire thickness of
the cheek along with the growth.
Reconstruction is done by using PMMC flap. Radiotherapy should not be given as it results in
persistence of fistula.
3. Carcinoma of the buccal mucosa with lymph nodes:
Along with the primary, submandibular nodes and
upper deep cervical nodes (levels I, II and III) are
removed, along with submandibular salivary gland.
This is called supraomohyoid block dissection. If
surgery has been used to treat the primary, the
lymph nodes also should be treated by surgery in
the form of neck dissection.
4. Carcinoma of buccal mucosa with fixed lymph
nodes: Both primary lesion and lymph nodes
should be treated by radiotherapy and reassessment
done after 3–4 weeks. If residual glands persist or if
the glands become mobile, neck dissection can be
done at a later date. Fixity to internal jugular vein
and sternocleidomastoid muscle are not contraindications for radical block dissection. Those
structures can be removed. However, when the
lymph nodes
are fixed to the carotid artery, radio-
therapy is preferred.
Section II • General Surgery
358
Manipal Manual of Surgery
STEPS OF PECTORALIS MAJOR MYOCUTANEOUS FLAP (PMMC FLAP) (Figs 35.15 to 35.21)
Fig. 35.15: Amount of tissue to
be removed (wide excision) is
ed. Horizontal incision is
mark
given in the neck for block
dissection
Fig. 35.19: Composite resection: Inner
aspect
(Courtesy: Dr Satadru Ray, former Professor and Head, Department of Surgical Oncology, KMC, Manipal)
Fig. 35.16: Skin paddle outlined
prior to elevation
Fig. 35.17: Skin paddle mobilised
Fig. 35.20: Composite resection: Outer
aspect
Fig. 35.18: Flap being turned
out (bipedaled) to provide inner
and outer lining for the tissue loss
Fig. 35.21: Completely mobilised PMMC
flap ready for reconstruction. Main vessels
in the paddle are pectoral branches of
acromiothoracic artery. Mandible
reconstruction is not mandatory
Prophylactic Neck Dissection
• It is advocated in T3 and T4 lesions irrespective of
nodal status. This amounts to minimal supraomohyoid
neck dissection with removal of l
evels I, II and III
lymph nodes. It has shown survival benefits.
• It is also indicated in carcinoma mandibular alveolus
or buccal mucosa extending into the floor of the
mouth.
Complications of Carcinoma Buccal Mucosa
1. Orocutaneous fistula
. Trismus: It can be due to direct infiltration of
2
pterygoid muscles or masseter or soft tissue fibrosis
Section II • General Surgery
following RT.
3. Recurrent respiratory tract infection
4. Cancer cachexia
CARCINOMA OF TONGUE
Pathological Types
1. Nonhealing ulcer, commonly on lateral border of
tongue in 60% of cases, with slough (Fig. 35.22)
2
. A proliferative growth, with everted edge
3. Frozen tongue or indurated variety (Fig. 35.23)
In this variety, there is maximum induration and
sometimes it is more than the size of tumour. The
tongue is converted into a hard woody “mass”.
4. Fissure variety: The tongue is indurated with deep
fissure.
Oral Cavity, Odontomes, Lip and Palate
spitting blood-stained saliva is suggestive of
carcinoma posterior 1/3rd of the tongue.
• Foetor oris is due to infected necrotic growth.
• Bilateral massive enlargement of lower deep cervical
nodes in an elderly patient is suggestive of carcinoma
of posterior 1/3rd. The patient may not be aware of
growth at all.
359
Fig. 35.22: Carcinoma
tongue lateral border—the
most common site
Fig. 35.24: Carcinoma
posterior 1/3rd easily missed
Fig. 35.26: Carcinoma tongue with absolute dysphagia, fixed
lymph nodes in the neck and involvement of mediastinal lymph
nodes-receiving radiotherapy—on Ryle’s tube feeding
Fig. 35.23: Frozen tongue—
ankyloglossia and dysphagia are
present
Fig. 35.25: Carcinoma tongue—
excavating ulcer
Clinical Presentation
• A bleeding ulcer non-healing and progressive
• Pain in the tongue is due to involvement of lingual
nerve. In such cases, pain from the tongue can be
referred to the ear and lower temporal region.
1
• Ankyloglossia is restricted mobility of the tongue. It
is due to infiltration of the floor of the mouth or mandible, or due to an advanced lesion (Figs 35.24 to 35.26).
• Disarticulation—difficulty in talking is due to
inability of the tongue to move freely.
• Dysphagia is a common presentation from carcinoma
of posterior 1/3rd (in 20% of cases). An elderly
gentleman sitting in the outpatient department
Tongue cancers tend to be more rapid in their onset than other
cancers in the oral cavity. Compared with other cancers within
the oral cavity, tongue cancers have greater potential of lymph
node metastasis.
Clinical Examination
• Inspection and palpation of the growth or the ulcer
should be described in the same manner as that of
carcinoma cheek. Typically, the ulcer bleeds on touch
with central slough. The edge, base and surrounding
area are indurated. Carcinoma of the tongue and
carcinoma of the penis are two places in the body
wherein induration can be much more extensive than
the primary growth or an ulcer. In some cases,
induration may be the only finding. Everted edge is
commonly seen (Figs 35.22 to 35.26).
• Digital palpation of posterior 1/3rd of tongue should
be done with a glove.
• Test for mobility of the tongue.
– Forward protrusion—genioglossus. This is the
muscle commonly involved.
– Backward movement—styloglossus
– Elevation—palatoglossus
– Depression—hyoglossus
All these muscles are supplied by hypoglossal
nerve except palatoglossus which is supplied by
glossopharyngeal nerve.
• Bidigital palpation of the mandible should be done
which may show thickening.
Lymphatic Spread (Fig. 35.27)
1. Apical vessels drain the tip of the tongue into sub-
mental lymph nodes, bilaterally.
2. Lateral vessels drain into submandibular lymph
nodes, from here to the lower deep cervical lymph
nodes and jugulo-omohyoid nodes—level
III.
3. Central vessels drain into submandibular nodes.
4. Basal vessels drain the posterior 1/3rd of the tongue.
There is criss-crossing of the lymphatics on both sides.
Hence, they drain into bilateral lower deep cervical
lymph nodes.
1
Auriculotemporal nerve and lingual nerve are posterior branches of mandibular division of trigeminal nerve.
Section II • General Surgery
360
Fig. 35.27: Lymphatic drainage of the tongue—see text for
numbers
Manipal Manual of Surgery
• In 50% of cases, the lymph node enlargement is
due to secondary infection. Such nodes are tender
and firm and respond to antibiotics. In remaining
cases, they are hard and fixed and hence, significant. However, in all such cases of lymph node
enlargement, ultrasound guided FNAC is done.
Posterior 1/3rd of tongue has very less cornification but has abundant lymphatics which explains massive nodes (Key Box 35.12).
biopsy can be taken under general anaesthesia. It
also provides an opportunity to examine in detail
the posterior spread of the disease into tonsils,
pharynx, etc. Biopsy is done to confirm the diagnosis,
to know the grade of the tumor (Broder’s classification page 256) and depth of invasion. More the
keratin pearls means it is well-differentiated
squamous cell carcinoma.
2. Orthopantomogram: X-ray of the mandible can
demonstrate an irregular defect due to invasion,
erosion or pathological fracture.
3. Chest X-ray is taken to rule out aspiration or inhala-
tion pneumonia.
4. Routine investigations such as complete blood picture,
fasting and postprandial sugar estimation to rule out
diabetes and electrocardiography to assess cardiovascular function should be done. These patients will
undergo often combined modalities specially in
advanced stages. ECOG criteria should be calculated.
5. Tongue lesions respond well to surgery and to
decide partial or hemiglossectomy MRI is the ideal
investigation.
Treatment
Carcinoma of the tongue is managed similar to a cancer in
the oral cavity. However, to preserve the function of the
tongue, widespread disease in the posterior one-third
tumours,
general health of patient (elderly with bad
bronchopneumonia) may decide the treatment in favour
of radiotherapy. However, results of surgery or radiotherapy for early carcinoma of tongue are equivalent.
Key Box 35.12
Carcinoma Posterior 1/3rd
It presents with dysphagia or with a change in voice.
Easily missed in a clinical examination
Biopsy should be done under general anaesthesia to
avoid aspiration and to assess the spread posteriorly.
Palpation will give the diagnosis—induration
It is one of the occult primaries for lymph node
secondaries in the neck.
Criss-crossing of the lymphatics explain bilateral
lymph nodes in the neck.
Blood spread is more common.
Prognosis is bad because well-differentiated carcinoma
in this location is rare.
Investigations
1. Wedge biopsy from edge of the ulcer can be taken
under local anaesthesia. In cases of proliferative
growth, punch biopsy is recommended. In cases of
Section II • General Surgery
growth arising from posterior 1/3rd of the tongue,
Various Types of Surgery
. Carcinoma in situ: This type is uncommon in our
1
country. Wide excision with 1 cm margin and a depth
of 1 cm is sufficient. Reconstruction of the tongue is
not necessary.
2. Partial glossectomy is indicated when the lesion is
less than 2 cm (T1) and confined to the lateral border
of the tongue. The principle is to do wide excision.
The wide excision should include at least 2 cm of
tissue away from the palpable indurated edge of the
tumour (Figs 35.28 to 35.30).
• Alternatively, radiotherapy can be given.
Fig. 35.29: HemiglossectomyFig. 35.28: Partial glossectomy
Oral Cavity, Odontomes, Lip and Palate
361
Fig. 35.30: Partial glossectomy done with the help of laser—
excellent tool for haemostasis. (Courtesy: Dr Balakrishnan,
Professor, Department of ENT and Head and Neck, KMC, Manipal)
3. Hemiglossectomy refers to removal of around 50%
of the tongue. This is indicated in a radio-residual
tumour, radio-recurrent tumour or where radiotherapy facilities are not available (Fig. 35.29).
Reconstruction of the tongue can be done by nasolabial flap and division of pedicle at a later date.
Radial forearm free flap can also be used.
4. Total glossectomy: Indications are similar to those
mentioned above. However, very extensive growth
involving the entire tongue is given radiotherapy
initially, to reduce the size of the tumour. Surgery
can then be undertaken. Total glossectomy carries
significant mortality and morbidity.
5. Commando’s operation: This is indicated when
carcinoma of tongue is fixed to the mandible with
infiltration of the floor of the mouth. Hemiglossectomy
with hemimandibulectomy, removal of the floor of
the mouth and radical neck dissection is described
as Commando’s operation (Key Box 35.13).
• However, in a few selected cases, removal of the
hemimandible is not necessary. Growth which
Key Box 35.13
Structures Removed in Radical Block
Dissection of the Neck
The fat, fascia, lymphatics from midline to the anterior
border of trapezius, from mandible to clavicle below.
The lymph nodes—submental, submandibular, upper
and lower deep cervical nodes, posterior group of
nodes (levels I–V).
Submandibular salivary gland, sternocleidomastoid
and one side internal jugular vein (IJV) are sacrificed.
Spinal accessory nerve is removed.
Lower pole of parotid is removed to facilitate lymph
node clearance.
Fig. 35.31: Modified radical neck dissection is in progress—
internal jugular vein, carotid artery and vagus nerve are seen
is close to the margin of the mandible without
infiltration (confirmed by X-ray) needs to be treated
by marginal mandibulectomy. Carcinoma of the
tongue with involvement of only a small portion
of mandible can be managed by segmental
excision. Advantage of this method is that it is not
only cosmetic but also preserves the function of
the tongue by preserving genioglossus. Hence, the
tongue may not fall backwards after surgery.
Treatment of Lymph Nodes (Fig. 35.31)
• Lymph node metastasis in the neck from squamous
cell carcinoma can be managed both by surgery as
well as radiotherapy. Radiotherapy can be given in
all stages of secondaries in the neck. However, its
main indication is a large primary tumour with neck
nodes. In such situations both the primary and
secondary can be managed with radiotherapy alone
which carries minimal morbidity and mortality.
• If the general condition of the patient is good and
the lymph nodes are hard and mobile, hemiglossectomy with excision of the floor of the mouth
with radical dissection of the neck is done
(Commando’s operation).
• If radical neck dissection has to be done on both
sides, the IJV should be preserved at least on one
side to prevent cerebral oedema. In such cases,
radiotherapy is a very good alternative.
Please note: Details about radical neck dissection is given in
Chapter 34, page 341.
Causes of Death in Carcinoma Tongue
1. Recurrent aspirational pneumonia
2
. Gross local recurrence, fungation, ulceration,
cachexia.
Section II • General Surgery
362
Manipal Manual of Surgery
3. Uncontrolled haemorrhage from growth: In such
cases, ligation of external carotid artery above
superior thyroid branch should be done (Fig. 35.32).
If ligature is applied below the origin of superior
thyroid artery, it results in eddy currents and
thrombus at bifurcation of common carotid artery.
Fig. 35.32: Ligation of external carotid artery
CARCINOMA OF LIP
• Incidence of carcinoma of the lip is about 10 to 12%.
It is common in the western, elderly, white people,
specially those exposed to sunlight. The actinic rays
produces actinic cheilitis—inflammation of the lip,
especially lower lip, which over a period of years can
turn into malignancy.
• Sinc e this is common in agriculturists, who are cons-
tantly exposed to sunlight, it is called Countryman’s
lip (Key Box 35.14).
• Carcinoma lip includes growth arising from
vermilion surfaces and mucosa.
• Leukoplakia is also responsible for squamous cell
carcinoma. Smoking, spirits and spices are the
common precipitating factors.
• Genetic factors also may play a role. Blacks are less
susceptible. On the other hand, increased incidence
of carcinoma lip has been found in Caucasians.
• Khaini chewers are more susceptible for carcinoma
of the lip (khaini is a mixture of tobacco and lime).
• It can also present as verrucous carcinoma of lip.
Clinical Features (Figs 35.33 and 35.34)
• Elderly males are affected in 90% of cases.
• Nonhealing ulcer or growth is a common presenta-
tion.
• Edge is everted and indurated. Induration of the edge
and the base is characteristic.
• Floor is covered with slough. Bleeding spots may be
visible.
• Mobility: Ulcer or the growth moves with the lip, it
is fixed to the subcutaneous structures of the lip.
• The entire upper lip and lateral portions of the lower
lip drain into upper deep cervical nodes. Central
portion of the lower lip drains to submental nodes
and submandibular nodes. Like elsewhere in the oral
cavity, in 50% of the cases, nodes are enlarged due to
secondary infections. In remaining 50% of the cases,
they are enlarged due to metastasis. Such nodes are
hard, with or without fixity. Blood spread is uncommon.
Fig. 35.33: Carcinoma lip—
everted edge and exophytic
growth—also observe coating
of the tongue
Fig. 35.34: A bleeding exophytic
lesion. Better managed by surgery
than radiotherapy
Key Box 35.14
Section II • General Surgery
Countryman’s Lip
Sunlight
Actinic rays
Cheilitis
Erythema
Cracks
Differential Diagnosis (Key Box 35.15)
In a classical case of carcinoma of the lip with everted edges
and induration, there is no differential diagnosis. However,
following are a few conditions to be remembered:
Key Box 35.15
Differential Diagnosis of Carcinoma Lip
Keratoacanthoma
Ectopic salivary gland tumour
Pyogenic granuloma
Leukoplakia
Oral Cavity, Odontomes, Lip and Palate
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1. Keratoacanthoma
• It is a cutaneous tumour arising from hair follicles
on the lips. It is common in White, Western males
between 50 and 70 years of age.
• Sunlight (actinic rays), chemical carcinogen, viral
factors may be responsible for this lesion.
• The central portion of the nodule may ulcerate. The
lesion may progress for 6 weeks and may resolve
spontaneously within 4–6 months.
2. Ectopic salivary gland tumour
• The lip is one of the common sites of malignant
salivary gland tumours. This presents with submucous nodules that grow slowly and ulcerate and
may mimic squamous cell carcinoma (Fig. 35.35).
• They are also indurated lesions.
• However, the characteristic everted edge may not
be seen.
• These are adenocarcinomas which are treated by
surgery.
3. Pyogenic granuloma
• Recurrent infections or trauma produces a poly-
poidal mass with significant bleeding.
• It is rich in granulation tissue and resembles a polyp.
• It is devoid of epithelium.
• Histologically, it is a capillary haemangioma.
• Absence of induration gives the diagnosis.
4. Leukoplakia
A slow developing leukoplakia presents as whitish
nodule or an ulcer. However, biopsy confirms the
diagnosis.
Treatment
Surgery and radiotherapy are the two modalities
available for the treatment of carcinoma of the lip.
I. Surgery
• T1 and T2 lesions can be excised followed by direct
suturing without much functional problems. This is
described as “V” excision which includes removal of
growth with 1 cm healthy margin. Care should be
taken to excise full thickness of the lip.
• When removal of more than 1/3rd of the lip is
required, flap reconstruction may be necessary. The
primary goal in lip reconstruction surgery is oral
competence.
Examples
1. Abbe flap: Based on upper labial artery—a
pedicled flap is rotated down and sutured to the
defect at the lower lip (Fig. 35.38).
Estlander’s flap: Wedge-shaped flap is used to
2.
reconstruct carcinoma of lower lip, when it
involves the angle (Fig. 35.37).
• Larger tumours: T3 and T4 lesions are irradiated
first. If the tumour persists after radiotherapy,
excision of the entire lip may be necessary followed
by PMMC flap reconstruction.
• Significant lymph nodes can be removed along
with the primary tumour—supraomohyoid block
dissection.
II. Radiotherapy
• It is indicated in all stages of carcinoma of the lip.
Radiotherapy produces tumour necrosis resulting in
a slow-healing rate. Treatment lasts for several weeks
and it delays the wound healing. Elderly patients who
are not fit for surgery and carcinoma lip with fixed
nodes are treated by irradiation.
• Commissure involvement is treated with RT than
surgery.
• Dose: 4000–6000 centigray (cGy) units.
Fig. 35.35: This lesion was diagnosed as carcinoma lip. However,
it did not have everted edges. It was indurated. Biopsy reported
as ectopic salivary gland tumour. On careful questioning, patient
says it started as a swelling not as an ulcer
Reconstruction of the Lips
• There are various methods available to reconstruct
the lip
• Up to 1/3rd of the lip can be sacrificed with direct
closure
• Details are given on page 364 and summary
(Table 35.2).
Please note: Students are advised to refer plastic surgery books
for more details. Knowledge of some of these flaps will help you
in getting more marks in the examinations.
Section II • General Surgery