41.Oral and Oropharyngeal Cancer and Precancer

8/13/2019 41.Oral and Oropharyngeal Cancer and Precancer

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41 Oral and oropharyngeal cancer and precancer

JOHN D. LANGDON

Oral and oropharyngeal cancer In global terms, oraloropharyngeal cancer is the sixth most common malignancy. Inthe estern !orld it acco"nts #or only $% per cent o# all malignant t"mo"rs,altho"gh there is no! good e&idence to sho! that the incidence is increasing

partic"larly in yo"nger people. 'y contrast, in Asia oraloropharyngeal malignancyis the commonest malignant t"mo"r !hich in parts o# India acco"nts #or no less than%( per cent o# all malignancy. It is estimated that globally there are nearly )(( (((ne! cases ann"ally and that by the year $((( there !ill be *.) million people ali&e!ith oral cancer at any one time.Oraloropharyngeal cancer is an almost entirely pre&entable disease being ca"sed by

tobacco either !ith or !itho"t alcohol. In the est this is mostly cigarette smo+ingcombined !ith alcohol ab"se, the ris+ o# both in combination being greater than thes"mmation o# the ris+s o# each indi&id"ally.In Asia and the ar -ast the "se o# an and re&erse smo+ing are the ma/or aetiologicalagents. -pidemiological e&idence strongly s"ggests that again it is the presence o#tobacco in the betel 0"id !hich is the ma/or agent, altho"gh there seems also to besome relationship to the so"rce o# sla+ed lime and the areca n"t itsel#.1he incidence in !omen appears to be increasing and there is a !orrying cohort o#yo"ng patients, mostly male and partic"larly !ith tong"e cancer, !ho sho! a sharpincrease in incidence a#ter a grad"al #all earlier in the t!entieth cent"ry. 1his recenttrend seems not to be related to tobacco and alcohol cons"mption and has been

obser&ed thro"gho"t -"rope and North America.Local control o# disease at the primary site and the management o# nec+ disease ha&eimpro&ed, yet despite this c"re rates and s"r&i&al rates ha&e not impro&ed d"ring thelast %( years remaining at approximately ))per cent s"r&i&al at ) years.'oth rec"rrence o# local disease and #ail"re to control lymphatic metastases in thenec+ are early e&ents and clearly ha&e a negati&e e##ect on )2year s"r&i&al #ig"res.1here is no do"bt, ho!e&er, that d"ring the past $( years great ad&ances ha&e beenmade in the management o# oral cancer, and persistence o# local disease andlymphatic metastasis are no! less common e&ents. hy then ha&e c"re rates notimpro&ed3

ield changes in the "pper aerodigesti&e tract res"lt in the phenomenon o# m"ltiple primary cancers. 1he longer a patient s"r&i&es his or her index t"mo"r, the greater theris+ o# de&eloping a second or third primary t"mo"r either else!here in the oral ca&ityor in the larynx, bronch"s or oesophag"s.-&en i# the patient does not de&elop a second primary t"mo"r, he or she is then at ris+o# de&eloping distant metastatic disease. It is probable that altho"gh "ntil recentlyrarely recognised d"ring li#e, metastasis &ia the bloodstream is a relati&ely early e&entin oral cancer. 4"rrently, $( per cent o# all cancer2related deaths in patients !ith at"mo"r in the oral ca&ity or oropharynx are d"e to distant metastasis !ith no e&idenceo# disease in the head or nec+. 1h"s, oral cancer is a 5systemic6 disease #rom an earlystage.7esection8"rgical ad&ances ha&e been primarily in techni0"es o# access s"rgery and inreconstr"ction. 1he !idespread adoption o# lip splitting and mandib"lotomy has


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#acilitated sa#e three2dimensional resections o# t"mo"rs in the tong"e and #loor o#mo"th incontin"ity !ith the lymphatics in the nec+. A better "nderstanding o# the

patterns o# in&asion o# the mandible by ad/acent t"mo"r has allo!ed the de&elopmento# rim resections, a&oiding the sacri#ice o# mandib"lar contin"ity in many cases,!itho"t ris+ing local rec"rrence. In recent years there has been the de&elopment o#

s+"ll base access s"rgery "sing !ell2established oral and #acial osteotomy techni0"es!hich ha&e rendered pre&io"sly inoperable t"mo"rs operable. 1his is partic"larly tr"e#or t"mo"r extending into the pterygoid, in#ratempotal and lateral pharyngeal regions.7econstr"ction

rimary reconstr"ction is no! the r"le to the great ad&antage o# patients. re&io"sreconstr"ction techni0"es !ere o#ten "nreliable, and !hen bony reconstr"ction !asin&ol&ed they !ere o#ten staged. It !as reasonably #elt that be#ore embar+ing on s"ch

prolonged and insec"re techni0"es a period o# time sho"ld be allo!ed to elapse todemonstrate that local rec"rrence !as "nli+ely be#ore reconstr"ction !as attempted.

ith c"rrent techni0"es based largely on m"scle #laps pectoralis ma/or, trape9i"sand latissim"s dorsi and #ree tiss"e trans#er, based on micro&asc"lar techni0"es,

primary reconstr"ction is not only reliable b"t prod"ces acceptable #"nctional andcosmetic res"lts.7adiotherapyHigh2energy beams, comp"terised planning and sim"lation ha&e greatly red"ced themorbidity o# radiotherapy by red"cing the dosage to the ad/acent tiss"es. 1eeth are nolonger ro"tinely extracted prior to radiotherapy regardless o# their state, andosteoradionecrosis is no! an "n"s"al complication.Altho"gh not a ne! techni0"e, brachytherapy "sing iridi"m !ire implants is regaining

pop"larity. or s"itable t"mo"r 1i and early 1$ t"mo"rs in mobile so#t tiss"es this techni0"e deli&ers &ery high2dose local irradiation contin"o"sly !ith &ery littleirradiation to ad/acent tiss"es : ig. %*.*;. Local control rates are excellent. 4"rrently,considerable interest is being sho!n in hyper#ractionation techni0"es, !hereby ahigher total t"mo"r dose can be achie&ed by gi&ing more b"t smaller #ractions o#radiation.4hemotherapyAltho"gh many single agents or combinations o# dr"gs can res"lt in a response ratearo"nd


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months to years prior to the onset o# malignant change and o#ten they !ill he presenttogether !ith the carcinoma at presentation. 'eca"se o# this association theass"mption !as made that s"ch lesions led directly to in&asi&e carcinoma and hence!ere themsel&es premalignant.8ome !hite pla0"es do "ndo"btedly ha&e a potential to "ndergo malignant

trans#ormation, and an examination o# established carcinomas !ill sho! many to existinassociation !ith !hite pla0"es. Ho!e&er, the ma/ority o# oral carcinomas is not

preceded by or is associated !ith le"copla+ia.Altho"gh historically oral 5le"copla+ia6 has been recognised as premalignant, the ris+o# malignant trans#ormation is not as great as !as pre&io"sly tho"ght. -arly literat"res"ggested a ?( per cent or higher incidence o# malignant trans#ormation o# theselesions !hereas more recent a"thors 0"ote an incidence o# bet!een ? and < per cent.1he #ollo!ing oral lesions are no! de#initely considered to carry a potential #ormalignant change@

le"copla+iaB erythropla+iaB chronic hyperplastic candidiasis.

A #"rther gro"p o# conditions, altho"gh not themsel&es premalignant, are associated!ith a higher than normal incidence o# oral cancer@

oral s"bm"co"s #ibrosisBsyphilitic glossitisBsideropenic dysphagia.

1here remains a #"rther gro"p o# oral conditions abo"t !hich there is still some do"btas to !hether their association !ith oral cancer is ca"sal or cas"al@

oral lichen plan"sBdiscoid l"p"s erythematos"sB dys+eratosis congenita.

Le"copla+iaCsing the term le"copla+ia : ig. %*.$; either in a histological or clinical context is amatter o# de#ining !hat one means by the term. 1he orld Health Organisation: HO; has de#ined le"copla+ia as 5any !hite parch or pla0"e that cannot becharacterised clinically or pathologically as any other disease6. 1his de#inition has nohistological connotation.4linical #eat"res4linically le"copla+ia may &ary #rom a small circ"mscribed !hite pla0"e to anextensi&e lesion in&ol&ing !ide areas o# the oral m"cosa. 1he s"r#ace may be smooth

or it may be !rin+led, and many lesions are tra&ersed by crac+s or #iss"res. 1hecolo"r o# the lesion may be !hite, yello!ish or grey, !ith some being homogeneo"s!hilst others are nod"lar or spec+led on an erythemato"s base. >any lesions are so#t!hereas other thic+er lesions #eel cr"sty. Ind"ration s"ggests malignant change and isan indication #or immediate biopsy. It is important to recognise that it is the spec+ledor nod"lar le"copla+ias !hich are the most li+ely to "ndergo malignant change.

otential #or malignant changeIt has been sho!n that the incidence o# "ltimate malignant change in oral le"copla+iaincreases !ith the age o# the lesion. One st"dy sho!ed a $.% per cent malignanttrans#ormation rate at *( years !hich increased to % per cent at $( years. It alsosho!ed that as the age o# the patient increased so did the ris+ o# malignant

trans#ormation@ #or patients yo"nger than )( years it !as I per cent !hereas #or those bet!een ( and =E years it !as .) per cent d"ring a )2year obser&ation period.


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8t"dies ha&e sho!n that, in so"thern -ngland, le"copla+ia o# the #loor o# the mo"thand &entral s"r#ace o# the tong"e has a partic"larly high incidence o# malignantchange. 1his st"dy s"ggested that this occ"rrence !as d"e to pooling o# sol"blecarcinogens in the 5s"mp6 o# the #loor o# the mo"th.Aetiology

1obacco smo+ing and che!ing are "ndo"btedly important aetiological #actors. InIndians !ho smo+e or che! tobacco :o#ten as a component o# the betel 0"id; theincidence o# le"copla+ia in those o#


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In *E


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excessi&ely &"lnerable to carcinogenic irritants. Altho"gh the anaemia !ill respond totreatment !ith iron s"pplements, it is not +no!n !hether s"ch treatment red"ces theris+ o# s"bse0"ent malignant change. 1here ha&e been some reports that in erosi&e oratrophic lichen plan"s : ig. %*. ; there is a ris+ o# malignant trans#ormation. I# thereis an association bet!een lichen plan"s and oral cancer the relation only exists !ith

atrophic or erosi&e lichen plan"s. All patients !ith erosi&e or atrophic lichen plan"ssho"ld be care#"lly re&ie!ed. -rosi&e lichen plan"s sho"ld be treated !ith topicalsteroids and, in se&ere cases, systemic steroids may be necessary.Discoid l"p"s erythematos"s1he oral lesions o# discoid l"p"s erythematos"s consist o# circ"mscribed, some!hatele&ated, !hite patches "s"ally s"rro"nded by a telangiectatic halo. -pithehialdysplasia may be seen on histological examination and this may lead to malignanttrans#ormation. >alignant change "s"ally occ"rs in those lesions o# the labial m"cosaad/acent to the &ermilion border, and occ"rs more o#ten in men than in !omen. 8"ch

patients !ith discoid l"p"s erythematos"s sho"ld be ad&ised to a&oid bright s"nlightand !hen in the open air to apply an "ltra&iolet barrier cream to the lips.Dys+eratosis congenita1his syndrome is characterised by retic"lar atrophy o# the s+in !ith pigmentation, naildystrophy and oral le"copla+ia. -&ent"ally, the oral m"cosa becomes atrophic and thetong"e loses its papillae. inally, the m"cosa becomes thic+ened, #iss"red and !hite.

4linical presentation and diagnosis o# oral cancer -arly diagnosis o# oral cancer sho"ld lead to better treatment res"lts and, ideally, theclinical diagnosis o# oral cancer sho"ld be easy. Oral lesions, "nli+e those at manyother sires, gi&e rise to early symptoms. In general, patients become a!are o# and"s"ally complain abo"t min"te lesions !ithin the mo"th and biopsy may be carriedo"r "nder local analgesia. et, despite all the abo&e, bet!een $ and )( per cent o#

patients present #or treatment !ith late lesions. >any o# these patients are elderly and#rail and, there#ore, delay the e##ort o# &isiting their doctor or dentist. >any o# thisgro"p o# patients !ear dent"res and are acc"stomed to discom#ort and "lceration inthe mo"th and th"s see no "rgency in see+ing treatment. "rthermore, the practitioneris o#ten not s"spicio"s that a lesion may be malignant and the lesion is o#ten treatedinitially !ith anti#"ngal therapy, antibiotics, steroids and mo"th2!ashes, th"scontrib"ting to #"rther delay in the "ltimate diagnosis and treatment. Another #actor isthat oral cancer is not "s"ally pain#"l "ntil s"ch rime as either the "lcer becomessecondarily in#ected or the t"mo"r in&ades sensory ner&e #ibres.

1he tong"e1he ma/ority o# tong"e cancers occ"rs on the middle third o# the lateral margins,extending early in the co"rse o# the disease on to the &entral aspect and #loor o# themo"th : ig. %*.=;. Approximately $) per cent occ"r on the posterior third o# thetong"e, $( per cent on the anterior third and rarely :% per cent; on the dors"m.-arly tong"e cancer may mani#est in a &ariety o# !ays. O#ten the gro!th is exophytic!ith areas o# "lceration. It may occ"r as an "lcer in the depths o# a #iss"re or as anarea o# s"per#icial "lceration !ith "ns"spected in#iltration into the "nderlying m"scle.Le"copla+ic patches may or may not be associated !ith the primary lesion. Aminority o# tong"e cancers may be asympromatic, arising in an atrophic depapillatedarea !ith an erythropla+ic patch !ith peripheral strea+s or areas o# le"copla+ia.

Later in the co"rse o# the disease a more typical malignant "lcer !ill "s"ally de&elop,o#ten se&eral centimetres in diameter. 1he "lcer is hard in consistency !ith heaped2"p


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and o#ten e&erted edges. 1he #loor is gran"lar, ind"rated and bleeds readily. O#tenthere are areas o# necrosis. 1he gro!th in#iltrates the tong"e progressi&ely ca"singincreasing pain and di##ic"lty !ith speech and s!allo!ing. 'y this stage pain is o#tense&ere and constant, radiating to the nec+ and ears. Lymph node metastases at thisstage are common indeed )( per cent may ha&e palpable nodes at presentation.

'eca"se o# the relati&ely early lymph node metastasis o# tong"e cancer, *$ per cent o# patients may present !ith no symptoms other than 5a l"mp in the nec+6. 1he #loor o# the mo"th1he #loor o# the mo"th is the second most common sire #or oral cancer : ig. %*.E;. Itis de#ined as the C2shaped area bet!een the lo!er al&eol"s and the &entral s"r#ace o#the tong"eB carcinomas arising at this sire in&ol&e ad/acent str"ct"res &ery early intheir nat"ral history. >ost t"mo"rs occ"r in the anterior segment o# the #loor o# themo"th to one side o# the midline.1he lesion "s"ally starts as an ind"rated mass !hich soon "lcerates. At an early stagethe tong"e and ling"al aspect o# the mandible become in&ol&ed. 1his earlyin&ol&ement o# the tong"e leads to the characteristic sl"rring o# the speech o#ten notedin s"ch patients. 1he in#iltration is decepti&e b"t may extend to reach the gingi&ae,tong"e and geniogloss"s m"scle. 8"bperiosteal spread is rapid once the mandible isreached. Lymphatic metastasis, altho"gh early, is less common than !ith tong"ecancer. 8pread is "s"ally to the s"bmandib"lar and /"g"lodigasrric nodes and may be

bilateral.4ancer in the #loor o# the mo"th cancer is associated !ith a pre2existing le"copla+iamore commonly than at other sites.1he gingi&a and al&eolar ridge4arcinoma o# the lo!er al&eolar ridge occ"rs predominantly in the premolar andmolar regions : ig. %*.*(;.1he patient "s"ally presents !ith proli#erati&e tiss"e at the gingi&al margins ors"per#icial gingi&al "lceration. Diagnosis is o#ten delayed beca"se there is a !ide&ariety o# in#lammatory and reacti&e lesions !hich occ"r in this region in association!ith the teeth or dent"res. Indeed, there !ill o#ten be a history o# tooth extraction !iths"bse0"ent #ail"re o# the soc+et to heal prior to de#initi&e diagnosis. Another commonstory is that o# s"dden di##ic"lty in !earing dent"res. 7egional nodal metastasis iscommon at presentation, &arying #rom ?( to =% per cent, altho"gh #alse2positi&e and#alse2negati&e clinical #indings are common.1he b"ccal m"cosa1he b"ccal m"cosa extends #rom the "pper al&eolar ridge do!n to the lo!er al&eolarridge and #rom the commiss"re anteriorly to the mandib"lar ram"s and retromolar

region posteriorly : ig. %*.**;. 80"amo"s cell carcinomas mostly arise either at thecommiss"re or along the occl"sal plane to the retromolar area, the ma/ority beingsit"ated posteriorly. -xophyric, "lcero2in#iltrati&e and &err"co"s types occ"r. 1heyare s"b/ect to occl"sal tra"ma !ith conse0"ent early "lceration and o#ten becomesecondarily in#ected. 1he onset o# the disease may be insidio"s, the patient sometimes

presenting !ith trism"s d"e to deep neoplastic in#iltration into the b"ccinaror m"scle.-xtension posteriorly in&ol&es the anterior pillar o# the #a"ces and so#t palate !ithconse0"ent !orsening o# the prognosis. Clcero2in#iltrati&e lesions !ill o#ten in&ol&ethe o&erlying s+in o# the chee+ res"lting in m"ltiple sin"ses. Lymph node spread is tothe s"bmental, s"bmandib"lar, parotid and lateral pharyngeal nodes.Ferr"co"s carcinoma occ"rs as a s"per#icial proli#erati&e exophytic lesion !ith

minimal deep in&asion and ind"ration. O#ten the lesion is densely +eratinised and


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presents as a so#t !hite &el&ety area mimic+ing benign hyperplasia. Lymph nodemetastasis is late and the t"mo"r beha&es as a lo!2grade s0"amo"s cell carcinoma.1he hard palate, maxillary al&eolar ridge and #loor o# antr"m1hese three sites are anatomically distinct, b"t a carcinoma arising #rom one site soonin&ol&es the others : ig. %*.*$;. 4onse0"ently, it can be di##ic"lt to determine the

exact site o# origin. -xcept in co"ntries !here re&erse smo+ing is practised, cancer o#the plate is relati&ely "ncommon. 1he ma/ority o# s0"amo"s cancers arises in theantr"m and later "lcerates thro"gh to in&ol&e the hard palate. 1he ma/ority o#malignant t"mo"rs arising #rom the palatal m"cosa is o# minor sali&ary gland origin.

alatal cancers "s"ally present as sessile s!ellings !hich "lcerate relati&ely late. A#inding in contrast to mandib"lar al&eolar t"mo"rsis that deep in#iltration into the"nderlying bone is "ncommon.4arcinomas arising in the #loor o# the maxillary anrr"m o#ten present as palaralt"mo"rs. Altho"gh the #"lly established pict"re o# antral carcinoma is di##ic"lt tomiss, the early symptoms are nonspeci#ic and may mimic chronic sin"sitis. t"mo"rs o#the lo!er hal# o# the antr"m belo! Ohngren6 s line "s"ally present !ith 5dental6symptoms beca"se o# early al&eolar in&asion. 1he commonest presenting #eat"re is

pain, s!elling or n"mbness o# the #ace. Later symptoms o# nasal obstr"ction,discharge or bleeding, and dental symptoms s"ch as pain#"l or loose teeth, ill2#ittingdent"res, oroantral #ist"la or #ail"re o# an extraction soc+et to heal, soon #ollo!.Lymph node metastasis #rom carcinomas o# the palate and #loor o# the antr"m occ"rslate b"t carries a poor prognosis.Diagnosis1he diagnosis o# intraoral carcinoma is primarily clinical, and a high index o#s"spicion is necessary #or all those clinicians seeing and treating patients !ith oralsymptoms. A care#"l and detailed history !ith partic"lar attention to recording thedates o# the onset o# partic"lar signs and symptoms precedes the clinical examination.All areas o# the oral m"cosa are care#"lly inspected and any s"spicio"s lesion is

palpated #or text"re, tethering to ad/acent str"ct"res and ind"ration o# "nderlyingtiss"e.

In&estigation8"rgical biopsyA clinical diagnosis o# oral cancer sho"ld al!ays be con#irmed histologically. ithinthe oral ca&ity a s"rgical biopsy can nearly al!ays be obtained "sing local

anaesthesia. An incisional biopsy is recommended in all cases. hene&er possible the patient sho"ld be seen at a combined clinic by a s"rgeon and radiotherapist be#oree&en the biopsy is carried o"t, b"t pro&ided care#"l records are made an initialincisional biopsy is acceptable and may sa&e time in the planning and exec"tion o#s"bse0"ent therapy. 1he biopsy sho"ld incl"de the most s"spicio"s area o# the lesionand incl"de some normal ad/acent m"cosa. Areas o# necrosis or gross in#ection sho"ld

be a&oided as they may con#"se the diagnosis.ine needle aspiration biopsy

1his techni0"e is applicable mainly to l"mps in the nec+, especially s"spicio"s lymphnodes in a patient !ith a +no!n primary carcinoma. It consists o# the perc"taneo"s

p"nct"re o# the mass !ith a #ine needle and aspiration o# material #or cytological

examination. 1he method o# aspiration needs no specialised e0"ipment and is #ast,almost painless and !itho"t complications. 1he node is #ixed bet!een #inger and


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th"mb and then p"nct"red by a $*G or $?G needle on a *(2ml syringe, the ga"ge o#the needle depending on the si9e o# the node. Important points to note are that theneedle is properly p"shed on to the syringe to pre&ent air lea+ing in !hen the pl"ngeris !ithdra!n and that a small amo"nt o# air is already in the syringe :abo"t $ ml;

be#ore the node is p"nct"red in order s"bse0"ently to expel the aspirate #rom the

needle on to the slide.7adiography

lain radiography is o# limited &al"e in the in&estigation o# oral cancer. At least )( per cent o# the calci#ied component o# bone m"st be lost be#ore any radiographicchange is apparent. "rthermore, the #acial bones are o# s"ch a complexity thatcon#"sion #rom o&erlying str"ct"res ma+es 2ray diagnosis more di##ic"lt. Ho!e&er,rotational pantomography o# the /a!s can be help#"l in assessing al&eolar and antralin&ol&ement, pro&ided that the abo&e limitations are "nderstood.4omp"terised tomography1he increasing a&ailability o# comp"terised tomography :41; scanning has"ndo"btedly been o# great bene#it in the in&estigation o# head and nec+ t"mo"rs.Ho!e&er, #or intraoral t"mo"rs its &al"e is more limited. or the e&al"ation o# antralt"mo"rs, partic"larly assessment o# the pterygoid regions, 41 has s"perseded plainradiography and con&entional tomography. 41 is also o# &al"e in the in&estigation o#metastatic disease in the l"ngs, li&er and s+eleton.7adion"clide st"dies1echneti"m :1c; pertechnetate bone scans o# the #acial s+eleton are o# little &al"e inthe diagnosis o# primary oral cancers. 1here !ill be ob&io"s clinical disease long

be#ore bone changes are &isible on a 1c scan. "rthermore, s"ch scans are nor speci#icand !ill sho! increased "pta+e !here&er there is increased metabolic acti&ity in the

bone.Cltraso"ndAbdominal "ltraso"nd to detect li&er metastases is probably as acc"rate as 41scanning. As it is nonin&asi&e, readily a&ailable and cost e##ecti&e, it is probably themost appropriate techni0"e #or assessing the li&er.

>anagement o# the primary t"mo"r 4hoice o# treatment1he principal treatments a&ailable #or primary t"mo"rs remain s"rgery andradiotherapy. 1he basic decision to be made is bet!een radical radiotherapy andelecti&e s"rgery. I# the #ormer is chosen, s"rgery is reser&ed #or 5sal&age6, i.e. #or

biopsy pro&en rec"rrent or resid"al disease. I# s"rgery is chosen, radiotherapy may be"sed in an ad/"&ant manner, either preoperati&ely or postoperati&ely, b"t the operationremains #"ndamentally the de#initi&e c"rati&e proced"re. re#erences #or one or other

policy &ary considerably bet!een treatment centres.>any #actors m"st be considered in deciding the optim"m management #or eachindi&id"al patient. 1hese incl"de the sire, stage and histology o# the t"mo"r, and themedical condition and li#estyle o# the patient. Ideally, e&ery patient sho"ld be seen ata /oint cons"ltation clinic by a s"rgeon and radiotherapist !ho assess ob/ecti&ely andagree the optim"m strategy o# management #or the partic"lar indi&id"al. 1he#ollo!ing #actors sho"ld in#l"ence the decision on treatment policy.8ite o# origin

1he choice o# treatment depends on the part o# the mo"th in !hich the t"mo"r arises.1he management o# primary t"mo"rs at the &ario"s anatomical sites is disc"ssed later.


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In general, s"rgery is pre#erred #or those t"mo"rs arising on or in&ol&ing the al&eolar processesB #or other sires s"rgery and radiotherapy are alternati&es.8tage o# diseaseA small lesion !hich can be excised readily !itho"t prod"cing any de#ormity ordisability is, in general, best managed s"rgically. 8"rgery is also "s"ally more

appropriate #or a &ery large mass or !here there is in&asion o# bone, pro&ided thet"mo"r is operable, beca"se o# the lo! c"re rates by radiotherapy in thesecirc"mstances. 1he management o# lesions o# intermediate stage, i.e. larger 1i, most1$ and early exophytic 1? t"mo"rs, is more contro&ersial as policies o# electi&es"rgery or radical radiotherapy prod"ce generally similar s"r&i&al ratesB hence,disc"ssion centres on the li+ely #"nctional res"lts and morbidity o# either approach.

hen there is in&ol&ement o# cer&ical lymph nodes the primary and nodes arenormally both treated s"rgically. Ho!e&er, there is no clear e&idence that a primaryt"mo"r is less li+ely to be c"red by radiotherapy in the presence o# lymph nodemetastases than in their absence.

re&io"s irradiationIt is not ad&isable to retreat a t"mo"r arising in pre&io"sly irradiated tiss"e. 8"ch at"mo"r is li+ely to be relati&ely radioresistant beca"se o# limited blood s"pply. 7e2irradiation o# normal tiss"e is &ery li+ely to res"lt in necrosis.

ield changehere m"ltiple primary t"mo"rs are present, or i# there is extensi&e premalignant

change, s"rgery is the pre#erred treatment. 7adiotherapy in these circ"mstances is"nsatis#actoryB irradiation o# the entire oral ca&ity ca"ses se&ere morbidity and maynot pre&ent s"bse0"ent ne! primary t"mo"rs arising #rom areas o# premalignantchange.Histology1he histology report on a biopsy specimen has a relati&ely small in#l"ence on choiceo# treatment. 1he less common adenocarcinoma and melanoma are relati&elyradioresistant, and there#ore sho"ld be treated s"rgically !hene&er possible. 1hegrade o# malignancy o# a s0"amo"s carcinoma does not normally in#l"ence itsmanagement, there being little e&idence to s"ggest that a !ell2di##erentiated primarysho"ld be treated di##erently #rom a poorly di##erentiated one.A possible exception is the &err"co"s carcinoma, !hich is the s"b/ect o# m"chcontro&ersy. 1he obser&ation has been made that !here large lesions o# thishistological type are treated by radiotherapy rec"rrences appear in some cases !hichare o# a m"ch more anaplastic pattern than the original primary, and it has become!idely accepted that radiotherapy ind"ces 5anaplasric trans#ormation6.

It seems probable that some &err"co"s carcinomas already contain #oci o# moremalignant cells prior to treatment, and that these cells are the ones most li+ely tos"r&i&e a#ter radiotherapy and gi&e rise to rec"rrence. In practice, most &err"co"scarcinomas present at an early stage as s"per#icialexophytic lesions and are s"itable#or local excision. hen they cannot be excised locally the !eight o# e&idences"ggests that they can be dealt !ith sa#ely in the same !ay as s0"amo"s carcinomaso# other types, and either s"rgery or radiotherapy be chosen as the primary treatmentmodality according to the site and stage o# the lesion and the condition o# the patient.Age1he patient6s age is o#ten 0"oted as an important #actor !hich m"st be ta+en intoacco"nt !hen deciding on a co"rse o# management. ith a yo"ng patient there is the

#ear that i# radiotherapy is gi&en it may ind"ce a malignancy in years to comeB in #act,this ris+ is &ery small compared !ith the mortality o# the disease itsel#. -lderly


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patients tend to be poor s"rgical ris+s, b"t they also rend to do badly !ith radio2therapy, especially external radiotherapy, and o#ten deteriorate and may die as a res"lto# the debility and poor n"tritional stat"s ind"ced by the irradiation. 4hronologicalage per se sho"ld not necessarily be regarded as a contraindication to s"rgery.4arcinoma o# the lip

4arcinoma o# the lip most commonly arises at the &ermilion border o# the lo!er lipa!ay #rom the line o# contact !ith the "pper lip. Only *) per cent arise #rom thecentral third and commiss"re regions, and ) per cent #rom the "pper lip.Initially the t"mo"rs tend to spread laterally rather than in#iltrating deeplyB e&ent"ally,i# "ncontrolled, they can spread into the anterior triangle o# the nec+ and in&ade themandible. Lymph node metastases occ"r late. 'oth s"rgery and radiotherapy are#re0"ently employed and are highly e##ecti&e methods o# treatment, each gi&ing c"rerates o# abo"t E( per cent.Cp to one2third o# the lo!er lip can be remo&ed !ith aor 2shaped excision !ith

primary clos"re : ig. %*.*?;. 1his method is s"itable #or t"mo"rs "p to $ cm indiameter. 1he resid"al de#ect is reconstr"cted by approximating and s"t"ring the

borders in three layersB m"cosa, m"scle and s+in. artic"lar attention sho"ld be paidto the correct alignment o# the &ermilion /"nction. 1his simple proced"re can readily

be per#ormed "nder local anaesthetic on an o"t2patient basis. Initially the lip !illappear tight, b"t this impro&es a#ter abo"t ? months.I# more than one2third o# the lip is remo&ed, primary clos"re res"lts in microstomia.1here#ore, #or more extensi&e lip resections it is necessary to "tilise local #laps #orreconstr"ction. or large central de#ects o# the lo!er lip, partic"larly in patients !hodo not ha&e ageing !rin+led #aces, the 5stepladder6 approach o# Johanson gi&esexcellent cosmesis as the reconstr"ction ad&ances symmetrical bilateral #laps #rom thelo!er third o# the #ace : ig. %*.*%;. 1his res"lts in a mini #aceli#t6 and the scars areconcealed in the labiomental groo&e aro"nd the chin point. or de#ects more laterally,in the lo!er lip, the "pper lip and partic"larly in&ol&ing the commiss"re, ries65"ni&ersal proced"re6 gi&es excellent #"nctional res"lts !ith acceptable cosmesisespecially in the ageing #ace : ig. %*.*);. ith this techni0"e, lateral #acial #laps arede&eloped #ollo!ing #"ll2thic+ness incisions in the chee+s parallel to the branches o#the #acial ner&e. 1hese #laps are then ad&anced into the lip de#ect !ith the sacri#ice o#'"rro!s6 triangles to pre&ent piling "p o# the #acial tiss"es.1he ma/ority o# lo!er lip cancers is ca"sed by "ltra&iolet radiation and o#ten theentire &ermilion border !ill sho! actinic changes. hene&er these changes are seen atotal lip sha&e !o"ld be "nderta+en in addition to resection o# the primary t"mo"r.1he resection is reconstr"cted either by ad&ancing labial or b"ccal m"cosal #laps or, i#

s"ch tiss"e is inade0"ate, by the "se o# a pedicled anteriorly based tong"e #lap. A#ter? !ee+s the pedicle is di&ided and the #lap #inally set into the lip.4arcinoma o# the tong"e8"rgery is the treatment o# choice #or early lesions s"itable #or simple intraoralexcision, #or t"mo"rs on the tip o# the tong"e and #or ad&anced disease !hen s"rgerysho"ld be combined !ith postoperati&e radiotherapy. or intermediate2stage diseases"rgery and radiotherapy ha&e similar o"tcomes. hen per#orming s"rgical excisiono# less than one2third o# the tong"e, #ormal reconstr"ction is not necessary. Indeed,the best res"lts are obtained by not attempting to close the de#ect or to apply a split2s+in gra#t. 1he base o# the resid"al de#ect sho"ld be #"lg"rated and then allo!ed togran"late and epithelialise spontaneo"sly. 8"ch treatment is relati&ely pain #ree and

res"lts in an "ndistorted tong"e. hen a&ailable a carbon dioxide laser may be "sed


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#or the partial glossectomy. 1he postoperati&e co"rse is relati&ely pain #ree, oedema isminimal and healing occ"rs !ith minimal scarring.Any tong"e carcinoma exceeding $ cm in diameter re0"ires at the &ery least ahemiglossectomy. >any s"ch t"mo"rs !ill in#iltrate deeply bet!een the #ibres o# thehyogloss"s m"scle. -xtensi&e tong"e lesions o#ten in&ol&e the #loor o# the mo"th and

al&eol"s. Cnder any o# these circ"mstances a ma/or resection is indicated. Access is best &ia a lip split and mandib"lotomy : ig. %*.*


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pro&ided a marginal resection is carried o"t !hich incl"des the in#erior dental canal#rom the ling"la to the mental #oramen.

hen there is e&idence o# gross t"mo"r in&asion o# the bone resection o# themandible is mandatory. In order to a&oid #"nctional and cosmetic de#ormity,immediate primary reconstr"ction is essential. 1he choice lies bet!een reconstr"ction

!ith &asc"larised bone, a #ree corticocancello"s gra#t or an alloplastic system "s"allys"pplemented !ith cancello"s bone m"sh.4arcinoma o# the b"ccal m"cosaLesions strictly con#ined to the b"ccal m"cosa sho"ld be excised !idely incl"ding the"nderlying b"ccinator m"scle, #ollo!ed by a 0"ilted split2s+in gra#t. or moreextensi&e lesions !ith more complicated three2dimensional shapes, i.e. lesionsextending posteriorly to the retromolar area, maxillary t"berosity or tonsillar #ossa,reconstr"ction !ith a #ree radial #orearm #lap is ad&isableB this adapts &ery !ell tos"ch shapes and remains so#t and mobile postoperati&ely : ig. %*.*=;.In sit"ations !here a #ree #lap is nor appropriate, alternati&es are the b"ccal #at pad orthe #orehead #lap. 1he b"ccal #at pad has pro&ed to be a "se#"l local #lap #or thereconstr"ction o# small intraoral de#ects "p to ? x )cm. 1his !ell&asc"larised #lap can

be le#t ra! to epithelialise spontaneo"sly, and is "sed to reconstr"ct maxillary de#ects,hard and so#t palate de#ects, and chee+ and retromolar de#ects. or large de#ects atthese sites its "se can be combined !ith the temporalis m"scle #lap.1he "se o# the #orehead #lap, an axial #lap based on the s"per#icial temporal artery,!as #irst described by >cGregor in *E


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8o#t2tiss"e co&er #or all o# these reconstr"ction techni0"es is critical. ithmicro&asc"lar #ree #laps the associated s+in is "sed. or cancello"s bone m"sh intitani"m trays, and #or corticocancello"s gra#ts, the pectoralis ma/or m"scle2only #lapis most "se#"l : ig. %*.$*;. 1he pedicle is bro"ght "p thro"gh the nec+ and the #lapintrod"ced into the #loor o# the mo"th. 1he #lap is then !rapped aro"nd the bone gra#t

and s"t"red bac+ on to itsel# on the labial aspect. 1h"s, the bone gra#t is totallyen&eloped in !ell2&asc"larised so#t tiss"e. 1he m"cosal resection margins are thens"t"red to the exposed m"scle at their appropriate sires and the bare m"scle allo!edto epithelialise spontaneo"sly. 8"ch #laps !ithstand immediate postoperati&eradiotherapy, and the s"bse0"ent insertion o# osteointegrated implants has not pro&edto be a problem.4arcinoma o# the retromolar trigone1he retromolar trigone is de#ined as the anterior s"r#ace o# the ascending ram"s o# themandible. It is ro"ghly triang"lar in shape !ith the base being s"perior behind thethird "pper molar tooth and the apex in#erior behind the third lo!er molar.t"mo"rs at this site may in&ade the ascending ram"s o# the mandible. 1hey may alsospread "p!ards in so#t tiss"e to in&ol&e the pterygomandib"lar space, !hich can bedi##ic"lt to detect clinically or radiologically.A lip split and mandib"lotomy are needed to gain access to the retromolar region.8mall de#ects can o#ten be reconstr"cted !ith a masseter or temporalis m"scle #lap.Larger de#ects are best reconstr"cted !ith a #ree radial #orearm #lap !hich can bemade to con#orm &ery !ell to the shape o# the de#ect at this site.4arcinoma o# the hard palate and "pper al&eol"s1hese sites are considered together as they are closely ad/acent and both are rare siteso# origin o# primary s0"amo"s carcinoma. A s0"amo"s carcinoma presenting at eithero# these sites is more li+ely to ha&e arisen in the maxillary antr"m than in the oralca&ity. An exception is on the Indian s"bcontinent !here carcinoma o# the hard palateis seen in association !ith re&erse smo+ing. t"mo"rs o# minor sali&ary glands arem"ch more common than s0"amo"s carcinomas on the hard palate. 1he &ast ma/orityo# s0"amo"s carcinomas !hich present in the "pper g"m or hard palate arises #romthe maxillary antr"m.A t"mo"r con#ined to the hard palate, "pper al&eol"s and #loor o# the antr"m can beresected by con&entional partial maxillectomy. A more extensi&e t"mo"r con#ined tothe in#rastr"ct"re o# the maxilla re0"ires total maxillectomy. I# the preoperati&ein&estigations indicate extension o# disease into the pterygoid space or in#ratemporal#ossa a more extensi&e proced"re is necessary. 1he chance o# obtaining a c"re bys"rgery alone is small, and postoperati&e radiotherapy is essential. A combined

anteroposterior or lateral #acial approach is re0"ired. I# the t"mo"r extends s"periorlyto in&ol&e the d"ra then a combined ne"ros"rgical proced"re !ill be re0"ired.ollo!ing a maxillary resection the res"lting ca&ity sho"ld be s+in gra#ted to ens"re

rapid healing and to pre&ent contract"re o# the o&erlying so#t tiss"es.1he de#ect created by s"rgery !ill re0"ire either reconstr"ction or a prosthesis.Fario"s techni0"es ha&e been described #or reconstr"ctionB Ob!egeser described atechni0"e "sing split ribs. >ore recently, the temporalis m"scle #lap has beenad&ocated. 1he temporalis m"scle #lap is a simple techni0"e and has the ad&antagethat it carries !ith it its o!n blood s"pply. It m"st be remembered that i# s"ch a recon2str"ction is to be "nderta+en s"bse0"ently, it is essential that at the rime o# theoriginal maxillectomy the coronoid process o# the mandible is not excised, beca"se i#

it is resected the blood s"pply to the mobilised temporalis m"scle !ill ha&e beencompromised and the #lap !ill necrose.


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>alignant melanomaOral melanomas are rare. 1he pea+ age incidence is bet!een %( and


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the incidence o# histologically positi&e nodes in electi&e nec+ dissections exceeds theincidence o# s"bse0"ent clinical nodal metastases, s"ggesting that some microscopic#oci are destroyed by the body6s de#encesB

the primary may rec"r or a second primary de&elop and metastasise into thedissected nec+, ma+ing s"bse0"ent management &ery di##ic"ltB

electi&e nec+ dissection gi&es no g"arantee against rec"rrence o# the t"mo"r in thenec+B

bloc+ dissection has a considerable morbidityB remo&al o# regional lymph nodes may remo&e a barrier to the #"rther spread o#

diseaseBthere is no prospecti&ely controlled trial to s"pport the arg"ment that electi&e nec+

dissection does impro&e the prognosis. On balance, the !eight o# these arg"ments #a&o"rs prophylactic nec+ dissection.As the s"bmandib"lar triangle o#ten has to be opened as part o# the resection o# the

primary, a #"nction sparing electi&e nec+ dissection #or t"mo"rs in the #loor o# themo"th and lo!er al&eolar ridge and tong"e is ad&ocated. 1his dissection, in !hichstr"ct"res s"ch as the accessory ner&e, internal /"g"lar &ein and sternocleido2mastoidm"scle are preser&ed, can be /"sti#ied. "rther, a s"r&ey sho!ed that o# )(* cancers o#the oral ca&ity, ?% per cent o# nodes !ere #o"nd to be positi&e a#ter electi&e radicalnec+ dissections. O&er E< per cent o# these histologically positi&e nodes !o"ld ha&e

been remo&ed by a s"pra2omohyoid dissection.1he operation sho"ld pre#erably be seen as a staging proced"re on !hich is based thedecision to gi&e radical postoperati&e radiotherapy. All patients !ith t!o or more

positi&e nodes or extracaps"lar spread sho"ld be treated !ith postoperati&eradiotherapy.An alternati&e approach is electi&e irradiation o# the clinically negati&e nec+, andindeed there is good e&idence that this is o# some bene#it in pre&enting s"bse0"entnodal disease. 4ertainly, electi&e irradiation to %( Gy carries less morbidity thanelecti&e nec+ dissection.

atients staged N* N$a N$b. At present, e&idence s"ggests that the treatment o#choice is radical nec+ dissection, either alone or combined !ith postoperati&eradiotherapy i# m"ltiple nodal in&ol&ement or extracaps"lar extension is #o"nd in theresected specimen : ig. %*.$?;. In those patients "n#it #or radical s"rgery, radicalexternal beam irradiation is indicated.

atients staged N$c. It is "ncommon #or patients !ith oral cancer to present !ith bilateral nodes. hen they do so, there is o#ten a large inoperable primary t"mo"r

!hich is best treated by external radiation. It there#ore seems logical to treat the nec+also by irradiation. Occasionally, partic"larly in yo"ng patients, bilateral nec+dissection can be /"sti#ied. A #"ll radical nec+ dissection is "nderta+en on theipsilateral side and the internal /"g"lar &ein is spared i# possible on the contralateralside. >ost o#ten postoperati&e radiotherapy !ill he re0"ired #or m"ltiple nodalin&ol&ement or extracaps"lar spread. In s"ch sit"ations, se&ere posttreatment oedemaor congestion o# the #ace and tong"e may be anticipated.

atients staged N?. N? indicates massi&e in&ol&ement, "s"ally !ith #ixation. Large#ixed nodes are o#ten associated !ith ad&anced primary disease !ith a poor prognosis.8"rgery is not normally ad&isable@ remo&al o# the common or internal carotid artery!ith replacement, or extensi&e resection o# the base o# the s+"ll, altho"gh technically

#easible, is seldom ad&isable. 1reatment is most o#ten by external radiotherapy. In a


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#e! yo"nger patients !ith resectable primaries, it is !orth rendering a #ixed mass inthe nec+ operable by preoperati&e radiotherapy. Nodal metastases appearing a#ter primary treatment

ro&ided that #ollo!2"p at reg"lar inter&als is rigoro"sly maintained, it sho"ld be possible to detect a lymph node metastasis !hile it is still relati&ely small and

there#ore operable. ine needle aspiration cytology is partic"larly "se#"l in thissit"ation to con#irm that the palpable node is a carcinoma rather than reacti&e.

hene&er positi&e, or i# there is any do"bt, a radical nec+ dissection is per#ormed,#ollo!ed by external irradiation i# m"ltiple in&ol&ed nodes or extracaps"lar spread are#o"nd.

"rther readingA&ery, '.8. :*EE=; Nec+ dissections. In Operati&e >axillo#acial 8"rgery :eds J.D.Langdon and >. . atel;, 4hapman K Hall, London, pp. $E)?($.4a!son, 7.A., Langdon, J.D. and -&eson, J. :*EE. :eds; :*EE); >alignant 1"mo"rs o# the >o"th, Ja!sand 8ali&ary Glands, Arnold, London.>cGregor, l.A. and >cGregor, .>. :*E=o"th,4h"rchill2Li&ingstone, -dinb"rgh.Ord, 7.A. :*EE=; Local resection and local reconstr"ction o# oral carcinomas, and /a!resection. In Operati&e >axillo#acial 8"rgery :eds J.D. Langdon and >. . arel;, 4hapman K Hall, London, pp. $ ?

E%.8o"tar, D.8. :*EE?; ree #laps in intra oral reconstr"ction. In >icro&asc"lar 8"rgeryand ree 1iss"e 1rans#er :ed. D.8. 8o"tar;, Arnold, London.Fa"ghan, -.D. :*EE(; 1he radial #orearm #ree #lap in oro#acial reconstr"ction,

personal experience in *$( consec"ti&e cases. Jo"rnal o# 4ranio2>axillo #acial8"rgery, *=, $ .

Documents

41.Oral and Oropharyngeal Cancer and Precancer