Lip cancer

ORAL AND MAXILLOFACIAL SURGERY

1. LIP CANCER DR SAQBA ALAM (Oral and MaxFac Surgery)

2. LIP CANCER (EVIDENCE BASED MANAGEMENT) DR SAQBA ALAM (ORAL AND MAXILLOFACIAL SURGERY)

3. INTRODUCTION INCIDENCE---- 1.8 IN 100,000 M>F Shares features of both oral and skin cancers. Complex tasks like articulation of speech, facial expression and oral deglutition. Median age 68-73 yrs 90%SCC=lower lip, BCC=more prevalent in upper lip SCC 95%lower lip,1%commisure 87%SCC,2%adenocarcinoma BCC arises from skin of upper lip adjacent to the mucocutaneous lesion hence not included in the mucosal lip category of carcinoma.(Early diagnosis/good prognosis)

4. ETIOLOGY UV light 50 +yrs White skinned Population working under the sun mostly in fields in rural areas. Pipe /cigar smoking HPV Chronic wounds and immune suppression Chemical carcinogens Tobacco chewing in synergy with alcohol consumption LOWER LIP 93% epithelial cancers. Upper lip only 7% (Ref Jatin Shah)

5. Composition Skin 2 parts: Mucosa (Dry vermillion covered by keratinized sq epithelium) Minor salivary glands and Muscles (Wet vermillion or mucosal lip containing minor salivary glands) Neurovascular structures BLOOD SUPPLY Superior labial,inferior Labial and branches of facial artery

6. Neck disease T1=7% CHANCE OF NECK METS T2-T4=16% A/c to size <1cm-------- 2% chance of occult Mets 4cm--------8% chance of occult Mets (Ref Werning Oral Cancer) Lower lip is formed by fusion of two lateral mandibular processes, this puts lip carcinomas at increased risk of contralateral neck metastasis.

7. Work up After a good clinical history and examination, the radiographic work up of early stage Lip Ca is usually not required.10% patients can present with clinically palpable neck nodes. Suspected bony invasion(tooth mobility) or neurovascular(numbness) invasion needs CT/MRI in advanced cases T2-T4.MRI-Normal fatty signal replaced by grayish tumor infiltration/ID nerve enhancement.

8. FACTORS AFFECTING CHOICE OF THERAPY TUMOR FACTORS T size Histology Depth of infiltration of labial musculature and involvement of commisure Extent of lip resection necessary Availability of local tissue for reconstruction Anticipated outcome of surgery PATIENT FACTORS Age Medical condition Compliance Cost

9. MANAGEMENT OF NECK DISEASE

10. LOWER LIP CA N0 Management depends on tumor size and stage. T1=occults mets less than 20% (options include close neck ultrasound surveillance and no neck dissection) T2/T3 N0 =involved lip resection with 1cm safe margin,END 1a,1b,II and III. T4 or advanced tumors involving commissure=involved mucosal or skin resection with mandibulectomy (marginal/segmental),superficial parotidectomy The inferior parotid nodes are most commonly involved, and patients generally have substantial associated cervical metastases. When treating patients who have oral or oropharyngeal cancer with substantial cervical metastasis, physicians should consider removing the inferior parotid lymph nodes

11. N0 DISEASE Suprahyoid neck dissection results in reduced morbidity related to radiotherapy and radical neck dissection. This surgical procedure removes nodal levels I (submandibular), II (high cervical) and III ( midcervical ). If the nodes removed are negative, then observation is recommended because of the possibility of positive nodes in level IV and V is very low. In positive cases, modified neck dissection is indicated.Radiotherapy should be added if further examination reveals multiple node metastasis or extracapsular invasion.

12. LOWER LIP CA n+ Submental and submandibular lymph nodes (level I) display the earliest involvement as a basis for tumour advancement. 5-year survival rate for patients with cervical metastasis is reported to be between 30% and 70%, with an average of 50% With regards to the first parameter, in the case of T1 tumours , lymph node engagement ranges from 3.4% to 7%. For T2 tumours , engagement ranges from 11.2% to 35%, and for T3 tumours , engagement ranges from 26.4% to 63%. Similarly, well-differentiated tumours are characterised by a 7% incidence of lymphnode metastasis compared with the 21% in the case of non-differentiated tumors.

13. prognosis Tumours of the lip are relatively common lesions and are not adequately acknowledged as potentially fatal. Well-controlled surgical excision of primary SCC achieves 5 years cure rate of 92% with overall recurrence rate of 8% In cases of local lymph node involvement, the five-year mortality is approximately 50%. Recurrence rate varies according to size, location, previous treatment and histology The risk of metastasis increases for tumors larger than 2 cm and deeper than 4 cm, recurrent tumors, bone invasion, perineural and perivascular involvement [13]. Approximately 95% of metastases are detected within 2 years and the reported 5-year survival for metastatic SCC is 25% The overall curability of patients with metastasised lower lip tumours approaches 50% [1,2,3]. The incidence of lip tumour metastasis to cervical lymph nodes ranges from 5% to 20%, with level I metastases being the most common

14. N+ disease Selective neck dissection I-IV as no drainage in level 5. Contralateral neck dissection for tumors involving FOM or approaching midline(adjuvant radiotherapy is another option) Some authors recommend MRND for N+disease . In patients with a cN + contralateral neck, a contralateral neck dissection should be performed. In patients with a cN0 contralateral neck, an elective contralateral neck dissection may be offered in patients with a tumor of the oral tongue and/or floor of the mouth that is T3 or T4, or approaches midline (ASCO 2019)

15. N+ An ipsilateral therapeutic selective neck dissection for a cN + neck should include nodal levels Ia , Ib , IIa , IIb, III, and IV. An adequate dissection should include at least 18 lymph nodes. Dissection of level V may be offered in patients with multistation disease (Type: evidence based; Evidence quality: intermediate, benefit outweighs harm; Strength of recommendation: moderate).

16. Goals of lip reconstruction FUNCTIONAL GOALS AESTHETIC GOALS Water tight seal Symmetric appearance at Restoration of orbicularis oris sphincter rest and dynamically Preservation of lip sensation Preservation of stability to support dentures Ideal scar/Flat/narrow Prevent drooling levelled/ colourmatch Avoid microstomia Parallel to relaxed tension lines

17. Size and site significance T1=Upto 2cm(less than 1/3 rd ) T2=2-4cm (between 1/3 rd to 2/3 rd ) T3=>4cm (more than 2/3 rd of lip) Advanced Cancers (T4) involves jaw bone, vessel and neural invasion

18. Surgical removal is the treatment of choice for squamous cell carcinoma of the lower lip, although radiotherapy or brachytherapy can be used to treat small lesions; tissue loss is treated using a variety of techniques, depending on the extent and location (median or lateral) of the defect,

19. Reconstruction A/C to size

20. SYNERGISTIC ABBE AND STAIRCASE FLAP STAIRCASE FLAP

21. Wave technique The wave technique22 uses the “steps” of the staircase flap, with retention of dimensions and extensions, but transforms straight lines into curves to achieve better esthetic results. The original Burow's triangle is now rounded, allowing the flap to readily slide to cover lost tissue

22. Primary closure WEDGE EXCISION AND PRIMARY CLOSURE VY ADVANCEMENT FOR VERMILLION RECONSTRUCTION

23. ABBE flap Central Abbe flap with bilateral upper lip advancement flaps and excision of perialar crescents (B). Inset (C). Final result (D).

24. KARAPANdZIC FLAP (clinical case with ND)

25. HARVESTING ANTERIOLATERAL THIGH FLAP

26. CLINICAL CASE DISCUSSIONS

27. CASE -1

28. T2N0M0 WLE WITH 1CM SAFE MARGIN NECK DISSECTION LEVEL I,II,III (SOMND)

29. Case 2 T1N2CM0 WLE WITH 1CM SAFE MARGIN NECK DISSECTION LEVELS LEVEL1-IV BILATERALLY

30. Case 3 ADVANCED stage 4

31. LIP SUPPORT VIA FASCIA LATA