LIP

MANAGEMENT OF PRIMARY: (Lip/Buccal Mucosa/Oral Tongue/Floor of mouth/Lower alveolus /Retro Molar Trigone)

Ø  T1, T2 Tumors: Surgery or RT Surgery: Wide excision Radiotherapy: Radical Radiotherapy / Brachytherapy.

Ø  T3, T4 Tumors: Surgery + Post operative RT/ CT-RT Surgery: Wide excision with marginal/ segmental / hemimandible resection with appropriate reconstruction.

BUCCAL MUCOSA

Ø  T1, T2 Tumors: Surgery or RT Surgery: wide excision +/- marginal mandibulectomy with appropriate reconstruction. Radiotherapy: Radical RT/ Brachytherapy

Ø  T3, T4 Tumors:Surgery + Post operative RT/ CT-RT Surgery: Composite resection of the buccal mucosa with mandible or upper alveolus or overlying skin with reconstruction.

ORAL TONGUE & FLOOR OF MOUTH

Ø  T1, T2 Tumors: Surgery or RT Surgery: Wide excision Glossectomy / Hemiglossectomy with appropriate reconstruction. Radiotherapy: Radical RT/ Brachytherapy.

Ø  T3, T4 Tumors:Surgery + Post operative Radiotherapy/ CTRT

Surgery: Appropriate wide excision glossectomy with mandibular swing or pull through along with lingual plate / segmental / hemimandibular resection, if required (based on extent of involvement) with reconstruction.

LOWER ALVEOLUS & RETRO MOLAR TRIGONE

Ø  Mandible uninvolved or minimally involved

Surgery: Wide Excision with marginal mandibulectomy (avoided in RMT disease, edentulous mandible, paramandibular disease, post radiotherapy) if required with reconstruction.

Ø  Indication for Marginal Mandibulectomy:

·       Whenever tumor is close to the mandible to achieve adequate margin (5 mm- 10mm)

·       Limited superficial bony erosion

·       Limited periosteal invasion

Mandible grossly involved

Surgery + Post operative/ CT-RT

Surgery: Wide Excision (cheek flap) with segmental/ hemimandible resection with reconstruction.

Indication for Segmental Mandibulectomy:

o   Gross tumor invading the mandible

o   Prior radiotherapy s

o   Edentulous mandible

o   Gross paramandibular disease

o   Whenever inferior soft tissue and bony margin of 1 cm is not possible (Eg. Retro Molar Trigone,gross periosteal invasion)

MANAGEMENT OF NECK NODES:

(Lip/Buccal Mucosa/Oral Tongue/Floor of mouth/Lower alveolus /Retro Molar Trigone)

·       T1, T2 Tumors N0: Observe or SOHD (if cheek flap is raised, USG suspicious, thick tumor>3-4mm ,high grade tumor or poor follow up expected) followed by FS, if positive nodes MND is required

·       N+: MND / RND :Post op RT as per earlier guidelines.

·       T3, T4 Tumors N0: SOHD followed by FS, if positive nodes MND is required

·       N+: MND / RND : Bilateral neck needs to be addressed if the primary disease is in midline or extending across midline (including middle third mandible). Post op RT/CT-RT as per earlier guidelines.

Primary:

Maxillary antrum not involved

·       Surgery: Upper alveolectomy / Partial maxillectomy

·       Radiotherapy: Radical RT / Brachytherapy for selected early T1-2 Hard palate lesions

Maxillary antrum involved

·       Surgery: Orbital floor preserving total maxillectomy with reconstruction.

Nodes: Neck needs to be addressed if the neck is clinically positive, if there is extension of the primary disease to the buccal mucosa or there is soft tissue infiltration or radiological suspicion of metastatic node. Post operative RT/ CT-RT as per guidelines mentioned earlier.

Reconstructive options for oral cavity

Objectives:

·       Achieve primary healing

·       Maintain oral competence

·       Facilitate swallowing

·       Prevent aspiration

·       Preserve speech

·       Cosmesis

Based on the size and composition of defect, the options are:

Mucosal defects

·       Leave raw

·       Primary closure

·       Split thickness skin graft (STSG)

·       Mucosal grafts

Full thickness defects

·       Local Flaps: Abbe-Estlander’s flap, Gille’s Flap (for lip)

·       Regional flaps: Tongue flap, Nasolabial flap, Facial artery myomucosal flap, Masseter flap, Platysmal flap, , Forehead flap

·       Distant Flaps: Pectoralis major myocutaneous flap, Deltopectoral flap, Latissimus dorsi myocutaneous flap

·       Free Flaps: Radial forearm flap, Lateral arm flap, Antero-lateral thigh flap

Mandibular Defects

Anterior mandibular defect needs to be reconstructed by

·       Free osteocutaneous flapsFibular osteocutaneous flap (preferred because of long bone length, easy contouring and dual blood supply), Radial osteo- cutaneous flap, Scapular osteocutaneous flap

·       Distant flapsPectoralis major myocutaneous flap, Latissimus dorsi osteocutaneous flap, Trapezius osteocutaneous flap

Lateral mandibular defects may be reconstructed with

·       adequate soft tissue replacement, complemented by proper use of guide bite prosthesis and appropriate postoperative isometric exercises.

Criteria for Inoperabilitsy:

Primary disease: Adequate surgical clearance is not achievable.

·       Extensive Infratemporal Fossa involvement

·       Extensive involvement of base skull.

·       Extensive induration /soft tissue disease till zygoma or hyoid.

Nodal Disease: s

·       Clinically fixed nodes.

·       Infiltration of Internal /Common carotid artery.

·       Extensive infiltration of prevertebral muscles, skull base.

These patients are usually treated with palliative intent with chemotherapy or radiotherapy. If general condition is good, then concurrent chemo radiotherapy can be offered. If general condition is poor, then only best supportive care.

Prognosis: Oral cavity stage 5 year relative survival (95% CI)

·       Stage I 69.5% - 73.5%

·       Stage II 55.5% - 60.4%

·       Stage III 41.8% – 47.3%

·       Stage IV 40.3% – 33.6%

Lip stage 5 year relative survival (95% CI)

·       Stage I 86.5% - 92.7%

·       Stage II 75.5% - 91.5%

·       Stage III 39.8% - 69.8%

Stage IV : 34.2% - 60.1%