48.1 The Lip

48.1.1 Surgical Pathology

• 6/1,000,000

• 93% lower lip, 5% upper, 2% angle

• 2:1 male to female

• 6th decade

48.1.2 Risk Factors

• White European ethnicity (×10) especially Celtic descent

• Cigarette/pipe smoking

• Poor dental hygiene

• Chronic alcoholism (combined with smoking is 15× increased risk)

• Chronic erosive skin diseases, e.g., lichen planus

• Immunosuppression

• Outdoor occupation

48.1.3 Tumour Type

• Squamous cell carcinoma (SCC) (98%)

Exophytic (commonest)

Verrucous

Ulcerative

• Rare lesions

Melanoma

Sarcoma

Salivary gland tumours (mucoepidermoid/adenoid cystic ca)

Myoblastomas

Pyogenic granulomas

Keratocanthoma

Granulomatous cheilitis, e.g., syphilis, sarcoid

• Upper lip and angular lesions metastasize sooner

• <10% of lower lip lesions present with LN mets

48.1.4 Staging

• T1—≤2 cm greatest dimension

• T2—2 ≤4 cm

• T3—>4 cm

• T4a—invades adjacent structures e.g., cortical bone, inf. alveolar nerve, deep muscle of tongue, maxillary sinus, tooth socket (superficial erosion alone is insufficient)

• T4b—invades masticator space, pterygoid plates, or skull base or encases the carotid a

48.1.5 Repair of Defects

• Vermilion

Mucosal advancement

• Lower lip

<1/3—primary closure

48.1.6 Aftercare following Lip Lesion Excision

• No sucking

• Keep wound clean by removing crusts twice a day

• Bactroban or fucidin may be applied

• Half of external sutures may be removed at 3 to 4 days; rest removed at 1 week as appropriate

• Soft diet

• Abbe lip switch:

Feed patient with feeding cup or straw

Transect pedicle after 3 weeks as second stage and complete suturing

48.1.7 Other Treatment Modalities

• 300 kV orthovoltage X-ray therapy: 50 Gy in 15 fractions over 3 weeks

• Interstitial therapy—rigid needles containing cesium

48.2 Oral Cavity

• Variable worldwide incidence but accounts for 50% of all cancers in India

• Male:female ratio 3–4:1

• More frequent after 5th decade of life

48.2.1 Anatomical Regions Subsites

• Buccal mucosa

Mucosal surfaces of upper and lower lips

Mucosal surfaces of cheeks

Retromolar areas

Buccoalveolar sulci, upper and lower

• Upper alveolus and gingiva

• Lower alveolus and gingiva

• Hard palate

• Tongue—anterior 2/3

• Floor of mouth

Sites of Minor Salivary Glands

• Submucosa of inner surface of lips

• Retromolar (parotid duct vicinity)

• Mucous membrane of cheek

• Floor of mouth

• Lesser sublinguals (near major sublingual)

• Glossopalatine (posterior to lesser sublinguals)

• Palatine—hard and soft palate and uvula (not midline)

• Lingual—inferior surface of tongue on each side of frenulum and at base and lateral borders of tongue

Channels of Spread of Tumours

• Small bony canals in hard palate

• Greater and lesser palatine foramina

• Lateral incisive foramina

48.2.2 Surgical Pathology Malignant Tumour Types

• SCC (85%) 3 types—exophytic, ulcerative, infiltrative

• Malignant salivary (5%)—adenoid cystic, mucoepidermoid

• Melanoma (1%)

• Hodgkin lymphoma (0.1%)

• Fibrosarcoma (0.5%)

• Metastases to tongue—breast, lung, kidney most common

Sites of Squamous Carcinoma

• Chronic glossitis

• Malnutrition

• Syphilis

• Cirrhosis

48.2.3 Premalignant Conditions

48.2.4 Biopsy Oral Lesions

• Incisional recommended

• Biopsy red part if speckled leukoplakia

• Staining with toluidine blue and Lugol’s iodine may help locate best biopsy site if multiple areas

Aggressive Features of Posterior Tongue Tumours

• Increased incidence of LN mets

• Tumour can spread to tonsillar pillars, retromolar area, and floor of mouth

• Large invasive carcinomas can extend beneath intact mucosa into muscles of posterior third of tongue and thence pre-epiglottic space

• Tumour extends within musculature of tongue particularly in posterior direction beneath intact mucosa

Hard Palate Tumours

• Minor salivary gland malignancy (mucoepidermoid, adenoid cystic carcinoma) followed by SCC most common aetiology

• Rarer pathology includes sarcoma, melanoma, or lymphoma

• Presentation

Swelling roof mouth

Ill-fitting dentures

Nasal obstruction with extension into nose and maxillary sinus

Trismus with posterior extension involving pterygoids

Middle ear effusion with extension into the nasopharynx, eustachian tube

Absent corneal reflex or palatal hypesthesia from invasion of maxillary division of trigeminal n in the sphenopalatine fossa

Masseter or temporalis wasting from invasion of mandibular division of trigeminal n

Gingiva involvement with extension to upper or lower alveolus via dental sockets with loosening of teeth

Lymph node involvement (levels I and II) in up to 30% of SCC ± retropharyngeal nodes

48.2.5 Overall Staging for Oral and Lip Tumours