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Oral cavity cancer Presented by: Dr.

ahmed mohmed ameen

The topic of malignant neoplasms of the oral cavity is synonymous with a discussion of oral squamous cell carcinoma. The oral cavity is unique in that, unlike other anatomic regions of the upper aerodigestive tract, the routine detection of early-stage lesions is possible. However, given the relatively common presentation of other benign pathology within the oral cavity such as aphthous ulceration, delay in diagnosis can occur.

Etiology
Tobacco and alcohol consumption are considered the most common preventable risk factors associated with the development of oral cavity squamous cell carcinoma. In addition, this relationship is synergistic, with alcohol serving as a promoter for the carcinogenic effects of tobacco. When compared with nonsmokers, smoking confers a 1.9-fold risk to males and 3-fold risk to females for development of head and neck squamous cell carcinoma. The risk is directly proportional to the years spent smoking and the number of cigarettes smoked per day. Common genetic alterations such as loss of heterozygosity at 3p, 4q, and 11q13 and the overall number of chromosomal microsatellite (repeated base sequences) losses were significantly more likely in the tumors of smokers. In addition, the rate of p53 mutations was markedly increased in this group of patients. Smoking and habitual use of alcohol have also been associated with p15 gene methylation. The human papillomavirus (HPV) is an epitheliotropic virus detected to varying degrees within samples of oral cavity squamous cell carcinoma. Infection alone is not considered sufficient for malignant conversion; however, results of multiple studies suggest a role of HPV in a subset of head and neck squamous cell carcinoma. Environmental ultraviolet light exposure has been associated with the development of lip cancer. The projection of the lower lip, as it relates to this solar exposure, has been implicated in the pathogenesis of squamous cell carcinomas arising on the vermilion border of the lower lip. Pipe smoking has also been associated with the development of lip carcinoma. Mechanical irritation, thermal injury, and chemical exposure are suspected etiologic factors contributing to lower lip cancer development in pipe-smoking patients. Other entities associated with oral malignancy include Plummer- Vinson syndrome (achlorhydria, iron deficiency anemia, and mucosal atrophy of the mouth, pharynx, and esophagus); chronic infection with syphilis; illfitting dentures; and long-term immunosuppression fold increase with

renal transplant). Although evidence linking HIV infection to squamous cell carcinoma of the head and neck is lacking, Kaposis sarcoma may arise in the oral cavity.

Molecular Biology
Tumor development represents the loss of multiple signaling mechanisms regulating the control of cell growth. After malignant transformation, the processes of replication (mitosis), programmed cell death (apoptosis), and the interaction of a cell with its surrounding environment are altered. H-ras, a member of the ras gene family, encodes a plasma protein (p21), which has a role in the transduction of mitogenic signals to the intracellular environment. A synergism between H-ras and HPV is believed to play a role in the induction of squamous cell carcinoma. In human studies, 22% of oral squamous cell carcinomas expressed H-ras, whereas 11% expressed H-ras and HPV. All specimens of oral verrucous carcinoma that expressed H-ras (25%) demonstrated evidence of HPV DNA. Over expression of mutant p53 has been associated with carcinogenesis at multiple sites. Point mutations in p53 have been reported in up to 45% of head and neck carcinomas.

Epidemiology
Oral cavity malignancies (excluding lip lesions) account for 14% of all head and neck cancers. In a review (1985-1996) of the National Cancer Data Base (NCDB), patients diagnosed with an oral cavity cancer had a mean age at presentation of 64 years with a male predominance (60%). Squamous cell carcinoma (SCC) represented the majority of lesions (86.3%), and adenocarcinoma (5.9%), verrucous carcinoma (2.0%), lymphoma (1.5%), and Kaposis sarcoma (1.5%) accounted for the remainder. At the time of diagnosis, 55% of patients had early-stage lesions (stage I-II). Patients 35 years old or younger were more likely to present with oral tongue SCC than older patients (76.1% vs. 33%) and less likely to present with a floor-of-mouth SCC (10.5% vs. 35.9%). Of note, the NCDB data did not reveal a poorer overall prognosis for those patients diagnosed at a younger age. In fact, younger patients demonstrated a better 5-year survival (63.7%) than older stagematched patients (51% for 36 to 65 years of age and 47.6% for older than 65 years of age). Blacks and lower income patients more frequently presented with advanced-stage lesions. Five-year survival was found to be worse for males, blacks, and older patients (older than 65 years).

Adenocarcinoma presented more commonly in women than men and was most frequently diagnosed on the hard palate.

Anatomy
Because of the pivotal role the oral anatomy has on articulation and deglutition, treatment of an oral malignancy can have a significant impact on a patients quality of life. The local, regional, and distant spread of oral cavity malignancies is dependent on the course of the neurovascular anatomy, lymphatic pathways, and the fascial planes of the head and neck. The latter serves as a barrier to the direct spread of tumor and can influence the pattern of local and regional lymphatic spread. In addition, perineural and angioinvasion can act as a conduit for the spread of head and neck malignancies. When present, these histologic findings can have a profound impact on the patients prognosis and long-term survival.

Arteriovenous Anatomy The arterial supply to the oral cavity includes multiple contributions from the external carotid artery. The lingual artery provides the majority of the vascular supply to the oral tongue and tongue base. Identification of the artery within the neck requires the exposure of the floor of the submandibular region. The artery is found deep to the hyoglossus muscle and requires the division of the muscle for maximal exposure. Superficial to the hyoglossus and deep to the mylohyoid muscle is the hypoglossal nerve and lingual veinsThe hard palate blood supply is derived from the greater palatine and the superior alveolar arteries. After branching off the descending palatine artery at the greater palatine foramen, in the region medial to the second maxillary molar, the artery runs anteromedially within the soft tissue of the hard palate The venous drainage is to the pterygoid plexus and subsequently to the internal jugular venous system. The superior alveolar arteries (anterior, middle, posterior) arise as terminal branches after the transition of the internal maxillary artery to sphenopalatine artery at the pterygopalatine fossa. These arteries provide blood supply to the maxillary gingiva, alveolar ridge, and dentition The facial artery crosses over the lateral aspect of the mandible approximately 1 cm anterior to the ascending ramus and courses toward the oral commissure where it gives rise to the labial arteries. These paired vessels are readily apparent during lip-splitting procedures and anastomose in the midline to create a vascular ring. The primary vascular supply to the mandible and the lower dentition is from the inferior alveolar artery. Blood supply from the mandibular periosteum becomes more important with advancing age. The inferior alveolar artery, vein, and nerve enter the mandibular foramen along the

medial aspect of the ramus of the mandible. Before their entryinto the foramen, both the nerve and artery send off branches that extend anteriorly to supply the mylohyoid muscle. The posterior floor of the mouth and retromolar trigone have an arterial supply and venous drainage similar to that of the anterior tonsillar region. The ascending pharyngeal and lesser palatine vessels contribute to the vascularity that may be encountered with surgical procedures at this site.

Subsites of the Oral Cavity Lips The lips represent a transition from external skin to internal mucous membrane that occurs at the vermilion border. The underlying musculature of the orbicularis oris, innervated by the facial nerve, creates a circumferential ring that allows the mouth to have a sphincter-like function. The sensation for the upper lip is supplied by the infraorbital nerve (CN V2), whereas the lower lip is provided by the mental nerve(CN V3). Lymphatics from both the upper and lower lips drain primarily to the submandibular lymph nodes, yet midline lower lip lesions may present with submental lymphatic spread. In addition, the upper lip may drain to preauricular, infraparotid, and perifacial lymph nodes. Alveolar Ridge The lateral aspect of each alveolar ridge is represented by the mucosal sulcus created by the transition of tissue to buccal mucosa. On the lower alveolus, the medial margin is marked by the transition to the floor of the mouth and, on the upper alveolus, the transition is the horizontalit is the superior aspect of the pterygopalatine arch for the upper alveolus. The close approximation of mucosa to underlying bone assists early bone invasion for malignant tumors in this region. Oral Tongue The oral cavity portion of the tongue is defined as that portion anterior to the linea terminalis. The tongue is composed of four intrinsic and four extrinsic muscles separated at the midline by the median fibrous lingual septum. The extrinsic muscles originate outside the substance of the tongue and include the genioglossus, hyoglossus, styloglossus, and palatoglossus. Of these, the genioglossus, which functions to depress and protrude, provides the majority of the bulk to the tongue. The paired intrinsic muscles of the tongue (superior-inferior longitudinal, transverse, and vertical) lie superficial to the genioglossus and function to alter the overall shape of the tongue. These muscles run with the tongue in three different orientations. This lack of distinct planes between muscles can allow for a diffusely infiltrating pattern of tumor growth. All of the

musculature of the tongue derives its innervations via the hypoglossal nerve with the exception of the palatoglossus, which is supplied by a pharyngeal branch of the vagus nerve. The general sensory innervation of the anterior two thirds of the tongue is provided by the lingual nerve. It arises deep to the lateral pterygoid muscle, spirals from lateral to medial around the submandibular duct, and divides into several branches that lie in the submucosa of the oral tongue. The special sensory innervation of the oral tongue for taste is provided by the chorda tympani nerve (CN VII) that travels to the anterior tongue along with the lingual nerve. In contrast, both functions are performed by the glossopharyngeal nerve for the base of tongue. The lymphatic drainage of the oral tongue varies by the region within the tongue. The tip drains preferentially to submental nodes, whereas the lateral tongue drains primarily to the levels I and II. However, it is important to note that a defined lymphatic pathway from the lateral tongue does exist and drains directly to the level III/IV nodal group. The base of the tongue drains to the upper cervical lymphatics. The lack of anastomoses between the anterior tongue lymphatics results in lateralized oral tongue lesions tending to drain ipsilaterally. This is not the case with base-of-tongue lesions where crossover and bilateral cervical lymphatic spread may readily occur. Retromolar Trigone This region is represented by the mucosa overlying the ascending ramus of the mandible toward the coronoid process. It is continuous with the buccal mucosa laterally and the anterior tonsillar pillar medially. The superior extent is the maxillary tuberosity and the anterior margin is the posterior aspect of the second mandibular molar. The same considerations that were true for alveolar lesions exist for this anatomic site, given the close approximation of mucosa to the underlying mandible. Lower lip paresthesia may be an indication of perineural invasion at the level of the mandibular foramen with these lesions. The sensation to this region is provided by the lesser palatine nerve and branches of the glossopharyngeal nerve. It is the presence of CN IX that causes patients with lesions within this area to present with referred otalgia. The primary lymphatic drainage for this region is to the upper cervical jugulodigastric nodal group. Floor of Mouth The floor of mouth is a mucosal surface bordered by the oral tongue and alveolar ridge laterally and anteriorly. The posterior margin is the anterior tonsillar pillar. The lingual frenulum divides the region into two oval spaces. The mylohyoid and hyoglossus muscles provide the structural support for contents of the space. The significance of the floor of mouth

comes from the anatomy that the region overlies. Hypoglossal or lingual nerve dysfunction may be the presenting complaint for patients with lesions in this portion of the oral cavity. The sublingual gland is vulnerable to direct invasion from lesions in this region. A branch of the lingual nerve provides sensation for the floor of mouth. The lymphatic drainage of the anterior aspect of this space may cross to contralateral submental-submandibular nodes, where as the posterior portion of the space tends to drain to ipsilateral upper cervical lymph nodes. Buccal Mucosa This surface extends from the posterior aspect of the lip to the alveolar ridges medially and the pterygomandibular raphe posteriorly. The parotid duct orifice is located next to the second maxillary molar after it exits the parotid and pierces the buccinator muscle. The sensation is provided by branches of the trigeminal nerve (CN V2 and CN V3). The lymphatics of this region drain preferentially to submental and submandibular lymph nodes. Hard Palate The hard palate has the maxillary alveolar ridges as anterior and lateral margins and the soft palate as a posterior border. Invasion through the hard palate results in extension of tumor into the nasal cavity or maxillary sinus. Infrastructure maxillectomy is frequently required for invasive lesions. A prosthetic obturator or flap reconstruction is necessary to reestablish oral competence and avoid hypernasal speech. The nasopalatine nerve (CN V2) provides sensation to the region. Most of the lymphatic drainage from this site is to the upper cervical lymphatics or lateral retropharyngeal nodes.

Pathology
Certain histopathologic findings have significant implications on treatment. Tumor thickness, in particular with oral tongue carcinoma, has been the subject of many reports. Tumor thickness has been shown to have a direct relationship to the incidence of regional metastatic spread and survivorship. The degree of differentiation and the presence of vascular or perineural invasion have important prognostic implications and may warrant the use of postoperative radiation therapy. Premalignant Lesions A discussion of the premalignant lesions of the oral cavity requires a review of the definitions commonly used in describing the gross and histologic appearance of these growths. Leukoplakia is white, mucosalbased keratotic plaque that cannot be wiped free from the underlying tissue. This is a clinical term without a definitive histologic definition.

Leukoplakic lesions may demonstrate parakeratosis, hyperkeratosis, and acanthosis on histologic examination. Paradoxically, an increased risk of malignant transformation of leukoplakic lesions is seen more commonly in nonsmokers compared with smokers. If a leukoplakic lesion is associated with an area of dysplasia (in 1% to 3% of all lesions), the risk of progression to malignancy increases seven-fold. Banoczy followed 670 patients with leukoplakic lesions for 3 years and noted that 31% of lesions disappeared, 30% improved, 25% experienced no change, and 7.5% demonstrated local spread. Only 6% of lesions demonstrated eventual progression to squamous cell carcinoma. Syphilitic leukoplakias seen in tertiary syphilis have a higher reported rate of malignant transformation. Erythroplakia is a red mucosal plaque that does not arise from any obvious mechanical or inflammatory cause and persists after removal of possible etiologic factors. The associated risk for progression to carcinoma is significantly greater than that for leukoplakic lesions. Submucosal fibrosis, most frequently encountered in individuals who chew betel nut, is associated with poor oral hygiene, advanced periodontitis, and oral carcinoma. The buccal mucosa becomes thickened and the entire cheek becomes fibrotic, resulting in trismus. Resection of tumors arising in the buccal mucosa in patients with submucosal fibrosis can be challenging and reconstruction can be complicated by wound breakdown and poor healing. Squamous Cell Carcinoma and Variants Several variants of squamous cell carcinoma exist and may be encountered in the oral cavity. Sarcomatoid squamous cell carcinoma demonstrates a heterogeneous appearance with spindle-shaped cells interwoven with squamous cells. The cytologic behavior of this variant is considered aggressive with a reported metastatic rate of 37%.40 Basaloid carcinoma is also considered a high-grade variant with reported 64% incidence of regional metastases and 44% incidence of distant metastases, and it is associated with 38% mortality at 17 months.41 However, one report notes that when clinical T and N staging are matched, the 5-year disease-free survival associated with oral basaloid carcinoma is similar to that of poorly differentiated and moderately differentiated oral carcinomas. A thick zone of nonproliferating and nonkeratinizing cells distinguishes verrucous carcinoma histologically. The typical presentation is on the buccal mucosa (50%). It is considered a low-grade variant of squamous cell carcinoma and is exophytic in appearance. It has the capacity to invade locally yet carries a low risk of regional spread. Traditionally, this

lesion has been considered to be radioresistant and surgical excision has been the treatment of choice.

Diagnostic Evaluation
History and Physical Examination When evaluating a patient for an oral lesion, inquiries into changes in the fit of a preexisting denture, otalgia, trismus, oral-dental pain, bleeding, halitosis, weight loss, dysphagia, odynophagia, dysarthria, and facial numbness should be made. Patients should be questioned about specific medications, allergies, medical diagnoses, and previous surgical interventions. This information can be critical when formulating a treatment plan tailored to a patients comorbidities. In addition, a detailed history of the patients tobacco and alcohol use should be obtained. The head and neck physical examination should allow for accurate staging of the tumor, assess the patients functional capacity before treatment, and include a careful search for synchronous upper aerodigestive tract cancers. The physician should evaluate the dimensions of the index lesion and the potential anatomy involved by direct spread of tumor. The lesion should be palpated to assess for fixation to the underlying periosteum suggesting potential mandibular or maxillary involvement. Determination of midline extension, regional lymphatic spread, and the need for reconstruction should be considered. The appropriateness of specific donor sites for free and/or pedicled flap reconstruction should also be assessed. Future screening for oral cancer may be possible with outpatient biomarker laboratory assays. St. John and colleagues have described the use of an assay for salivary interleukin (IL)-8 and serum IL-6 with promising results in patients with oral cavity and oropharyngeal carcinoma. Preoperative Assessment Imaging to assess the primary extent of tumor and cervical lymph nodes includes either computed tomography (CT) or magnetic resonance imaging (MRI). CT is best for demonstrating cortical bone erosion and lymph node metastases. MRI is favored for demonstrating soft tissue invasion by tumor and extension into medullary bone. Newer imaging modalities such as positron emission tomography (PET), PET-CT, single photon emission computed tomography (SPECT) scanning have been used to stage patients with head and neck cancer, but their role in preoperative assessment is not uniform and continues to evolve. Assessment for distant metastases may be performed using one of these modalities or via CT of the chest with contrast.

Preoperative Interventions Anticipating the nutritional needs of patients may prevent an extended need for hospitalization or treatment breaks during postoperative radiation. Malnutrition in the perioperative period can predispose patients to wound complications. Preoperative consultation for gastrostomy tube placement should be considered for those patients in which the ability to take oral nutrition is compromised before surgery or anticipated to extend for a prolonged period of time postoperatively. For those requiring postoperative radiation therapy, mucositis can result in a delay in the normal resumption of oral intake for several weeks to months. In addition, dental evaluation is essential for patients with poor dentition and those who may require radiation as part of their treatment. Prosthodontic evaluation is indicated for those who will undergo maxillectomy and require a surgical obturator. For patients with the potential for significant speech and swallowing impairment postoperatively, consultation and counseling with a speech-language pathologist can aid in long-term rehabilitation. Endoscopy Panendoscopy including bronchoscopy, esophagoscopy, and direct laryngoscopy has been advocated for the preoperative assessment of head and neck cancer patients. Given that the reported risk of harboring synchronous second lesion is between 5% and 10% in newly diagnosed patients, some consider panendoscopy necessary. Others advocate direct laryngoscopy but reserve performing esophagoscopy and bronchoscopy in symptomatic patients (with pretreatment dysphagia, odynophagia, cough, and/or hemoptysis) or if the preoperative thoracic imaging (chest x-ray or CT) is abnormal. If a percutaneous endoscopic gastrostomy tube placement is planned before definitive surgery, evaluation of the esophagus can be deferred to that procedure. Alternatively, a preoperative barium swallow can serve as a screening tool to exclude a second primary tumor; however, false-negative findings associated with the technique can occur. The extent of investigations for excluding second primary tumors is individualized according to physician preferences and the needs of an individualized patient.

Staging
Staging for oral cavity malignancies is defined by the American Joint Committee on Cancer (AJCC) and follows TNM (primary Tumor, regional Nodal metastases, distant Metastasis) staging format.

Primary tumor TX T0 No Tis T1 T2 Unable to assess primary tumor evidence of primary tumor Carcinoma in situ Tumor 2 cm in greatest dimension Tumor 2 cm and 4 cm in greatest dimension T3 Tumor 4 cm in greatest dimension T4 (lip) Primary tumor invading cortical bone inferior alveolar nerve, floor of mouth, or skin of face (e.g., nose, chin) T4a (oral) Tumor invades adjacent structures (e.g., cortical bone, into deep tongue musculature, maxillary sinus) or skin of face T4b (oral) Tumor invades masticator space, pterygoid plates, or skull base or encases the internal carotid artery Regional lymphadenopathy NX Unable to assess regional lymph nodes N0 No evidence of regional metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm in greatest dimension N2a Metastasis in single ipsilateral lymph node, 3 cm and 6 cm N2b Metastasis in multiple ipsilateral lymph nodes, all nodes 6 cm N2c Metastasis in bilateral or contralateral lymph nodes, all nodes 6 cm N3 Metastasis in a lymph node 6 cm in greatest dimension Distant metastases MX metastases M0 M1

Unable to assess for distant No distant metastases Distant metastases

TNM staging Stage 0 Stage I Stage II Stage III Stage IVa

Stage IVb Stage IVc

Tis N0 M0 T1 N0 M0 T2 N0 M0 T3 N0 M0 T1-3 N1 M0 T4a N0 M0 T4a N1 M0 T1-4a N2 M0 Any T N3 M0 T4b Any N M0 Any T Any N M1

Treatment Considerations
The precise assessment of the tumor stage for oral cancers is necessary in order to develop an appropriate treatment approach. The general physical and psychologic condition of a patient should also be taken into consideration. Key questions that must be answered are: Is the patient medically fit for an extensive procedure? Can the patients health status be optimized? Does the patient comprehend the treatment options and possible sequelae .

Multiple general statements can be made concerning the surgical management of oral cancer as a whole. A detailed discussion of the treatment of each oral cavity subsite follows within this chapter. For earlystage lesions of the oral cavity (T1/T2), transoral resection tends to be possible with complete tumor removal and adequate margin control. Primary closure, healing by secondary intention or placement of a splitthickness skin graft may be used for reconstruction of small defects. Larger and more posteriorly located lesions may require a pullthrough or mandibulotomy-based technique to aid exposure for resection and reconstruction. When the tumor closely approximates the mandible, marginal versus segmental mandibulectomy needs to be considered. Reconstructive options for advanced T-stage lesions include microvascular free tissue or pedicled flap reconstruction. Traditionally, T4b lesions have been considered inoperable. Liao and colleagues demonstrated equivalent results with T4a and selected T4b lesions (without carotid encasement and skull base extension) when aggressive surgical management of the primary site and regional lymphatics with postoperative radiation or chemoradiation therapy was performed. Free tissue reconstruction was necessary in 95% of patients. Local control, disease free, and overall survival numbers were similar.

SurgeryTreatment of the Primary Lesion


Operative Approaches The surgical approach to the oral cavity primary site is dictated by the size, location, and associated involved anatomy relative to the tumors presentation. Resection of limited (T1, small T2s) primary lesions can typically be performed transorally. Using transtumoral cuts, larger lesions can also be excised to a negative margin using the transoral approach. Advanced-stage oral tongue lesions, in particular those with posterior extension, may require a mandibulotomy-based approach to allow adequate access for the resection of the posterior margin of the tumor and allow for reconstruction. Advanced-staged tumors of the anterior oral tongue and floor of mouth, in particular those that involve the genioglossus and mylohyoid musculature (without mandibular involvement), can be efficiently managed with a visor or degloving approach. This approach can allow for excellent visualization enabling wide resection of the deeply invasive primary lesion while sparing the patient from a mandibulotomy and a possible postoperative nonunion. Specific considerations relative to the resection of various types of presentations at the different oral cavity sites are discussed as follows. Lip The majority of neoplastic lesions that affect this subsite present on the lower (88% to 95%) as opposed to the upper lip (2% to 7%) or the commissure (1%) Small primary lesions may be treated with surgery or radiation with equal success and acceptable cosmetic results. However, surgical excision with histologic confirmation of tumor-free margins is the preferred modality. The reconstruction of lip defects after tumor excision requires innovative techniques to provide oral competence, maintenance of dynamic function, and acceptable cosmesis. With small lesions, defects up to one third of the lips length, simple excision with primary closure is possible. When lesions require resection of up to one third to two thirds of a lips length, reconstructive options include a lip-switch (Abbe-Estlander) or a Johansson stepladder flap.67 For tumors requiring resection of more than two thirds of the lip, the reconstructive options are the Gilles fan flap, bilateral advance-ment flaps, Karapandzic, or a free radial forearm with palmaris longus tendon. The Karapandzic flap is a sensate, neuromuscular flap that includes the remaining orbicularis oris muscle. The blood supply for this flap is the corresponding branches of the labial artery. Microstomia is a potential complication with these methods of lip reconstruction. For large defects, Webster or Bernard procedures using lateral nasolabial flaps with buccal advancement have been described. In addition, for aggressive and advanced-staged lesions, an evaluation for

perineural spread should be performed at the time of resection. Potential biopsy of the mental nerve with a retrograde dissection in an attempt to obtain a negative margin should be considered. With extensive perineural invasion, a drill-out of the mental nerve or hemimandibulectomy may be required.

Alveolar Ridge
Squamous cell carcinoma of the mandibular and maxillary alveolar ridges represents approximately 10% of all oral cavity cancers. Lower alveolar ridge carcinomas present more frequently than upper lesions. Given that the mucosa closely approximates the underlying bone of the alveolus, osseous erosion and/or invasion at presentation is common. Tumors extending within adjacent dental sockets are associated with a higher likelihood of bone invasion. In this situation, preoperative radiographic evaluation can significantly aid in treatment planning.
When tumors approach but do not invade the periosteum, a subperiosteal resection with mandibular preservation is possible with primary closure or splitthickness skin graft reconstruction. When the periosteum is invaded, marginal mandibulectomy is indicated. Marginal resection may be performed in two planes. The classic rim or coronal marginal mandibulectomy removes the superior aspect of the involved mandible, whereas a lingual sagittal marginal mandibulectomy removes the lingual cortex of the mandible contacting the tumor. With lesions surrounding intact dentition, extraction and alveolar resection are required to obtain an adequate margin. When the tumor extends down the tooth socket into the medullary bone, segmental mandibulectomy is frequently necessary. With segmental mandibular defects of the symphysis, reconstruction with vascularized free tissue transfer with an osseous flap remains the standard of care. For lateral mandibular defects, the options are more varied and may include primary closure, pedicled and/or vascularized free flap soft tissue reconstruction, or vascularized osseous free tissue transfer.

Oral Tongue A partial glossectomy, which may remove a significant portion of the lateral oral tongue, can still permit reasonably effective postoperative function. However, treatment of larger tumors that invade deeply within the tongue can result in a significant functional impairment. With resection of approximately one quarter to one third of the oral tongue, healing by secondary intention is an acceptable option. If a limited portion of the floor of mouth is resected, reconstruction with a splitthickness skin graft should be used to prevent tongue tethering. Resection of approximately one half of the tongue results in loss of tongue bulk and scar contracture if limited reconstructive options are pursued. Lingual contact with the palate, lip, and teeth is decreased and can result in impaired articulation. Posterior propulsion of the food bolus and liquids

may also be affected. The use of soft pliable fasciocutaneous free flaps such as a radial forearm or anterolateral thigh free flap can provide intraoral bulk and preservation of existing tongue mobility. A palatal augmentation prosthesis allows for contact between the remaining tongue tissue and the palate and may improve speech and swallowing function. For patients undergoing a partial glossectomy with a significant resection of the floor of mouth, free flap reconstruction to maintain tongue mobility is indicated. At initial presentation, 40% of patients with oral tongue carcinoma demonstrate evidence of cervical metastases. For patients with T1 and T2 tumors with clinically N0 neck examination, 20% to 30% of elective neck dissection specimens are pathologically positive. Patients with advanced-stage lesions (III or IV) require surgery and postoperative radiation therapy to achieve the best locoregional control rates. Floor of Mouth The treatment of choice for early-stage lesions, not involving the mandible, is transoral resection. For more extensive anterior and lateral floor of mouth cancers without mandibular involvement, a pullthrough technique can spare the need to perform a mandibulotomy. Paramedian or lateral mandibulotomy is seldom necessary except for some posterior floor of mouth tumors. The resection of larger tumors of the floor of mouth usually requires immediate reconstruction. The goals of reconstruction are to obtain a watertight closure to avoid salivary fistula and preserve tongue mobility. For extensive mucosal and soft-tissue deficits, the radial forearm free flap offers the best reconstructive option to accomplish these goals. Additional reconstructive options include the nasolabial, platysma, and pectoralis major flaps. The platysmal flap can be used for small lateral defects, whereas the pectoralis major myocutaneous flap can be used for larger soft tissue defects, preferably when the posterolateral mandible is resected. For lesions without evidence of bony invasion but demonstrating involvement with the lingual periosteum, a coronal partial mandibulectomy may be required (Fig. 96-23). For massive lesions associated with mandibular destruction, composite resection with segmental mandibulectomy is necessary. Buccal Mucosa
Small lesions can be excised transorally. Intermediate-staged primary tumors may be resected transorally or through a lip-splitting incision. With the exception of superficial lesions, the buccinators muscle should be resected in continuity, thus providing an adequate deep margin. Although primary closure or healing by secondary intention is acceptable for small primary tumors, larger

defects should be repaired with a fasciocutaneous flap to avoid scar contracture and trismus, which are frequent sequelae of skin grafting. Local intraoral spread may necessitate resection of the alveolar ridge of the mandible or maxilla. For invasive squamous cell carcinomas and minor salivary gland tumors, the buccinator muscle should be included with the specimen at the time of resection. Deep invasion into the cheek may require through-and-through resection.