Surgical treatment of oral cavity cancers

1. Introduction
The oral cavity is the most common location for cancers of the upper aerodigestive tract. Currently,
these attacks are frequent and this may be the consequence of the increase in risk factors, such as
tobacco or alcohol.

• The treatment of oral cavity cancers depends on the stage of the disease, the general condition
of the patient and the decision of the RCP bringing together surgeons, oncologists,
radiotherapists, radiologists and anatomo-cytopathologists. Surgery remains the treatment of
choice for oral cavity cancers when possible. It can be carried out alone or combined with
radiotherapy and/or chemotherapy.

2. Prognostic factors
A certain number of criteria must be taken into account to generally evaluate the prognosis of tumors
of the oral cavity.

1- Tumor-related clinical factors:

Macroscopic characteristics : budding or vegetating lesions have a better prognosis than

infiltrating and especially ulcerating lesions .

Anatomical location : the tumor of the lip has an excellent prognosis, that of the movable tongue
has an intermediate prognosis and gingival lesions are much more poor.

2- Histological factors:

The degree of histological differentiation of the tumor observed on the biopsy or on the surgical
specimen does not appear to play a role, even if it is classic to consider that poorly differentiated
tumors are both more progressive but respond better to radiotherapy treatment .

The existence of reaching the limits of excision, capsular rupture, invasion of numerous lymph nodes,
the presence of perineural invasion or the presence of lymphangitis carcinomatous are poor prognosis.

3- Biological factor: Genetics and markers:

Several studies have shown mutations in the “P53” tumor suppressor gene in tumors of the upper
aerodigestive tract; there is a strong correlation between these mutations and tobacco consumption,
suggesting that the latter induces mutations in the P53 gene. However, studies only find a positive P53
in one out of two cases of invasive carcinoma.

4- General clinical factors:

More than the weight at the time of treatment, the notion of significant and rapid weight loss is
unfavorable. It is the same in the medium term for the continuation of alcohol and tobacco
intoxication.

3. General principles of oncological excision

 - The excision must be carried out in good lighting after having identified the borders of the
lesion as best as possible using palpation. The outline of the incision is made beforehand.
- The excision line must pass through healthy tissue with a margin of at least 01 cm all around
the tumor (even in depth). This safety margin is the guarantee of satisfactory locoregional
control by limiting microscopically incomplete resections.
- The excision is carried out using a punch.
- Intraoperatively , extemporaneous examinations can be carried out in case of doubt about the
complete nature of the resection and can thus guide its continuation.
- The piece is oriented and accompanied by a diagram. As in all cancer surgery,
- In larger tumors, resection is often followed by local or distant flap repair. In this case, there
must be total independence between the excision and the reconstruction; Healing should not
be compromised due to insufficient excision for cosmetic reasons.
- From the infiltrative stage (T1), surgery is associated with dissection of the cervical sub -
mento -mandibular and jugulo -carotid lymph node areas.
- The unilateral or bilateral nature of lymph node surgery depends on the location of the tumor
and the clinical and radiological lymph node status.

 Surgical approaches:

 Direct route (intraoral): the intraoral route is recommended to maintain the aesthetics
of the face.
 Indirect route (external, transcutaneous route): the most frequently used, for large
tumors, which makes extra- periosteal resection ( hemimandibulectomy , etc.) easy;
 Combined approach: (pull through ): in cases of mandibular tumors with pelvic
extension.

4. Therapeutic indications

1. Carcinoma of the tongue:

• Glossotomy: the removal of the tongue

1.1. Partial glossotomy: it is the marginal or tip of the tongue removal

1.2. Hemi- glossectomy : concerns infiltrating tumors ;

1.3. Glossectomy _ sub-total or total: it is offered exceptionally after failure of other therapies.

The phonetic aftereffects are important and feeding is possible through compensatory
movements of the cheek .

2. Carcinoma of the lip :

• 2.1. Vermillectomy : allows the excision of the entire mucosa of the lip, the reconstitution is
done at separate points with the cutaneous -mucosa line.
 • 2.2. Resection: is indicated for infiltrative lesions which involve less than 1/3 of the lip with a
large oral orifice. The technique consists of excision of the entire thickness of the lip with a V-
shaped incision and the edges are brought together thanks to the elasticity of the lip.

3. Cheek carcinoma :
Surgical treatment depends on the surface extension and the degree of deep infiltration of the tumor.

For small lesions, excision is performed with simple suture.

infiltrative lesions , excision of the tumor, the buccinator muscle and the skin is performed. The
reconstruction is carried out using the myocutaneous flap of the pectoralis major.

4. Carcinoma of the floor of the mouth:

. Wide excisions: indicated for lesions invading the floor, tongue, gum and mandible, we can cite:

• Hemiglosso - pelvi interruptive and non-interruptive mandibulectomy .

• Glosso - palvi - interrupting and non-interrupting symphysectomy

5- Mandibulectomy :
It is indicated in cases of tumors which originate in the mandible (primitive) or which have spread
there secondarily.

Depending on the degree of mandibular damage, we can resort to:

- Pelvi non-interruptive (marginal) mandibulectomy : excision of the tumor from part of the mandible
with preservation of the basilar rod of the bone.

- Pelvi - interruptive mandibulectomy : Where the total excision of the tumor is carried out with
the part of the affected mandibular bone.

- Hemi- mandibulectomy (end resection ): carried out in cases of large tumors having blown out
at least two bony walls and invaded the surrounding soft tissues, it consists of a
temporomandibular disarticulation and a section which can take place at the level of the
parasymphyseal region or the branch contralateral horizontal.

6- maxillectomy :
Three variants are described:

- maxillectomy of the palatal infrastructure not involving the alveolar crest, without bone
invasion: the vault will be sectioned according to the limits of excision determined with a
direct approach via the palatal intraoral route .
If the nasal or sinus floor is affected, a section of the nasal -sinus wall will be carried out to allow the
one-piece disinsertion of the operating part.

- maxillectomy of the palatal infrastructure involving the alveolar crest, without bone invasion:

The invaded alveolar ridge will be included in the tumor excision . A double palatal and
vestibular approach is then necessary.

- Maxillectomy with bone invasion:

• Depending on the degree of bone invasion, a subtotal osteotomy may be performed with
preservation of the orbital floor as well as the entire or posterior part of the maxillary sinus via
vestibular and endobuccal approach .

• An obturator prosthesis or reconstruction should be considered as a solution to the loss of

substance after the operation.

5- Lymphectomy _

Lymph node surgery is both exploratory and therapeutic.

The type of dissection depends on the extent of lymph node extension. Depending on the
location of the tumor, lymphatic drainage can be done bilaterally, requiring bilateral
dissection.

An extemporaneous histological examination of the subdigastric and supra- omohyoid

lymph node relays “ obligatory ” passageways makes it possible to determine whether it is
necessary to extend the cleaning to the underlying chains.

Histological examination of the lymph node dissection result

• A conventional histological study specifies:

– the number of lymph nodes identified

– the number of invaded lymph nodes: N+

– their headquarters

– the existence or not of a capsular rupture: R+ or R.

Additional radiotherapy is essential in case of multiple N+ or in case of R+.

• Radical lymph node dissection:

• It was customary to perform a radical lymph node dissection including at least 5 levels of
cervical lymph nodes. But this method caused significant morbidity due to the sacrifice of
important anatomical structures (the accessory nerve and/or the internal jugular vein and/or
the sternocleidomastoid muscle ).

• functional cervical lymph node dissection

includes V ganglion groups , but spares the accessory nerve and/or the internal jugular vein and/or the
sternocleidomastoid muscle . It is performed for probable or macroscopically obvious lymph node
metastases that do not infiltrate these nonlymphatic structures.

• selective lymph node dissection

includes one or more lymph node groups at high risk of metastatic disease early. Its design is based
on the location of the primary tumor and preferential anatomical lymphatic drainage. It can be
supraomohyoid , posterolateral , and/or central.

• A reconstruction

• Reconstruction is necessary in the event of extensive mucosal and/or bone loss. It is done
using regional pedicled flaps or by

 micro-anastomosed transplants:

• pedicled flaps:

• nasolabial flap ;

• pectoralis major myocutaneous flap ;

• latissimus dorsi myocutaneous flap ;

• temporalis muscle flap;

 micro anastomosing transfers:

• antebrachial flap , also called Chinese flap;

• musculocutaneous composite transfer of fibula , latissimus dorsi or pectoralis major.

• In the event of interruption of continuity, the after-effect is the loss of mastication and,
incidentally, a change in facial aesthetics which can be remedied by sometimes offering a
guide device to avoid mandibular deviations, sometimes bone rehabilitation. microsurgical
(micro-anastomotic transfer of iliac crest or fibula ).

Other surgical means

• Laser surgery

The CO2 laser can be proposed for the treatment of precancerous leukoplakia of the oral cavity:
intense pain, slow healing, sometimes recurrence are observed. Its use has been described in addition
to a first-line surgical excision procedure on the tumor resection margins.

• Cryotherapy

• It uses very low temperatures for the in situ destruction of tumor cells. Its development was
initially limited by the unreliability of freezing control and the risks of damage to neighboring
organs. Rapid freezing by pressurized liquid nitrogen followed by slow warming is the most
lethal methodology for tumor cells.
• Despite interesting results for T1-T2 carcinomas of the tongue, in association with cervical
lymph node dissection, its lingual application remains poorly developed, due to the
importance of the local inflammatory reaction causing respiratory complications.

• Dynamic phototherapy

• Its aim is to destroy the tumor tissue in two stages: a photosensitizing molecule ( photobrake )
is injected through the bloodstream and concentrates in the malignant cells; Laser
electromagnetic radiation causes selective cytotoxicity .

• This is linked to the production of free radicals and oxygen. Laser treatment therefore has a
photochemical and not thermal effect. This still underdeveloped therapy could avoid surgical
treatment for small lingual tumors. Photosensitization is the most common side effect.

Conclusion
• Epidemiology does not show a real reduction in cancers. Prevention campaigns against
alcohol and smoking risks must therefore remain active. Therapeutic indications reflect
multiple trends: while small tumors can be treated equally by radiotherapy or surgery, the
treatment of larger lesions most often requires a radio-surgical combination.

• The role of chemotherapy remains to be evaluated. In all cases, the presence of metastatic
cervical lymphadenopathy is a primary factor in poor prognosis.