The type of surgical procedure for tumours of the lips and oral cavity depends on the precise location of the tumour, its T-stage, the presence of nodal disease, concurrent second primary lesions and the health of the patient.
Adequate local clearance with preservation of function is the aim with surgical treatment for intraoral cancers; large defects are repaired with microvascularised free-tissue flaps. A margin of 10 mm is the ideal but anatomical constraints and the large size of some of the tumours mean that surgical clearance is often restricted to 2 or 3 mm. In addition, extensive areas of abnormal mucosa are often present around the tumours.
Small superficial tumours of the tip or lateral border of the tongue can be treated by local "wedge" excision although formal hemiglossectomy is preferable for deeply infiltrative lesions. Subtotal or total glossectomy is performed for large tumours invading widely across the midline fibrous septum, involving the extrinsic muscles or affecting the posterior one-third.
The ipsilateral sublingual gland is usually included with resections of anterior floor of mouth mucosa; both sublingual glands are included for midline lesions. Partial glossectomy will be included with resections for tumours of the anterior floor of the mouth that spread into the tongue. Likewise, with tumours encroaching on the gingiva, compromised mucosa from the lower alveolus will be resected.
Resection may be restricted to the alveolar mucosa for superficial tumours of the upper and lower gingiva but larger tumours often require extensive resection. For example, a widely infiltrative carcinoma of the retromolar trigone may require removal of a portion of lower alveolar mucosa and bone, lingual sulcus, posterior buccal mucosa with lower and upper sulci, the posterior portion of the upper alveolar mucosa, the tonsillar bed and part of the soft palate. Part of the posterior tongue may also be included.
A full-thickness wedge excision of lip (V-shaped or W-shaped) is the commonest treatment for squamous cell carcinoma of the lip. To limit the development of new lesions, in-continuity mucosal "shave" excision of adjacent mucosal changes on the vermilion border is more often than not carried out at the same time.
When tumour encroaches on the periosteum at any intraoral site, the decision to resect bone depends on whether or not there has been previous radiotherapy to the jaw, the precise anatomical relationship of tumour and bone and how easily the periosteum dissects from the bone. The clinical extent of disease is almost always greater than that detected radiographically but the periosteum offers a considerable barrier to bone invasion and the usual pathway for direct spread into the jawbone is from the alveolar crest rather than through the cortical plate. In the non-irradiated jawbone with no bone erosion, there is no need to resect bone if tumour-bearing periosteum elevates easily. With radiographic bone destruction, marginal mandibulectomy (rim resection) or segmental mandibulectomy (hemimandibulectomy) is performed. Where there is radiation injury to the bone, this periosteal barrier is lost and direct spread through the cortical bone is more likely, warranting bone removal.
Ideally, where there is proven or a high likelihood of regional lymph node metastasis, an in-continuity neck dissection is performed.
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