CARCINOMA BUCCAL
MUCOSA
Dr. Abhilash G
JR-3
ANATOMY
The buccal mucosa includes the
mucosal surfaces of the cheek and lips
from the line of contact of the opposing
lips to the pterygomandibular raphe
posteriorly.
This extends to the line of attachment
of the mucosa of the upper and lower
alveolar ridge superiorly and inferiorly.
The muscle of the cheek is the buccinator
muscle.
The buccal fat pad is superficial to the
fascia covering the buccinator muscle and
gives the cheeks a rounded contour.
Branches of the maxillary and mandibular
nerves (cranial nerves V2 and V3) provide
sensory innervation to the skin, the cheek,
and the mucous membranes lining the
cheeks.
The facial nerve (cranial nerve VII)
provides motor innervation to the muscles
of the cheeks and lips.
The lips and cheeks function together
as an oral sphincter propelling food into
the oral cavity.
If the facial nerve is paralyzed, food
tends to accumulate within the cheek
along the affected side so that saliva
and food dribble out of the corner of
the mouth.
CLINICAL PRESENTATION
After carcinoma of the lip, oral tongue, floor of the
mouth, and lower gum, carcinoma of the buccal
mucosa is the fifth most common carcinoma of the
oral cavity.
It is the most common carcinoma of the oral cavity
in India, Malaysia, and Taiwan.
It usually occurs in the sixth and seventh decades of
life, and is more prevalent in men than in women.
Tobacco and betel nut chewing appear to play an
important role in the cause of these tumors.[
Carcinomas of the buccal mucosa often
occur in association with pre-existing
leukoplakia and tend to have multiple
primary sites and recurrence.
Excision of the oral leukoplakia may reduce
the subsequent development of carcinoma.
These tumors usually arise in the area
adjacent to the lower molars along the
occlusal line of the teeth.
PREMALIGNANT LESIONS
Leukoplakia - A chronic white
mucosal macule which cannot
be scraped off, cannot be given
another specific diagnostic
name, and does not disappear
with removal of potential
etiologic factors (excepting
tobacco).
4-18% progress to invasive
carcinoma
ERYTHROPLAKIA
Erythroplakia is the clinical
diagnostic term - A chronic red
mucosal macule which cannot be
given another specific diagnostic
name and cannot be attributed
to traumatic, vascular or
inflammatory causes, i.e. it is a
diagnosis of exclusion.
Higher risk of cancer
development (~ 30%)
ORAL SUB MUCOUS FIBROSIS (SMF)
4.5 7.5 % progress to oral cancer
Clinically, there are three distinct types: exophytic,
ulcerative, and verrucous.
The patient may present with pain or bleeding, trismus, or
cervical lymphadenopathy.
Posterior extension may result in involvement of the lingual
or dental nerves, which may cause ear pain.
Extension behind the pterygomandibular raphe into the
pterygoid muscles or into the buccinator and masseter
muscles may cause trismus.
In advanced stages, the tumor may destroy the entire cheek
and invade the adjacent bones and the neck. Infection is
common and mastication becomes difficult. Death usually
occurs as a result of poor nutrition and general debilitation
Symptoms
with
Signs
Associates
Ulcer
Ulceration/growth Leukoplakia
Burning sensation Induration
SMF
Mild irritation
Ankyloglosia
Erythroplakia
Pain
Bleeding ulcer
Earache
Trismus
Bleeding
Parotid enlargement
ROUTES OF SPREAD
Infiltrating lesions of the buccal mucosa
can invade the buccinator muscle,
extend to the buccal fat pad, and
invade the subcutaneous tissue.
Carcinomas of the buccal mucosa
frequently spread by direct invasion into
the gingivobuccal sulcus, the upper and
lower alveolar ridges, the hard palate,
the maxilla, and the mandible.
Lymph node metastasis occurs in
approximately 9% to 31% of the patients
during the course of the disease.
The submandibular lymph nodes are most
frequently involved; involvement of the
upper cervical and the parotid lymph nodes
is less common. The risk of subclinical
disease is 16%.
Distant metastases are rare, as patients
often die of uncontrolled local disease before
distant metastases are manifested clinically.
PATHOLOGY
>90 % Squamous cell carcinomas
Spectrum of diseases from benign
lesions like leukoplakia, lichen
planus, SMF to verrucous carcinoma
to well differentiated squamous
carcinoma
Malignant Minor salivary gland
tumors such as Adenoid cystic,
Adenocarcinoma, Mucoepidermiod
carcinoma (< 10%) are uncommon
Malignant Melanoma, Lymphoma,
sarcoma occur rarely.
DIAGNOSTIC WORK UP
History & Clinical examination , including head &
neck examination
Clinical staging
Assessment of performance & nutritional status
Investigations for histological diagnosis Punch
Biopsy
Investigations to determine the extent of the disease
OPG/ Dental occlusal view
CT Scan / MRI for extent of disease
EUA
USG for N0 neck in select cases
Routine Investigations
CXR
Routine blood counts
Blood chemistry profile
Urinalysis
STAGING
INTENT OF TREATMENT
Stage I IV A : Curative
Stage IV B-C : Palliative
The aim of treatment:
Cure
Loco regional control
Preservation of anatomy & function
Reasonable cosmesis
Quality of life
Tumor factors
Primary site
Size
Proximity to bone
Status of cervical nodes
Tumor pathology ( histological type, grade, & depth of
invasion)
Patient factors
Age
General medical conditions
Tolerance of treatment
Acceptance of expected sequelae of therapy
Socioeconomic considerations
TREATMENT ALGORITHM
T1,T2 TUMORS
Primary
Surgery : wide excision +/- marginal
mandibulectomy
Radiotherapy : Radical external RT/ Brachytherapy
Nodes
N0 : Observe or
SOHD ( if cheek flap raised , USG suspicious, thick
tumor or poor follow up expected) followed by
Frozen section, if positive nodes, MND is required.
N+ : MND/RND
Post op RT as per guidelines
T3, T4 TUMORS
Surgery + Post op RT or CT-RT
Primary
Surgery : Composite resection of the buccal
mucosa with mandible or upper alveolus or
overlying skin with reconstruction
Nodes
N0 : SOHD followed by FS, if positive nodes,
MND required.
N+ : MND/ RND
VERRUCOUS CARCINOMA
Management is controversial
Perceived risk that the tumor may become
more aggressive if it recurs after RT.
Many tumors that recur after treatment are
biologically more aggressive. Therefore, it is
reasonable to treat these lesions with
irradiation if surgery is not feasible.
Wang reported a series of patients with
verrucous carcinoma treated with RT; the
results were comparable to those for patients
treated for squamous cell carcinoma.
SURGERY
Used as single modality in early disease
(Stage I & II )
Combined with post operative adjuvant
radiotherapy in advanced disease(Stage III &
IV)
Wide excision of tumor in all dimensions with
adequate margins & appropriate neck
dissection essential for locoregional control of
disease
ADVANTAGES OF SURGERY
Treatment time is shorter.
The risk of immediate and late radiation sequel are
avoided.
Irradiation is reserved for recurrence, which may not be
resectable.
Pathological assessment, accurate staging.
Disadvantage: functional & cosmetic impairment,
increased morbidity when bilateral neck is addressed.
Modified neck dissection is sufficient treatment
for the ipsilateral neck for patients with N1
without PNE.
Radiation therapy is added for
N1 with PNE/LVI
N2,N3 stages, for control of contra lateral
subclinical disease
For invasion through the capsule of the node,
For multiple positive nodes
NECK DISSECTION
RND : superficial & deep cervical fascia with its enclosed LN
(level I-V) is removed in continuity of SCM, omohyoid muscle,
internal & external jugular veins, spinal accessory N &
submandibular gland
MND : is finding more acceptance & preference to RND in
managing N0 neck because of severe morbidity related to
RND such as, shoulder dysfunction, poor cosmesis, facial
edema (level I-V LN)
SOHND : least morbid, provides most satisfactory sampling
of the LN at the level I, II, III which are greatest risk
Extended SOHND : level I-IV LN dissection
MANDIBULECTOMY
Marginal mandibulectomy: partial-thickness (marginal)
mandibular resection
Segmental Mandibulectomy
For small lesions with minimal bone invasion, a short section
of mandible is removed in continuity with the tumor (e.g.,
removal of the mandible from the angle to the mental
foramen).
Hemimandibulectomy
- Removal of the mandible symphysis to the condyle on one
side.
- Major cosmetic and functional loss
- Reconstruction is performed with a composite
osteomyocutaneous flap
MARGINAL MANDIBULECTOMY
SEGMENTAL MANDIBULECTOMY
HPE REPORT
Gross pathology
1. Morphology
2. Location & extent of the tumor / lesion
3. Tumor dimensions
4. Distance from various margins of excision
5. Nodal dissection
Microscopy
1. Histologic type
2. Grade
3. Extent of disease including depth of infiltration
4. Perineural invasion
5. Lymphovascular invasion
6. Bone / Cartilage / Skin / Soft tissue involvement
7. Margins of excision, submucosal spread, In situ changes
8. Nodal status no. & size of nodes, perinodal extension &
level of nodes
9. Status of cut margins
Miscellaneous features
1. In RND/ MND status of internal jugular vein
2. Presence of predisposing factors - leukoplakia, SMF
3. Dysplasia/ in situ elements
Unresectable Disease
Primary disease
Adequate surgical clearance is not achievable
Extensive Infra Temporal Fossa involvement
Extensive involvement of base skull
Extensive soft tissue disease skin edema / ulceration
Nodal disease
Clinically fixed nodes
Infiltration of Internal / Common carotid artery
Extensive infiltration of prevertebral muscles
IRRADIATION
Better functional and cosmetic outcome
Elective irradiation of the lymph nodes can be
included with little added morbidity, whereas the
surgeon must either observe the neck or proceed
with an elective neck dissection (sometimes bilateral
depending on the primary site),
The surgical salvage of irradiation failure is probably
more likely than the salvage of a surgical failure.
The risk of postoperative complications is avoided
BRACHYTHERAPY
Accessible lesions
Small (preferably < 3cm ) tumors
Well defined borders
Lesion away from bone
Superficial lesions
Tumors of the anterior two thirds of the
buccal mucosa without involvement of
gingiva are ideally suited for brachytherapy
alone.
INDICATIONS OF POST OP RT
Primary:
Advanced primary T3 or T4
Close or positive margins of excision
Depth of invasion
High grade tumor
LVI & PNI
Nodes:
Bulky nodal disease N2/N3
Extra nodal extension
Multiple level involvement
IRRADIATION TECHNIQUES
T1 and T2 lesions
Ipsilateral field arrangement that includes the
primary lesion and the level I and II lymph
nodes.
The anterior and superior borders of the field
should be at least 2 cm from the borders of the
primary tumor. The posterior border should be
at the posterior aspect of the spinous
processes if the nodes are to be irradiated.
Inferior border is at the thyroid notch.
T3 and T4 lesions
Patients with significant tumor extension
toward the midline are treated with
parallel opposed fields weighted 3 : 2
toward the side of the lesion.
The low neck is treated with an anterior
field with a 6-MV x-ray beam to 50 Gy in
25 fractions once daily
Target Volumes (Postoperative)
CTV - postoperative bed + draining
lymphatics include ipsilateral levels Ia/b, II,
and III when electively treating. If high-risk
disease, or N+, treat ipsilateral levels I to V.
Consider contralateral neck irradiation if
primary lesion approaches midline
PTV - as per general principles
RT DOSE
Doses of 66Gy in 2-Gy fractions for positive
margins.
60Gy in 2-Gy fractions or 59.4 to 63Gy in 1.8Gy fractions to high-risk regions.
54Gy in 1.8-Gy fractions for low-risk regions.
An LAN is often used, treated to either 50Gy in
2-Gy fractions or 50.4Gy in 1.8-Gy fractions.
Interstitial implants with iridium wires or
seeds in nylon ribbons can be considered for
treatment of early, small lesions that have
not invaded the buccogingival sulcus, the
gingiva, or bone.
Usually a minimum tumor dose of 60 to
70Gy in 5 to 8 days is delivered through a
single-plane or double-plane implant on the
thickness of the lesion.
The buccal mucosa tolerates high-dose
RT with a low risk of late complications.
Trismus may develop if the muscles of
mastication receive high doses of
irradiation.
CHEMOTHERAPY
Cisplatin
- Used in NACT (T4b and N3 cases)
- Used in CTRT
THANK YOU
