41 Oral and oropharyngeal cancer and precancer

JOHN D. LANGDON Oral and oropharyngeal cancer In global terms, oraloropharyngeal cancer is the sixth most common malignancy. In the estern !orld it acco"nts #or only $% per cent o# all malignant t"mo"rs, altho"gh there is no! good e&idence to sho! that the incidence is increasing partic"larly in yo"nger people. 'y contrast, in Asia oraloropharyngeal malignancy is the commonest malignant t"mo"r !hich in parts o# India acco"nts #or no less than %( per cent o# all malignancy. It is estimated that globally there are nearly )(( ((( ne! cases ann"ally and that by the year $((( there !ill be *.) million people ali&e !ith oral cancer at any one time. Oraloropharyngeal cancer is an almost entirely pre&entable disease being ca"sed by tobacco either !ith or !itho"t alcohol. In the est this is mostly cigarette smo+ing combined !ith alcohol ab"se, the ris+ o# both in combination being greater than the s"mmation o# the ris+s o# each indi&id"ally. In Asia and the ,ar -ast the "se o# .an and re&erse smo+ing are the ma/or aetiological agents. -pidemiological e&idence strongly s"ggests that again it is the presence o# tobacco in the betel 0"id !hich is the ma/or agent, altho"gh there seems also to be some relationship to the so"rce o# sla+ed lime and the areca n"t itsel#. 1he incidence in !omen appears to be increasing and there is a !orrying cohort o# yo"ng patients, mostly male and partic"larly !ith tong"e cancer, !ho sho! a sharp increase in incidence a#ter a grad"al #all earlier in the t!entieth cent"ry. 1his recent trend seems not to be related to tobacco and alcohol cons"mption and has been obser&ed thro"gho"t -"rope and North America. Local control o# disease at the primary site and the management o# nec+ disease ha&e impro&ed, yet despite this c"re rates and s"r&i&al rates ha&e not impro&ed d"ring the last %( years remaining at approximately ))per cent s"r&i&al at ) years. 'oth rec"rrence o# local disease and #ail"re to control lymphatic metastases in the nec+ are early e&ents and clearly ha&e a negati&e e##ect on )2year s"r&i&al #ig"res. 1here is no do"bt, ho!e&er, that d"ring the past $( years great ad&ances ha&e been made in the management o# oral cancer, and persistence o# local disease and lymphatic metastasis are no! less common e&ents. hy then ha&e c"re rates not impro&ed3 ,ield changes in the "pper aerodigesti&e tract res"lt in the phenomenon o# m"ltiple primary cancers. 1he longer a patient s"r&i&es his or her index t"mo"r, the greater the ris+ o# de&eloping a second or third primary t"mo"r either else!here in the oral ca&ity or in the larynx, bronch"s or oesophag"s. -&en i# the patient does not de&elop a second primary t"mo"r, he or she is then at ris+ o# de&eloping distant metastatic disease. It is probable that altho"gh "ntil recently rarely recognised d"ring li#e, metastasis &ia the bloodstream is a relati&ely early e&ent in oral cancer. 4"rrently, $( per cent o# all cancer2related deaths in patients !ith a t"mo"r in the oral ca&ity or oropharynx are d"e to distant metastasis !ith no e&idence o# disease in the head or nec+. 1h"s, oral cancer is a 5systemic6 disease #rom an early stage. 7esection 8"rgical ad&ances ha&e been primarily in techni0"es o# access s"rgery and in reconstr"ction. 1he !idespread adoption o# lip splitting and mandib"lotomy has

#acilitated sa#e three2dimensional resections o# t"mo"rs in the tong"e and #loor o# mo"th incontin"ity !ith the lymphatics in the nec+. A better "nderstanding o# the patterns o# in&asion o# the mandible by ad/acent t"mo"r has allo!ed the de&elopment o# rim resections, a&oiding the sacri#ice o# mandib"lar contin"ity in many cases, !itho"t ris+ing local rec"rrence. In recent years there has been the de&elopment o# s+"ll base access s"rgery "sing !ell2established oral and #acial osteotomy techni0"es !hich ha&e rendered pre&io"sly inoperable t"mo"rs operable. 1his is partic"larly tr"e #or t"mo"r extending into the pterygoid, in#ratempotal and lateral pharyngeal regions. 7econstr"ction .rimary reconstr"ction is no! the r"le to the great ad&antage o# patients. .re&io"s reconstr"ction techni0"es !ere o#ten "nreliable, and !hen bony reconstr"ction !as in&ol&ed they !ere o#ten staged. It !as reasonably #elt that be#ore embar+ing on s"ch prolonged and insec"re techni0"es a period o# time sho"ld be allo!ed to elapse to demonstrate that local rec"rrence !as "nli+ely be#ore reconstr"ction !as attempted. ith c"rrent techni0"es based largely on m"scle #laps pectoralis ma/or, trape9i"s and latissim"s dorsi and #ree tiss"e trans#er, based on micro&asc"lar techni0"es, primary reconstr"ction is not only reliable b"t prod"ces acceptable #"nctional and cosmetic res"lts. 7adiotherapy High2energy beams, comp"terised planning and sim"lation ha&e greatly red"ced the morbidity o# radiotherapy by red"cing the dosage to the ad/acent tiss"es. 1eeth are no longer ro"tinely extracted prior to radiotherapy regardless o# their state, and osteoradionecrosis is no! an "n"s"al complication. Altho"gh not a ne! techni0"e, brachytherapy "sing iridi"m !ire implants is regaining pop"larity. ,or s"itable t"mo"r 1i and early 1$ t"mo"rs in mobile so#t tiss"es this techni0"e deli&ers &ery high2dose local irradiation contin"o"sly !ith &ery little irradiation to ad/acent tiss"es :,ig. %*.*;. Local control rates are excellent. 4"rrently, considerable interest is being sho!n in hyper#ractionation techni0"es, !hereby a higher total t"mo"r dose can be achie&ed by gi&ing more b"t smaller #ractions o# radiation. 4hemotherapy Altho"gh many single agents or combinations o# dr"gs can res"lt in a response rate aro"nd <( per cent, there is no e&idence that this res"lts in an increase in s"r&i&al time or c"re rate. 8ome centres ad&ocate the "se o# ind"ction chemotherapy prior to s"rgery b"t, again, there is no e&idence based "pon prospecti&e st"dies that this impro&es s"r&i&al. .alliati&e chemotherapy "sing agents s"ch as cisplatin and )2 #l"ro"racil are sometimes help#"l #or pain#"l or #"ngating t"mo"rs. 4linical aspects Oral cancer has a predeliction #or certain sites !ithin the mo"th, notably the lateral margins and &entral tong"e, #loor o# mo"th, retromolar trigone, b"ccal m"cosa and palate. 1he ma/ority more than =)per cent is m"cosal s0"amo"s cell carcinomas. >alignant t"mo"rs arising in the minor sali&ary glands are next in #re0"ency !ith lymphomas, malignant melanomas, sarcomas and metastatic t"mo"rs ma+ing "p the remainder. .remalignant lesions 1he association o# oral carcinoma and other oral m"cosal lesions has been recognised #or many years. O#ten these lesions are in the #orm o# !hite pla0"es :5le"copla+ia6; or bright red &el&ety pla0"es :5erythropla+ia6;. 1hey may be present #or periods o#

months to years prior to the onset o# malignant change and o#ten they !ill he present together !ith the carcinoma at presentation. 'eca"se o# this association the ass"mption !as made that s"ch lesions led directly to in&asi&e carcinoma and hence !ere themsel&es premalignant. 8ome !hite pla0"es do "ndo"btedly ha&e a potential to "ndergo malignant trans#ormation, and an examination o# established carcinomas !ill sho! many to exist in association !ith !hite pla0"es. Ho!e&er, the ma/ority o# oral carcinomas is not preceded by or is associated !ith le"copla+ia. Altho"gh historically oral 5le"copla+ia6 has been recognised as premalignant, the ris+ o# malignant trans#ormation is not as great as !as pre&io"sly tho"ght. -arly literat"re s"ggested a ?( per cent or higher incidence o# malignant trans#ormation o# these lesions !hereas more recent a"thors 0"ote an incidence o# bet!een ? and < per cent. 1he #ollo!ing oral lesions are no! de#initely considered to carry a potential #or malignant change@ A le"copla+iaB A erythropla+iaB A chronic hyperplastic candidiasis. A #"rther gro"p o# conditions, altho"gh not themsel&es premalignant, are associated !ith a higher than normal incidence o# oral cancer@ Aoral s"bm"co"s #ibrosisB Asyphilitic glossitisB Asideropenic dysphagia. 1here remains a #"rther gro"p o# oral conditions abo"t !hich there is still some do"bt as to !hether their association !ith oral cancer is ca"sal or cas"al@ Aoral lichen plan"sB Adiscoid l"p"s erythematos"sB A dys+eratosis congenita. Le"copla+ia Csing the term le"copla+ia :,ig. %*.$; either in a histological or clinical context is a matter o# de#ining !hat one means by the term. 1he orld Health Organisation : HO; has de#ined le"copla+ia as 5any !hite parch or pla0"e that cannot be characterised clinically or pathologically as any other disease6. 1his de#inition has no histological connotation. 4linical #eat"res 4linically le"copla+ia may &ary #rom a small circ"mscribed !hite pla0"e to an extensi&e lesion in&ol&ing !ide areas o# the oral m"cosa. 1he s"r#ace may be smooth or it may be !rin+led, and many lesions are tra&ersed by crac+s or #iss"res. 1he colo"r o# the lesion may be !hite, yello!ish or grey, !ith some being homogeneo"s !hilst others are nod"lar or spec+led on an erythemato"s base. >any lesions are so#t !hereas other thic+er lesions #eel cr"sty. Ind"ration s"ggests malignant change and is an indication #or immediate biopsy. It is important to recognise that it is the spec+led or nod"lar le"copla+ias !hich are the most li+ely to "ndergo malignant change. .otential #or malignant change It has been sho!n that the incidence o# "ltimate malignant change in oral le"copla+ia increases !ith the age o# the lesion. One st"dy sho!ed a $.% per cent malignant trans#ormation rate at *( years !hich increased to % per cent at $( years. It also sho!ed that as the age o# the patient increased so did the ris+ o# malignant trans#ormation@ #or patients yo"nger than )( years it !as I per cent !hereas #or those bet!een D( and =E years it !as D.) per cent d"ring a )2year obser&ation period.

8t"dies ha&e sho!n that, in so"thern -ngland, le"copla+ia o# the #loor o# the mo"th and &entral s"r#ace o# the tong"e has a partic"larly high incidence o# malignant change. 1his st"dy s"ggested that this occ"rrence !as d"e to pooling o# sol"ble carcinogens in the 5s"mp6 o# the #loor o# the mo"th. Aetiology 1obacco smo+ing and che!ing are "ndo"btedly important aetiological #actors. In Indians !ho smo+e or che! tobacco :o#ten as a component o# the betel 0"id; the incidence o# le"copla+ia in those o# <( years o# age is $( per cent, !hereas in those !ho neither smo+e not che! tobacco the incidence is * per cent. 1he role o# alcohol in the de&elopment o# oral le"copla+ia is di##ic"lt to assess. ,e! st"dies ha&e been reported, b"t it has been sho!n that in patients !ith le"copla+ia the incidence o# excessi&e alcohol cons"mption is greater than in those #ree o# le"copla+ia. >anagement In any patient presenting #or the #irst time !ith oral le"copla+ia a care#"l history partic"larly loo+ing #or aetiological #actors and a detailed clinical examination sho"ld precede the histological examination o# biopsies o# any s"spicio"s areas. 8"spicion sho"ld be aro"sed by any areas o# "lceration or ind"ration or !here the "nderlying tiss"es are bright red and hyperemic. I# there is a history o# tobacco cons"mption then the patient sho"ld be pers"aded to stop immediately. It has been sho!n that i# the patient stops smo+ing entirely #or * year the le"copla+ia !ill disappear in <( per cent o# the cases. hene&er se&ere epithelial dysplasia or carcinoma in sit" is present, s"rgical excision or carbon dioxide laser excision o# the lesions is mandatory. 8mall lesions may be excised, the margins o# the ad/acent m"cosa "ndermined and the de#ect closed by ad&ancing the margins. ,or larger de#ects the area sho"ld be le#t to epithelialise spontaneo"sly or alternati&ely the area can be s+in gra#ted. On the tong"e the gra#t is 0"ilted on to the ra! area, !hereas on the chee+, #loor o# mo"th or palate the gra#t can be retained in place by s"t"ring a s"itable pac+ o&erlying it. hen only mild to moderate epithelial dysplasia is present the patient sho"ld be #ollo!ed "p at %2monthly inter&als and the lesions recorded in the notes either photographically or diagrammatically. -rythropla+ia -rythropla+ia :,ig. %*.?; is de#ined as 5any lesion o# the oral m"cosa that presents as bright red &el&ety pla0"es !hich cannot be characterised clinically or pathologically as any other recognisable condition6. 8"ch lesions are "s"ally irreg"lar in o"tline, altho"gh clearly demarcated #rom ad/acent normal epitheli"m. 1he s"r#ace may be nod"lar. In some cases erythropla+ia coexists !ith areas o# le"copla+ia. 1he incidence o# malignant change in erythropla+ias is *D2#old higher than in le"copla+ia. In e&ery case o# erythropla+ia there are areas o# epithelial dysplasia, carcinoma in sit" or in&asi&e carcinoma. 4learly, all erythropla+ic areas m"st be completely excised either s"rgically or !ith a carbon dioxide laser, and the specimens s"bmitted #or care#"l pathological examination. 4hronic hyperplastic candidiasis In chronic hyperplastic candidiasis :,ig. %*.%;, dense chal+y pla0"es o# +eratin are #ormed, the pla0"es being thic+er and more opa0"e than in noncandidal le"copla+ia. 8"ch lesions are partic"larly common at the oral commiss"res extending on to the ad/acent s+in o# the #ace.

In *E<E 4a!son dre! attention to the high incidence o# malignant trans#ormation in these candidal le"copla+ias, s"ggesting that the in&asi&e candidal in#ection is the ca"se o# the le"copla+ia and not merely a s"perimposed in#ection. It has also been s"ggested that in s"ch patients there may be an imm"nological de#ect !hich allo!s the 4andida albicans to in&ade the epitheli"m and may render the patient s"sceptible to malignant change. It is tho"ght that treatment !ith nystatin, amphotericin or micona9ole to eliminate the candidal in#ection !ill red"ce the ris+ o# malignant change. Ho!e&er, treatment may be necessary #or many months to eliminate the organisms and rein#ection is a constant problem. 8"rgical excision is recommended #or persistent lesions. Oral s"bm"co"s #ibrosis Oral s"bm"co"s #ibrosis :,ig. %*.);is a progressi&e disease in !hich #ibro"s bands #orm beneath the oral m"cosa. 1hese bands progressi&ely contract so that "ltimately opening is se&erely limited. 1ong"e mo&ements may also be limited. 1he condition is almost entirely con#ined to Asians. Histologically it is characterised by /"xta2 epithelial #ibrosis !ith atrophy or hyperplasia o# the o&erlying epitheli"m !hich also sho!s areas o# epithelial dysplasia. .aymaster in *E)< #irst disc"ssed the precancero"s nat"re o# s"bm"co"s #ibrosis. He noted the onset o# a slo!ly gro!ing s0"amo"s cell carcinoma in one2third o# s"ch patients. 1he aetiology is obsc"re. Hypersensiti&ity to chilli, betel n"t, tobacco and &itamin de#iciencies ha&e been implicated. 4anni## has in&estigated the &ario"s en9yme components o# the constit"ents o# the 5betel 0"id6, and has characterised some al+aloids and collagenases that may be responsible #or the connecti&e tiss"e changes !hich lead to epithelial atrophy and "ltimate malignant degeneration. 1iss"e c"lt"re experiments ha&e sho!n that al+aloids in the betel n"t partic"larly arecoline stim"late collagen synthesis and the proli#eration o# b"ccal m"cosal #ibroblasts. 1annins also present in the betel n"t stabilise the collagen #ibrils and render them resistant to degradation by collagenase. 1he scar bands o# s"bm"co"s #ibrosis !hich res"lt in di##ic"lty in opening can be treated either by intralesional in/ection o# steroids or by s"rgical excision and gra#ting, b"t this has little e##ect in pre&enting the onset o# s0"amo"s cell carcinoma in the generally atrophic oral m"cosa. Any aetiological #actors sho"ld, o# co"rse, be eliminated. 8yphilitic glossitis .rior to the antibiotic era, syphilis !as an important predisposing #actor in the de&elopment o# oral le"copla+ia and oral cancer. 1he syphilitic in#ection prod"ces an interstitial glossitis !ith an endarteritis !hich res"lts in atrophy o# the o&erlying epitheli"m. 1his atrophic epitheli"m appears to be more &"lnerable to those other irritants !hich ca"se oral cancer or oral le"copla+ia. As these changes are irre&ersible there is no speci#ic treatment, altho"gh acti&e syphilis m"st be treated. 7eg"lar #ollo!2"p is essential. It sho"ld be noted that s0"amo"s cell carcinomas may arise in syphilitic glossitis e&en in the absence o# le"copla+ia. 8ideropenic dysphagia :.l"mmerFinson syndrome, .atersonGelly syndrome; In *E?< Ahlbom sho!ed the relation bet!een sideropenic dysphagia and oral cancer. 8ideropenic dysphagia :,ig. %*.<; is partic"larly common in 8!edish !omen, and this acco"nts #or the high incidence o# cancer o# the "pper alimentary tract in this gro"p and the higher incidence o# !omen !ith oral cancer in 8!eden. o# !omen !ith oral cancer in 8!eden, $) per cent !ere sideropenic. 1he pathogenesis o# oral cancer in s"ch patients may he similar to that o# syphilitic glossitis. 1he sideropenic dysphagia leads to epithelial atrophy, !hich in itsel# is

excessi&ely &"lnerable to carcinogenic irritants. Altho"gh the anaemia !ill respond to treatment !ith iron s"pplements, it is not +no!n !hether s"ch treatment red"ces the ris+ o# s"bse0"ent malignant change. 1here ha&e been some reports that in erosi&e or atrophic lichen plan"s :,ig. %*.D; there is a ris+ o# malignant trans#ormation. I# there is an association bet!een lichen plan"s and oral cancer the relation only exists !ith atrophic or erosi&e lichen plan"s. All patients !ith erosi&e or atrophic lichen plan"s sho"ld be care#"lly re&ie!ed. -rosi&e lichen plan"s sho"ld be treated !ith topical steroids and, in se&ere cases, systemic steroids may be necessary. Discoid l"p"s erythematos"s 1he oral lesions o# discoid l"p"s erythematos"s consist o# circ"mscribed, some!hat ele&ated, !hite patches "s"ally s"rro"nded by a telangiectatic halo. -pithehial dysplasia may be seen on histological examination and this may lead to malignant trans#ormation. >alignant change "s"ally occ"rs in those lesions o# the labial m"cosa ad/acent to the &ermilion border, and occ"rs more o#ten in men than in !omen. 8"ch patients !ith discoid l"p"s erythematos"s sho"ld be ad&ised to a&oid bright s"nlight and !hen in the open air to apply an "ltra&iolet barrier cream to the lips. Dys+eratosis congenita 1his syndrome is characterised by retic"lar atrophy o# the s+in !ith pigmentation, nail dystrophy and oral le"copla+ia. -&ent"ally, the oral m"cosa becomes atrophic and the tong"e loses its papillae. ,inally, the m"cosa becomes thic+ened, #iss"red and !hite. 4linical presentation and diagnosis o# oral cancer -arly diagnosis o# oral cancer sho"ld lead to better treatment res"lts and, ideally, the clinical diagnosis o# oral cancer sho"ld be easy. Oral lesions, "nli+e those at many other sires, gi&e rise to early symptoms. In general, patients become a!are o# and "s"ally complain abo"t min"te lesions !ithin the mo"th and biopsy may be carried o"r "nder local analgesia. Het, despite all the abo&e, bet!een $D and )( per cent o# patients present #or treatment !ith late lesions. >any o# these patients are elderly and #rail and, there#ore, delay the e##ort o# &isiting their doctor or dentist. >any o# this gro"p o# patients !ear dent"res and are acc"stomed to discom#ort and "lceration in the mo"th and th"s see no "rgency in see+ing treatment. ,"rthermore, the practitioner is o#ten not s"spicio"s that a lesion may be malignant and the lesion is o#ten treated initially !ith anti#"ngal therapy, antibiotics, steroids and mo"th2!ashes, th"s contrib"ting to #"rther delay in the "ltimate diagnosis and treatment. Another #actor is that oral cancer is not "s"ally pain#"l "ntil s"ch rime as either the "lcer becomes secondarily in#ected or the t"mo"r in&ades sensory ner&e #ibres. 1he tong"e 1he ma/ority o# tong"e cancers occ"rs on the middle third o# the lateral margins, extending early in the co"rse o# the disease on to the &entral aspect and #loor o# the mo"th :,ig. %*.=;. Approximately $) per cent occ"r on the posterior third o# the tong"e, $( per cent on the anterior third and rarely :% per cent; on the dors"m. -arly tong"e cancer may mani#est in a &ariety o# !ays. O#ten the gro!th is exophytic !ith areas o# "lceration. It may occ"r as an "lcer in the depths o# a #iss"re or as an area o# s"per#icial "lceration !ith "ns"spected in#iltration into the "nderlying m"scle. Le"copla+ic patches may or may not be associated !ith the primary lesion. A minority o# tong"e cancers may be asympromatic, arising in an atrophic depapillated area !ith an erythropla+ic patch !ith peripheral strea+s or areas o# le"copla+ia. Later in the co"rse o# the disease a more typical malignant "lcer !ill "s"ally de&elop, o#ten se&eral centimetres in diameter. 1he "lcer is hard in consistency !ith heaped2"p

and o#ten e&erted edges. 1he #loor is gran"lar, ind"rated and bleeds readily. O#ten there are areas o# necrosis. 1he gro!th in#iltrates the tong"e progressi&ely ca"sing increasing pain and di##ic"lty !ith speech and s!allo!ing. 'y this stage pain is o#ten se&ere and constant, radiating to the nec+ and ears. Lymph node metastases at this stage are common indeed )( per cent may ha&e palpable nodes at presentation. 'eca"se o# the relati&ely early lymph node metastasis o# tong"e cancer, *$ per cent o# patients may present !ith no symptoms other than 5a l"mp in the nec+6. 1he #loor o# the mo"th 1he #loor o# the mo"th is the second most common sire #or oral cancer :,ig. %*.E;. It is de#ined as the C2shaped area bet!een the lo!er al&eol"s and the &entral s"r#ace o# the tong"eB carcinomas arising at this sire in&ol&e ad/acent str"ct"res &ery early in their nat"ral history. >ost t"mo"rs occ"r in the anterior segment o# the #loor o# the mo"th to one side o# the midline. 1he lesion "s"ally starts as an ind"rated mass !hich soon "lcerates. At an early stage the tong"e and ling"al aspect o# the mandible become in&ol&ed. 1his early in&ol&ement o# the tong"e leads to the characteristic sl"rring o# the speech o#ten noted in s"ch patients. 1he in#iltration is decepti&e b"t may extend to reach the gingi&ae, tong"e and geniogloss"s m"scle. 8"bperiosteal spread is rapid once the mandible is reached. Lymphatic metastasis, altho"gh early, is less common than !ith tong"e cancer. 8pread is "s"ally to the s"bmandib"lar and /"g"lodigasrric nodes and may be bilateral. 4ancer in the #loor o# the mo"th cancer is associated !ith a pre2existing le"copla+ia more commonly than at other sites. 1he gingi&a and al&eolar ridge 4arcinoma o# the lo!er al&eolar ridge occ"rs predominantly in the premolar and molar regions :,ig. %*.*(;. 1he patient "s"ally presents !ith proli#erati&e tiss"e at the gingi&al margins or s"per#icial gingi&al "lceration. Diagnosis is o#ten delayed beca"se there is a !ide &ariety o# in#lammatory and reacti&e lesions !hich occ"r in this region in association !ith the teeth or dent"res. Indeed, there !ill o#ten be a history o# tooth extraction !ith s"bse0"ent #ail"re o# the soc+et to heal prior to de#initi&e diagnosis. Another common story is that o# s"dden di##ic"lty in !earing dent"res. 7egional nodal metastasis is common at presentation, &arying #rom ?( to =% per cent, altho"gh #alse2positi&e and #alse2negati&e clinical #indings are common. 1he b"ccal m"cosa 1he b"ccal m"cosa extends #rom the "pper al&eolar ridge do!n to the lo!er al&eolar ridge and #rom the commiss"re anteriorly to the mandib"lar ram"s and retromolar region posteriorly :,ig. %*.**;. 80"amo"s cell carcinomas mostly arise either at the commiss"re or along the occl"sal plane to the retromolar area, the ma/ority being sit"ated posteriorly. -xophyric, "lcero2in#iltrati&e and &err"co"s types occ"r. 1hey are s"b/ect to occl"sal tra"ma !ith conse0"ent early "lceration and o#ten become secondarily in#ected. 1he onset o# the disease may be insidio"s, the patient sometimes presenting !ith trism"s d"e to deep neoplastic in#iltration into the b"ccinaror m"scle. -xtension posteriorly in&ol&es the anterior pillar o# the #a"ces and so#t palate !ith conse0"ent !orsening o# the prognosis. Clcero2in#iltrati&e lesions !ill o#ten in&ol&e the o&erlying s+in o# the chee+ res"lting in m"ltiple sin"ses. Lymph node spread is to the s"bmental, s"bmandib"lar, parotid and lateral pharyngeal nodes. Ferr"co"s carcinoma occ"rs as a s"per#icial proli#erati&e exophytic lesion !ith minimal deep in&asion and ind"ration. O#ten the lesion is densely +eratinised and

presents as a so#t !hite &el&ety area mimic+ing benign hyperplasia. Lymph node metastasis is late and the t"mo"r beha&es as a lo!2grade s0"amo"s cell carcinoma. 1he hard palate, maxillary al&eolar ridge and #loor o# antr"m 1hese three sites are anatomically distinct, b"t a carcinoma arising #rom one site soon in&ol&es the others :,ig. %*.*$;. 4onse0"ently, it can be di##ic"lt to determine the exact site o# origin. -xcept in co"ntries !here re&erse smo+ing is practised, cancer o# the plate is relati&ely "ncommon. 1he ma/ority o# s0"amo"s cancers arises in the antr"m and later "lcerates thro"gh to in&ol&e the hard palate. 1he ma/ority o# malignant t"mo"rs arising #rom the palatal m"cosa is o# minor sali&ary gland origin. .alatal cancers "s"ally present as sessile s!ellings !hich "lcerate relati&ely late. A #inding in contrast to mandib"lar al&eolar t"mo"rsis that deep in#iltration into the "nderlying bone is "ncommon. 4arcinomas arising in the #loor o# the maxillary anrr"m o#ten present as palaral t"mo"rs. Altho"gh the #"lly established pict"re o# antral carcinoma is di##ic"lt to miss, the early symptoms are nonspeci#ic and may mimic chronic sin"sitis. t"mo"rs o# the lo!er hal# o# the antr"m belo! Ohngren6 s line "s"ally present !ith 5dental6 symptoms beca"se o# early al&eolar in&asion. 1he commonest presenting #eat"re is pain, s!elling or n"mbness o# the #ace. Later symptoms o# nasal obstr"ction, discharge or bleeding, and dental symptoms s"ch as pain#"l or loose teeth, ill2#itting dent"res, oroantral #ist"la or #ail"re o# an extraction soc+et to heal, soon #ollo!. Lymph node metastasis #rom carcinomas o# the palate and #loor o# the antr"m occ"rs late b"t carries a poor prognosis. Diagnosis 1he diagnosis o# intraoral carcinoma is primarily clinical, and a high index o# s"spicion is necessary #or all those clinicians seeing and treating patients !ith oral symptoms. A care#"l and detailed history !ith partic"lar attention to recording the dates o# the onset o# partic"lar signs and symptoms precedes the clinical examination. All areas o# the oral m"cosa are care#"lly inspected and any s"spicio"s lesion is palpated #or text"re, tethering to ad/acent str"ct"res and ind"ration o# "nderlying tiss"e.

In&estigation 8"rgical biopsy A clinical diagnosis o# oral cancer sho"ld al!ays be con#irmed histologically. ithin the oral ca&ity a s"rgical biopsy can nearly al!ays be obtained "sing local anaesthesia. An incisional biopsy is recommended in all cases. hene&er possible the patient sho"ld be seen at a combined clinic by a s"rgeon and radiotherapist be#ore e&en the biopsy is carried o"t, b"t pro&ided care#"l records are made an initial incisional biopsy is acceptable and may sa&e time in the planning and exec"tion o# s"bse0"ent therapy. 1he biopsy sho"ld incl"de the most s"spicio"s area o# the lesion and incl"de some normal ad/acent m"cosa. Areas o# necrosis or gross in#ection sho"ld be a&oided as they may con#"se the diagnosis. ,ine needle aspiration biopsy 1his techni0"e is applicable mainly to l"mps in the nec+, especially s"spicio"s lymph nodes in a patient !ith a +no!n primary carcinoma. It consists o# the perc"taneo"s p"nct"re o# the mass !ith a #ine needle and aspiration o# material #or cytological examination. 1he method o# aspiration needs no specialised e0"ipment and is #ast, almost painless and !itho"t complications. 1he node is #ixed bet!een #inger and

th"mb and then p"nct"red by a $*G or $?G needle on a *(2ml syringe, the ga"ge o# the needle depending on the si9e o# the node. Important points to note are that the needle is properly p"shed on to the syringe to pre&ent air lea+ing in !hen the pl"nger is !ithdra!n and that a small amo"nt o# air is already in the syringe :abo"t $ ml; be#ore the node is p"nct"red in order s"bse0"ently to expel the aspirate #rom the needle on to the slide. 7adiography .lain radiography is o# limited &al"e in the in&estigation o# oral cancer. At least )( per cent o# the calci#ied component o# bone m"st be lost be#ore any radiographic change is apparent. ,"rthermore, the #acial bones are o# s"ch a complexity that con#"sion #rom o&erlying str"ct"res ma+es I2ray diagnosis more di##ic"lt. Ho!e&er, rotational pantomography o# the /a!s can be help#"l in assessing al&eolar and antral in&ol&ement, pro&ided that the abo&e limitations are "nderstood. 4omp"terised tomography 1he increasing a&ailability o# comp"terised tomography :41; scanning has "ndo"btedly been o# great bene#it in the in&estigation o# head and nec+ t"mo"rs. Ho!e&er, #or intraoral t"mo"rs its &al"e is more limited. ,or the e&al"ation o# antral t"mo"rs, partic"larly assessment o# the pterygoid regions, 41 has s"perseded plain radiography and con&entional tomography. 41 is also o# &al"e in the in&estigation o# metastatic disease in the l"ngs, li&er and s+eleton. 7adion"clide st"dies 1echneti"m :1c; pertechnetate bone scans o# the #acial s+eleton are o# little &al"e in the diagnosis o# primary oral cancers. 1here !ill be ob&io"s clinical disease long be#ore bone changes are &isible on a 1c scan. ,"rthermore, s"ch scans are nor speci#ic and !ill sho! increased "pta+e !here&er there is increased metabolic acti&ity in the bone. Cltraso"nd Abdominal "ltraso"nd to detect li&er metastases is probably as acc"rate as 41 scanning. As it is nonin&asi&e, readily a&ailable and cost e##ecti&e, it is probably the most appropriate techni0"e #or assessing the li&er. >anagement o# the primary t"mo"r 4hoice o# treatment 1he principal treatments a&ailable #or primary t"mo"rs remain s"rgery and radiotherapy. 1he basic decision to be made is bet!een radical radiotherapy and electi&e s"rgery. I# the #ormer is chosen, s"rgery is reser&ed #or 5sal&age6, i.e. #or biopsy pro&en rec"rrent or resid"al disease. I# s"rgery is chosen, radiotherapy may be "sed in an ad/"&ant manner, either preoperati&ely or postoperati&ely, b"t the operation remains #"ndamentally the de#initi&e c"rati&e proced"re. .re#erences #or one or other policy &ary considerably bet!een treatment centres. >any #actors m"st be considered in deciding the optim"m management #or each indi&id"al patient. 1hese incl"de the sire, stage and histology o# the t"mo"r, and the medical condition and li#estyle o# the patient. Ideally, e&ery patient sho"ld be seen at a /oint cons"ltation clinic by a s"rgeon and radiotherapist !ho assess ob/ecti&ely and agree the optim"m strategy o# management #or the partic"lar indi&id"al. 1he #ollo!ing #actors sho"ld in#l"ence the decision on treatment policy. 8ite o# origin 1he choice o# treatment depends on the part o# the mo"th in !hich the t"mo"r arises. 1he management o# primary t"mo"rs at the &ario"s anatomical sites is disc"ssed later.

In general, s"rgery is pre#erred #or those t"mo"rs arising on or in&ol&ing the al&eolar processesB #or other sires s"rgery and radiotherapy are alternati&es. 8tage o# disease A small lesion !hich can be excised readily !itho"t prod"cing any de#ormity or disability is, in general, best managed s"rgically. 8"rgery is also "s"ally more appropriate #or a &ery large mass or !here there is in&asion o# bone, pro&ided the t"mo"r is operable, beca"se o# the lo! c"re rates by radiotherapy in these circ"mstances. 1he management o# lesions o# intermediate stage, i.e. larger 1i, most 1$ and early exophytic 1? t"mo"rs, is more contro&ersial as policies o# electi&e s"rgery or radical radiotherapy prod"ce generally similar s"r&i&al ratesB hence, disc"ssion centres on the li+ely #"nctional res"lts and morbidity o# either approach. hen there is in&ol&ement o# cer&ical lymph nodes the primary and nodes are normally both treated s"rgically. Ho!e&er, there is no clear e&idence that a primary t"mo"r is less li+ely to be c"red by radiotherapy in the presence o# lymph node metastases than in their absence. .re&io"s irradiation It is not ad&isable to retreat a t"mo"r arising in pre&io"sly irradiated tiss"e. 8"ch a t"mo"r is li+ely to be relati&ely radioresistant beca"se o# limited blood s"pply. 7e2 irradiation o# normal tiss"e is &ery li+ely to res"lt in necrosis. ,ield change here m"ltiple primary t"mo"rs are present, or i# there is extensi&e premalignant change, s"rgery is the pre#erred treatment. 7adiotherapy in these circ"mstances is "nsatis#actoryB irradiation o# the entire oral ca&ity ca"ses se&ere morbidity and may not pre&ent s"bse0"ent ne! primary t"mo"rs arising #rom areas o# premalignant change. Histology 1he histology report on a biopsy specimen has a relati&ely small in#l"ence on choice o# treatment. 1he less common adenocarcinoma and melanoma are relati&ely radioresistant, and there#ore sho"ld be treated s"rgically !hene&er possible. 1he grade o# malignancy o# a s0"amo"s carcinoma does not normally in#l"ence its management, there being little e&idence to s"ggest that a !ell2di##erentiated primary sho"ld be treated di##erently #rom a poorly di##erentiated one. A possible exception is the &err"co"s carcinoma, !hich is the s"b/ect o# m"ch contro&ersy. 1he obser&ation has been made that !here large lesions o# this histological type are treated by radiotherapy rec"rrences appear in some cases !hich are o# a m"ch more anaplastic pattern than the original primary, and it has become !idely accepted that radiotherapy ind"ces 5anaplasric trans#ormation6. It seems probable that some &err"co"s carcinomas already contain #oci o# more malignant cells prior to treatment, and that these cells are the ones most li+ely to s"r&i&e a#ter radiotherapy and gi&e rise to rec"rrence. In practice, most &err"co"s carcinomas present at an early stage as s"per#icialexophytic lesions and are s"itable #or local excision. hen they cannot be excised locally the !eight o# e&idence s"ggests that they can be dealt !ith sa#ely in the same !ay as s0"amo"s carcinomas o# other types, and either s"rgery or radiotherapy be chosen as the primary treatment modality according to the site and stage o# the lesion and the condition o# the patient. Age 1he patient6s age is o#ten 0"oted as an important #actor !hich m"st be ta+en into acco"nt !hen deciding on a co"rse o# management. ith a yo"ng patient there is the #ear that i# radiotherapy is gi&en it may ind"ce a malignancy in years to comeB in #act, this ris+ is &ery small compared !ith the mortality o# the disease itsel#. -lderly

patients tend to be poor s"rgical ris+s, b"t they also rend to do badly !ith radio2 therapy, especially external radiotherapy, and o#ten deteriorate and may die as a res"lt o# the debility and poor n"tritional stat"s ind"ced by the irradiation. 4hronological age per se sho"ld not necessarily be regarded as a contraindication to s"rgery. 4arcinoma o# the lip 4arcinoma o# the lip most commonly arises at the &ermilion border o# the lo!er lip a!ay #rom the line o# contact !ith the "pper lip. Only *) per cent arise #rom the central third and commiss"re regions, and ) per cent #rom the "pper lip. Initially the t"mo"rs tend to spread laterally rather than in#iltrating deeplyB e&ent"ally, i# "ncontrolled, they can spread into the anterior triangle o# the nec+ and in&ade the mandible. Lymph node metastases occ"r late. 'oth s"rgery and radiotherapy are #re0"ently employed and are highly e##ecti&e methods o# treatment, each gi&ing c"re rates o# abo"t E( per cent. Cp to one2third o# the lo!er lip can be remo&ed !ith aor 2shaped excision !ith primary clos"re :,ig. %*.*?;. 1his method is s"itable #or t"mo"rs "p to $ cm in diameter. 1he resid"al de#ect is reconstr"cted by approximating and s"t"ring the borders in three layersB m"cosa, m"scle and s+in. .artic"lar attention sho"ld be paid to the correct alignment o# the &ermilion /"nction. 1his simple proced"re can readily be per#ormed "nder local anaesthetic on an o"t2patient basis. Initially the lip !ill appear tight, b"t this impro&es a#ter abo"t ? months. I# more than one2third o# the lip is remo&ed, primary clos"re res"lts in microstomia. 1here#ore, #or more extensi&e lip resections it is necessary to "tilise local #laps #or reconstr"ction. ,or large central de#ects o# the lo!er lip, partic"larly in patients !ho do not ha&e ageing !rin+led #aces, the 5stepladder6 approach o# Johanson gi&es excellent cosmesis as the reconstr"ction ad&ances symmetrical bilateral #laps #rom the lo!er third o# the #ace :,ig. %*.*%;. 1his res"lts in a mini #aceli#t6 and the scars are concealed in the labiomental groo&e aro"nd the chin point. ,or de#ects more laterally, in the lo!er lip, the "pper lip and partic"larly in&ol&ing the commiss"re, ,ries6 5"ni&ersal proced"re6 gi&es excellent #"nctional res"lts !ith acceptable cosmesis especially in the ageing #ace :,ig. %*.*);. ith this techni0"e, lateral #acial #laps are de&eloped #ollo!ing #"ll2thic+ness incisions in the chee+s parallel to the branches o# the #acial ner&e. 1hese #laps are then ad&anced into the lip de#ect !ith the sacri#ice o# '"rro!s6 triangles to pre&ent piling "p o# the #acial tiss"es. 1he ma/ority o# lo!er lip cancers is ca"sed by "ltra&iolet radiation and o#ten the entire &ermilion border !ill sho! actinic changes. hene&er these changes are seen a total lip sha&e !o"ld be "nderta+en in addition to resection o# the primary t"mo"r. 1he resection is reconstr"cted either by ad&ancing labial or b"ccal m"cosal #laps or, i# s"ch tiss"e is inade0"ate, by the "se o# a pedicled anteriorly based tong"e #lap. A#ter ? !ee+s the pedicle is di&ided and the #lap #inally set into the lip. 4arcinoma o# the tong"e 8"rgery is the treatment o# choice #or early lesions s"itable #or simple intraoral excision, #or t"mo"rs on the tip o# the tong"e and #or ad&anced disease !hen s"rgery sho"ld be combined !ith postoperati&e radiotherapy. ,or intermediate2stage disease s"rgery and radiotherapy ha&e similar o"tcomes. hen per#orming s"rgical excision o# less than one2third o# the tong"e, #ormal reconstr"ction is not necessary. Indeed, the best res"lts are obtained by not attempting to close the de#ect or to apply a split2 s+in gra#t. 1he base o# the resid"al de#ect sho"ld be #"lg"rated and then allo!ed to gran"late and epithelialise spontaneo"sly. 8"ch treatment is relati&ely pain #ree and res"lts in an "ndistorted tong"e. hen a&ailable a carbon dioxide laser may be "sed

#or the partial glossectomy. 1he postoperati&e co"rse is relati&ely pain #ree, oedema is minimal and healing occ"rs !ith minimal scarring. Any tong"e carcinoma exceeding $ cm in diameter re0"ires at the &ery least a hemiglossectomy. >any s"ch t"mo"rs !ill in#iltrate deeply bet!een the #ibres o# the hyogloss"s m"scle. -xtensi&e tong"e lesions o#ten in&ol&e the #loor o# the mo"th and al&eol"s. Cnder any o# these circ"mstances a ma/or resection is indicated. Access is best &ia a lip split and mandib"lotomy :,ig. %*.*<;. 1he p"ll2thro"gh proced"re is not recommended as it is &ery di##ic"lt to achie&e ade0"ate excision in all three dimensions !ith a limited access. As the resection opens the s"bmandib"lar space the resection sho"ld incl"de a dissection o# the nec+ on the same side as the t"mo"r. 1he type o# nec+ dissection !ill depend "pon the node stat"s o# the patient. A rim resection o# the mandible is indicated i# the t"mo"r reaches b"t does not in&ade the al&eol"s. 8"ch extensi&e de#ects re0"ire reconstr"ction !ith distant #laps. I# the &ol"me o# the tong"e de#ect does not exceed t!o thirds o# the original tong"e a radial #orearm #ree #lap !ith micro&asc"lar anastomoses gi&es a good #"nctional res"lt. ,or &ery large &ol"me de#ects, #or total glossectomy or #or deeply in#iltrating t"mo"rs, !hen the resection extends to the hyoid bone, more b"l+y #laps are re0"ired to #ill in the dead space and pre&ent #ood pooling. A pectoralis ma/or m"scle #lap is the best method. hene&er it is possible, !itho"t compromising the resection, at least one o# the hypoglossal ner&es sho"ld be preser&ed. I# this is done, most patients !ill e&ent"ally relearn to s!allo! and !ill establish reasonable speech. 4arcinoma o# the #loor o# the mo"th ,loor o# mo"th cancers spread to in&ol&e the "nder s"r#ace o# the tong"e and the lo!er al&eol"s at a relati&ely early stage. 1here#ore, s"rgical excision !ill nearly al!ays incl"de partial glossectomy and marginal resection o# the mandible. 1he res"ltant de#ect m"st al!ays be reconstr"cted !ith either a local or a distant #lap. It is "nacceptable to ad&ance the lateral margin o# the resid"al tong"e to the b"ccal m"cosa as this ca"ses &ery se&ere di##ic"lties !ith speech and mastication. 8mall t"mo"rs o# the #loor o# the mo"th that do not sho! deep in#iltration can be treated by simple excision. It is important that a *2cm margin o# normal2appearing m"cosa be excised aro"nd the t"mo"r. 1he res"lting de#ect can either be le#t to gran"late i# a carbon dioxide laser !as "sed #or the excision, or #"lg"rated i# diathermy excision !as "sed. Alternati&ely, i# the de#ect is large it can be repaired "sing bilateral nasolabial #laps t"nnelled into the mo"th and interdigitated anteriorly. 1he s"bmandib"lar d"ct sho"ld be identi#ied proximally, !ell clear o# the distal margin o# the excision and bro"ght o"r into the #loor o# the mo"th or ling"al g"tter posteriorly. ,or larger lesions and those in&ol&ing the &entral tong"e andJor the al&eol"s, s"rgical access is gained &ia a midline or lateral :anterior to the mental #oramen; mandib"lotomy and lip split. As these extensi&e t"mo"rs ha&e a high incidence o# nodal in&ol&ement, the resection is "nderta+en in contin"ity !ith an ipsilateral nec+ dissection :,ig. %*.*D;. 7ecent !or+ has demonstrated the pattern o# bone in&asion by carcinoma o# the #loor o# the mo"th. In&asion in the edent"lo"s mandible is almost excl"si&ely &ia de#iciencies in the cortical bone o# the al&eolar crest. In the dentate mandible in&asion is "s"ally &ia the periodontal ligament and is nearly al!ays abo&e the insertion o# the mylohyoid m"scle. Once t"mo"r has in&aded the mandible it soon enters the in#erior dental canal and perine"ral spread occ"rs anteriorly and posteriorly. 4onse0"ently, in many cases the contin"ity o# the mandible can sa#ely be maintained

pro&ided a marginal resection is carried o"t !hich incl"des the in#erior dental canal #rom the ling"la to the mental #oramen. hen there is e&idence o# gross t"mo"r in&asion o# the bone resection o# the mandible is mandatory. In order to a&oid #"nctional and cosmetic de#ormity, immediate primary reconstr"ction is essential. 1he choice lies bet!een reconstr"ction !ith &asc"larised bone, a #ree corticocancello"s gra#t or an alloplastic system "s"ally s"pplemented !ith cancello"s bone m"sh. 4arcinoma o# the b"ccal m"cosa Lesions strictly con#ined to the b"ccal m"cosa sho"ld be excised !idely incl"ding the "nderlying b"ccinator m"scle, #ollo!ed by a 0"ilted split2s+in gra#t. ,or more extensi&e lesions !ith more complicated three2dimensional shapes, i.e. lesions extending posteriorly to the retromolar area, maxillary t"berosity or tonsillar #ossa, reconstr"ction !ith a #ree radial #orearm #lap is ad&isableB this adapts &ery !ell to s"ch shapes and remains so#t and mobile postoperati&ely :,ig. %*.*=;. In sit"ations !here a #ree #lap is nor appropriate, alternati&es are the b"ccal #at pad or the #orehead #lap. 1he b"ccal #at pad has pro&ed to be a "se#"l local #lap #or the reconstr"ction o# small intraoral de#ects "p to ? x )cm. 1his !ell&asc"larised #lap can be le#t ra! to epithelialise spontaneo"sly, and is "sed to reconstr"ct maxillary de#ects, hard and so#t palate de#ects, and chee+ and retromolar de#ects. ,or large de#ects at these sites its "se can be combined !ith the temporalis m"scle #lap. 1he "se o# the #orehead #lap, an axial #lap based on the s"per#icial temporal artery, !as #irst described by >cGregor in *E<?. It is a &ery reliable #lap able to reach most areas !ithin the mo"th incl"ding the anterior #loor o# the mo"th. Ho!e&er, it is no! rarely "sed beca"se it res"lts in a &ery ob&io"s cosmetic de#ect at the donor siteB it is a t!o2stage proced"re re0"iring di&ision o# the pedicle at ? !ee+sB and it re0"ires the creation o# a t"nnel, either deep or s"per#icial, to the 9ygomatic arch !hen the #lap is needed in the oral ca&ity. 4arcinoma o# the lo!er al&eol"s In general, s"rgery is the treatment modality o# choice #or all al&eolar carcinomas, except #or patients "n#it #or s"rgery. Access is achie&ed &ia a lip2split approach. No! that the patterns o# bone in&asion are better "nderstood, the contin"ity o# the mandible can o#ten be preser&ed by per#orming a marginal resection. I# bone in&asion is so extensi&e that the mandible m"st be resected in contin"ity, primary reconstr"ction sho"ld al!ays be "nderta+en as the res"lts are al!ays better than those o# delayed reconstr"ction. 8e&eral techni0"es are a&ailable #or immediate reconstr"ction o# the mandible. Historically, #ree corticocancello"s gra#ts har&ested #rom the iliac crest or rib gra#ts ha&e been "sed. .ro&ided there is a good !atertight co&er to the gra#t, res"lts can be &ery satis#actory, altho"gh it is di##ic"lt to reconstr"ct the chin prominence !ith this techni0"e. 'oyne and Lea+e ha&e ad&ocated the "se o# cancello"s bone #rom the ili"m pac+ed into mesh trays pre#ormed to march the resected part o# the mandible. 1he early dacron trays did nor pro&e s"ccess#"l, b"t the titani"m trays c"rrently a&ailable ha&e gi&en excellent res"lts :,ig. %*.*E;. >icro&asc"lar tiss"e trans#er is c"rrently #a&o"red #or immediate mandib"lar reconstr"ction. 1he radial #orearm #lap !ith a section o# the radi"s, the compo"nd groin #lap based on the deep circ"m#lex iliac &essels and #ree #ib"la #laps ha&e all been ad&ocated :,ig. %*.$(;. A problem !ith the radial #lap is that the har&ested bone, altho"gh restoring mandib"lar contin"ity, is barely ade0"ate #or prosthetic reconstr"ction.

8o#t2tiss"e co&er #or all o# these reconstr"ction techni0"es is critical. ith micro&asc"lar #ree #laps the associated s+in is "sed. ,or cancello"s bone m"sh in titani"m trays, and #or corticocancello"s gra#ts, the pectoralis ma/or m"scle2only #lap is most "se#"l :,ig. %*.$*;. 1he pedicle is bro"ght "p thro"gh the nec+ and the #lap introd"ced into the #loor o# the mo"th. 1he #lap is then !rapped aro"nd the bone gra#t and s"t"red bac+ on to itsel# on the labial aspect. 1h"s, the bone gra#t is totally en&eloped in !ell2&asc"larised so#t tiss"e. 1he m"cosal resection margins are then s"t"red to the exposed m"scle at their appropriate sires and the bare m"scle allo!ed to epithelialise spontaneo"sly. 8"ch #laps !ithstand immediate postoperati&e radiotherapy, and the s"bse0"ent insertion o# osteointegrated implants has not pro&ed to be a problem. 4arcinoma o# the retromolar trigone 1he retromolar trigone is de#ined as the anterior s"r#ace o# the ascending ram"s o# the mandible. It is ro"ghly triang"lar in shape !ith the base being s"perior behind the third "pper molar tooth and the apex in#erior behind the third lo!er molar. t"mo"rs at this site may in&ade the ascending ram"s o# the mandible. 1hey may also spread "p!ards in so#t tiss"e to in&ol&e the pterygomandib"lar space, !hich can be di##ic"lt to detect clinically or radiologically. A lip split and mandib"lotomy are needed to gain access to the retromolar region. 8mall de#ects can o#ten be reconstr"cted !ith a masseter or temporalis m"scle #lap. Larger de#ects are best reconstr"cted !ith a #ree radial #orearm #lap !hich can be made to con#orm &ery !ell to the shape o# the de#ect at this site. 4arcinoma o# the hard palate and "pper al&eol"s 1hese sites are considered together as they are closely ad/acent and both are rare sites o# origin o# primary s0"amo"s carcinoma. A s0"amo"s carcinoma presenting at either o# these sites is more li+ely to ha&e arisen in the maxillary antr"m than in the oral ca&ity. An exception is on the Indian s"bcontinent !here carcinoma o# the hard palate is seen in association !ith re&erse smo+ing. t"mo"rs o# minor sali&ary glands are m"ch more common than s0"amo"s carcinomas on the hard palate. 1he &ast ma/ority o# s0"amo"s carcinomas !hich present in the "pper g"m or hard palate arises #rom the maxillary antr"m. A t"mo"r con#ined to the hard palate, "pper al&eol"s and #loor o# the antr"m can be resected by con&entional partial maxillectomy. A more extensi&e t"mo"r con#ined to the in#rastr"ct"re o# the maxilla re0"ires total maxillectomy. I# the preoperati&e in&estigations indicate extension o# disease into the pterygoid space or in#ratemporal #ossa a more extensi&e proced"re is necessary. 1he chance o# obtaining a c"re by s"rgery alone is small, and postoperati&e radiotherapy is essential. A combined anteroposterior or lateral #acial approach is re0"ired. I# the t"mo"r extends s"periorly to in&ol&e the d"ra then a combined ne"ros"rgical proced"re !ill be re0"ired. ,ollo!ing a maxillary resection the res"lting ca&ity sho"ld be s+in gra#ted to ens"re rapid healing and to pre&ent contract"re o# the o&erlying so#t tiss"es. 1he de#ect created by s"rgery !ill re0"ire either reconstr"ction or a prosthesis. Fario"s techni0"es ha&e been described #or reconstr"ctionB Ob!egeser described a techni0"e "sing split ribs. >ore recently, the temporalis m"scle #lap has been ad&ocated. 1he temporalis m"scle #lap is a simple techni0"e and has the ad&antage that it carries !ith it its o!n blood s"pply. It m"st be remembered that i# s"ch a recon2 str"ction is to be "nderta+en s"bse0"ently, it is essential that at the rime o# the original maxillectomy the coronoid process o# the mandible is not excised, beca"se i# it is resected the blood s"pply to the mobilised temporalis m"scle !ill ha&e been compromised and the #lap !ill necrose.

>alignant melanoma Oral melanomas are rare. 1he pea+ age incidence is bet!een %( and <( yearsB nearly )( per cent are on the hard palate and abo"t $) per cent are on the "pper gingi&ae. Abo"t ?( per cent o# melanomas are preceded by an area o# hyperpigmentation, o#ten by many years. .igmentation &aries #rom blac+ to bro!n, !hile rare nonpigmented melanomas :*)per cent o# oral melanomas; are red. Oral melanomas may be #lat b"t are "s"ally raised or nod"lar, and asymptomatic initially, b"t may later become "lcerated and pain#"l or bleed. 'eca"se o# their rapid gro!th, most oral melanomas are at least * cm across, and approximately )( per cent o# patients ha&e metastases at presentation :,ig. %*.$$;. 4linically, si9e and rapid gro!th, partic"larly i# associated !ith destr"ction o# "nderlying bone or presence o# metastases, are ob&io"s indicators o# a poor o"tcome. >icroscopically, t"mo"r thic+ness, meas"red in millimetres #rom the gran"lar cell layer to the deepest identi#iable melanocyte :the 'reslo! thic+ness;, is the main g"ide to prognosis. ith c"taneo"s melanomas the )2year s"r&i&al rate is in&ersely proportional to the 'reslo! thic+ness. 1he poor prognosis o# oral melanomas is probably d"e to their later detection than more conspic"o"s s+in t"mo"rs. Other indicators o# poor prognosis are malignant melanocytes in blood &essels and m"ltiple, or atypical, mitoses. 1he morphology o# the melanocytes or the amo"nt o# the melanin does not appear to a##ect the o"tcome. Once the diagnosis has been con#irmed, the only hope o# c"re is pro&ided by the !idest possible excision #ollo!ed by radical radiotherapy. 1here is no e&idence that chemotherapy is o# signi#icant &al"e except #or palliation. 1he o&er )2year s"r&i&al rate appears to be abo"t ) per cent. >anagement o# the nec+ .atients staged NO. 1he regional lymph nodes, altho"gh clinically impalpable, sometimes contain occ"lt #oci o# malignant cells. It seems reasonable to expect, there#ore, that remo&al or treatment o# regional lymph nodes, e&en !hen clinically clear, !o"ld impro&e c"re rates. Alternati&ely, it can be arg"ed that treatment o# the regional nodes in all cases is "nnecessary, as only a minority has metastases in the nodes. 1he arg"ments expressed in #a&o"r o# electi&e bloc+ dissection are@ A the incidence o# histologically in&ol&ed nodes in NO nec+s &aries #rom $) to <) per centB A s"r&i&al rates are considerably lo!er in patients !ho de&elop node metastasesB A the rec"rrence rare #ollo!ing bloc+ dissection is higher in ad&anced disease !hen there is extracaps"lar spread or m"ltiple nodesB A by !aiting #or clinically detectable disease to de&elop, many patients !ill ha&e a !orse prognosisB Asome patients #ail to attend reg"lar #ollo!2"p and may not appear again "ntil nodal metastases are extensi&eB Abloc+ dissection o# the nec+ carries negligible mortality and an acceptable morbidityB A retrospecti&e re&ie!s con#irm that patients "ndergoing electi&e nec+ dissection ha&e higher s"r&i&al ratesB A #ail"re to control nodal metastases is a #re0"ent ca"se o# death. 1he arg"ments against electi&e nec+ dissection are that@ A it is rare #or treatment to #ail in the nec+ !hen the primary is controlled only %.) per cent in one large seriesB

Athe incidence o# histologically positi&e nodes in electi&e nec+ dissections exceeds the incidence o# s"bse0"ent clinical nodal metastases, s"ggesting that some microscopic #oci are destroyed by the body6s de#encesB A the primary may rec"r or a second primary de&elop and metastasise into the dissected nec+, ma+ing s"bse0"ent management &ery di##ic"ltB A electi&e nec+ dissection gi&es no g"arantee against rec"rrence o# the t"mo"r in the nec+B A bloc+ dissection has a considerable morbidityB A remo&al o# regional lymph nodes may remo&e a barrier to the #"rther spread o# diseaseB Athere is no prospecti&ely controlled trial to s"pport the arg"ment that electi&e nec+ dissection does impro&e the prognosis. On balance, the !eight o# these arg"ments #a&o"rs prophylactic nec+ dissection. As the s"bmandib"lar triangle o#ten has to be opened as part o# the resection o# the primary, a #"nction sparing electi&e nec+ dissection #or t"mo"rs in the #loor o# the mo"th and lo!er al&eolar ridge and tong"e is ad&ocated. 1his dissection, in !hich str"ct"res s"ch as the accessory ner&e, internal /"g"lar &ein and sternocleido2mastoid m"scle are preser&ed, can be /"sti#ied. ,"rther, a s"r&ey sho!ed that o# )(* cancers o# the oral ca&ity, ?% per cent o# nodes !ere #o"nd to be positi&e a#ter electi&e radical nec+ dissections. O&er E< per cent o# these histologically positi&e nodes !o"ld ha&e been remo&ed by a s"pra2omohyoid dissection. 1he operation sho"ld pre#erably be seen as a staging proced"re on !hich is based the decision to gi&e radical postoperati&e radiotherapy. All patients !ith t!o or more positi&e nodes or extracaps"lar spread sho"ld be treated !ith postoperati&e radiotherapy. An alternati&e approach is electi&e irradiation o# the clinically negati&e nec+, and indeed there is good e&idence that this is o# some bene#it in pre&enting s"bse0"ent nodal disease. 4ertainly, electi&e irradiation to %( Gy carries less morbidity than electi&e nec+ dissection. .atients staged N*JN$aJN$b. At present, e&idence s"ggests that the treatment o# choice is radical nec+ dissection, either alone or combined !ith postoperati&e radiotherapy i# m"ltiple nodal in&ol&ement or extracaps"lar extension is #o"nd in the resected specimen :,ig. %*.$?;. In those patients "n#it #or radical s"rgery, radical external beam irradiation is indicated. .atients staged N$c. It is "ncommon #or patients !ith oral cancer to present !ith bilateral nodes. hen they do so, there is o#ten a large inoperable primary t"mo"r !hich is best treated by external radiation. It there#ore seems logical to treat the nec+ also by irradiation. Occasionally, partic"larly in yo"ng patients, bilateral nec+ dissection can be /"sti#ied. A #"ll radical nec+ dissection is "nderta+en on the ipsilateral side and the internal /"g"lar &ein is spared i# possible on the contralateral side. >ost o#ten postoperati&e radiotherapy !ill he re0"ired #or m"ltiple nodal in&ol&ement or extracaps"lar spread. In s"ch sit"ations, se&ere posttreatment oedema or congestion o# the #ace and tong"e may be anticipated. .atients staged N?. N? indicates massi&e in&ol&ement, "s"ally !ith #ixation. Large #ixed nodes are o#ten associated !ith ad&anced primary disease !ith a poor prognosis. 8"rgery is not normally ad&isable@ remo&al o# the common or internal carotid artery !ith replacement, or extensi&e resection o# the base o# the s+"ll, altho"gh technically #easible, is seldom ad&isable. 1reatment is most o#ten by external radiotherapy. In a

#e! yo"nger patients !ith resectable primaries, it is !orth rendering a #ixed mass in the nec+ operable by preoperati&e radiotherapy. Nodal metastases appearing a#ter primary treatment .ro&ided that #ollo!2"p at reg"lar inter&als is rigoro"sly maintained, it sho"ld be possible to detect a lymph node metastasis !hile it is still relati&ely small and there#ore operable. ,ine needle aspiration cytology is partic"larly "se#"l in this sit"ation to con#irm that the palpable node is a carcinoma rather than reacti&e. hene&er positi&e, or i# there is any do"bt, a radical nec+ dissection is per#ormed, #ollo!ed by external irradiation i# m"ltiple in&ol&ed nodes or extracaps"lar spread are #o"nd. ,"rther reading A&ery, '.8. :*EE=; Nec+ dissections. In Operati&e >axillo#acial 8"rgery :eds J.D. Langdon and >.,. .atel;, 4hapman K Hall, London, pp. $E)?($. 4a!son, 7.A., Langdon, J.D. and -&eson, J. :*EE<; 8"rgical .athology o# the >o"th and Ja!s, right, Ox#ord. Langdon, J.D. and Hen+, J.>. :eds; :*EE); >alignant 1"mo"rs o# the >o"th, Ja!s and 8ali&ary Glands, Arnold, London. >cGregor, l.A. and >cGregor, ,.>. :*E=<; 4ancer o# the ,ace and >o"th, 4h"rchill2Li&ingstone, -dinb"rgh. Ord, 7.A. :*EE=; Local resection and local reconstr"ction o# oral carcinomas, and /a! resection. In Operati&e >axillo #acial 8"rgery :eds J.D. Langdon and >.,. .arel;, 4hapman K Hall, London, pp. $D? E%. 8o"tar, D.8. :*EE?; ,ree #laps in intra oral reconstr"ction. In >icro&asc"lar 8"rgery and ,ree 1iss"e 1rans#er :ed. D.8. 8o"tar;, Arnold, London. Fa"ghan, -.D. :*EE(; 1he radial #orearm #ree #lap in oro#acial reconstr"ction, personal experience in *$( consec"ti&e cases. Jo"rnal o# 4ranio2>axillo #acial 8"rgery, *=, $D.