Lip Cancer: Treatment and Reconstruction

By Antonia Kolokythas

This textbook is intended as a comprehensive reference that will provide easy-to-follow and well-organized guidance on the management of lip cancer, from diagnosis to treatment and reconstruction. After discussion of anatomy and premalignant conditions, detailed attention is paid to squamous cell carcinoma of the lip. Surgical management is explained, and the roles of radiation therapy and chemotherapy, discussed. Reconstruction techniques following ablative surgery are then described in depth, with reference to defect size and complexity. In addition, the potential complications of treatment and reconstruction are presented, with advice on their management. The closing chapter considers other malignant lesions of the lip. The informative text is complemented by high-quality illustrations and clinical and radiographic material. The contributors all have extensive experience and in-depth knowledge of the topics they address.​

• Language: English
• Publisher: Springer
• Release date: Oct 21, 2013
• ISBN: 9783642381805

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Antonia Kolokythas (ed.)Lip Cancer2014Treatment and Reconstruction10.1007/978-3-642-38180-5_1

© Springer-Verlag Berlin Heidelberg 2014

1. Lip Cancer: General Considerations

Michael Han¹ and Jasjit Dillon¹  

(1)

Department of Oral and Maxillofacial Surgery, University of Washington, B-241 Health Sciences Bldg, 357134, Seattle, WA 98195-7134, USA

Jasjit Dillon

Email: [e-mail]

Abstract

The lips play crucial roles in speech, mastication, swallowing, maintenance of dental arch integrity, and esthetics. Therefore, cancers of the lip can lead to various functional and esthetic problems. Due to their location, lip cancers are easily detected and diagnosed at relatively early stages. As with all pathology of the oral and maxillofacial region, the role of the dental professional in early detection of lip cancers cannot be overemphasized.

Cancers of the lip occupy up to 30 % of all malignant tumors of the oral cavity. The vast majority of malignancies of the lips are squamous cell carcinoma (SCC), followed by melanoma and minor salivary gland carcinomas. The American Joint Committee on Cancer (AJCC) defines the boundaries of the lips as the junction of the vermilion border with the skin and [including] only the vermilion surface or that portion of the lip that comes into contact with the opposing lip …joined at the commissures of the mouth, considering only the cutaneous portions of the lips. The Union International Contre le Cancer (UICC) uses the same definition to classify lip cancers. The International Classification of Diseases for Oncology Manual, however, includes cancers of the mucosal surface in a subcategory of lip cancers, together with cancers of the oral cavity and pharynx. The variation in classification is due to the differences in histologic characteristics as well as in the environment the cutaneous and mucosal portions of the lip are exposed to (in general, carcinoma of the vermilion is thought be pathophysiologically differ from intraoral cancers and be closer to carcinoma of skin). Unfortunately, confusion exists in the data regarding lip cancers due to such variations and inconsistencies in classification.

1.1 Introduction

The lips play crucial roles in speech, mastication, swallowing, maintenance of dental arch integrity, and esthetics. Therefore, cancers of the lip can lead to various functional and esthetic problems. Due to their location, lip cancers are easily detected and diagnosed at relatively early stages. As with all pathology of the oral and maxillofacial region, the role of the dental professional in early detection of lip cancers cannot be overemphasized.

Cancers of the lip occupy up to 30 % of all malignant tumors of the oral cavity [1–3]. The vast majority of malignancies of the lips are squamous cell carcinoma (SCC), followed by melanoma and minor salivary gland carcinomas [4]. The American Joint Committee on Cancer (AJCC) defines the boundaries of the lips as the junction of the vermilion border with the skin and [including] only the vermilion surface or that portion of the lip that comes into contact with the opposing lip …joined at the commissures of the mouth, considering only the cutaneous portions of the lips [5]. The Union International Contre le Cancer (UICC) uses the same definition to classify lip cancers. The International Classification of Diseases for Oncology Manual, however, includes cancers of the mucosal surface in a subcategory of lip cancers, together with cancers of the oral cavity and pharynx [6]. The variation in classification is due to the differences in histologic characteristics as well as in the environment the cutaneous and mucosal portions of the lip are exposed to (in general, carcinoma of the vermilion is thought be pathophysiologically differ from intraoral cancers and be closer to carcinoma of skin). Unfortunately, confusion exists in the data regarding lip cancers due to such variations and inconsistencies in classification.

1.2 Epidemiology

Cancers of the lip make up to 30 % of all malignant tumors of the oral cavity. They also predominantly occur in the lower lip. The lower lip is affected in 85–95 % of cases, compared to the much lower incidences found in the upper lip (2–7 %) and lip commissure (1–4 %) [3]. This is presumed to be due to the higher risk of sun exposure in the lower lip associated with its anatomical location and orientation.

The incidence of lip cancer varies considerably depending on the population. In the USA, the average incidence is approximately 1.8 per 100,000; however, significantly higher rates are seen in certain parts of the country (12 per 100,000 in Utah) [7, 8]. Greater variations in incidence are seen among different regions and countries. For example, the incidence in Southern Australia is reported to be 13 per 100,000 and that of a population of fishermen in Newfoundland over 50 per 100,000 [7]. On the other hand, the overall prevalence of lip cancer is low in Asia. Age-adjusted incidences in Osaka, Japan, and Mumbai, India, have been reported to be 0.1 and 0.3 per 100,000, respectively [8]. It is important to note that direct comparison is difficult to interpret because of differences in data collection, as well as cultural and behavioral factors. Despite this, the overall annual incidence of lip cancer has shown a downward trend in many parts of the world, including the USA, and most notably Great Britain [7, 8].

Interestingly, the prevalence of lip cancer appears to be inversely related to that of other oral cancers in many parts of the world. For example, India, which as a high incidence of oral cancer, by comparison has a much lower incidence of lip cancer [8]. On the other hand, parts of Canada and Utah have an especially high prevalence of lip cancer but fewer rates of carcinomas of the oral cavity [8].

1.3 Demographics

Malignancies of the lip are most commonly seen in patients between ages 50 and 70 years [9]. Less than 15 % of patients with lip cancer are under age 40, and a sharp rise in incidence is seen with increasing age [3, 10]. There is a distinct male predilection of over 95 %. In particular, cancers involving the lower vermilion are reported to be 36-fold more common in males (5.5-fold for upper vermillion cancers) [11]. The lifetime risk of developing lip cancer is reported to be 0.15 % for men and 0.07 % for women [10]. Several explanations exist for the marked male predilection of lip cancers, including a greater percentage of males holding outdoor occupations (and thus a higher exposure to ultraviolet radiation), smoking, protective properties against ultraviolet radiation in certain components of women’s cosmetics, specifically lipstick. However, the degree of male predilection may vary depending on the population. For example, the incidence of lip cancer in males is only twice of that in females (0.2 per 100,000 and 0.1 per 100,000, respectively) in Bas-Rhin, France [8], and in some parts of Asia, a higher incidence of lip carcinoma is seen in females [12].

Other susceptible populations include light-skinned individuals (especially those with long-term ultraviolet exposure or a positive history of acute sunlight damage), tobacco (particularly pipe and cigar) smokers, outdoor workers, immunocompromised patients, and individuals of low socioeconomic status. Carcinoma of the lip is typically found in white males and is relatively rare in the black population. Surveillance, Epidemiology and End Results (SEER) data demonstrate this difference, showing an incidence of 1.9 per 100,000 in white individuals in the USA compared to 0.04 per 100,000 in blacks [12]. A survey-based investigation of 171 lip cancer patients in Finland showed a higher percentage of light-haired, light-eyed individuals compared to a control group of 124 head and neck skin cancer patients [13]. The same study revealed both smoking and outdoor work as strong risk factors in males; however each of these factors did not pose a significant risk when analyzed separately. Immunocompromised patients, including those pharmacologically immunosuppressed after solid organ transplantation, have been found to have a higher risk of developing cutaneous SCC [14, 15]. These patients are also more likely to develop carcinoma of the lip [16–18] and at an earlier age. In a number of studies, the incidence of lip cancer was reported to be as much as 30-fold greater in renal transplantation patients [7, 16, 17]. From a socioeconomic standpoint, the incidence of lip carcinoma was found to be negatively correlated with socioeconomic status in a large study of 3,169 cases of lip cancer in Finland, published in 1979 [19].

1.4 Historical Perspectives

Historical and fossil evidence of cancer from ancient times exist, and although the latter is generally limited to hard tissue tumors, written records clearly suggest that both hard and soft tissue cancers of the head and neck date back thousands of years. Ancient Greek physicians recognized cancer as an independent disease entity. Hippocrates described cancers arising from the nasopharynx, and later, cancers of the head, neck, and oral cavity were recorded by numerous authors including Rufus, Galen, and Aetius. In particular, Rufus (first century AD) was one of the first to describe lip cancer. Celsus, a Roman physician during the first century, described surgical excision of facial carcinomas including those of the lip. Avicenna (c.980–1037), a Persian physician, was known to routinely perform surgery for oral carcinomas [20, 21]. Since then, surgical management has become the mainstay of care for lip cancer, and the development of local, regional, and free flaps expanded the indications of treatment and improved treatment outcome. Radiation therapy and Mohs micrographic excision have also been developed as primary or adjunctive treatment modalities.

References

1.

Bailey BJ (ed) (1993) Head & neck surgery – otolaryngology, vol 2. JB Lippincott, Philadelphia

2.

Thawley SE, Panje WR (eds) (1987) Comprehensive management of head and neck tumors. WB Saunders, Philadelphia

3.

Shah JP, Johnson NW, Batsakis JG (2003) Oral cancer. Martin Dunitz, London/Thieme, New York

4.

Shah JP (2003) Head and neck surgery and oncology. Mosby, Edinburgh

5.

Greene FL, Page DL, Fleming ID et al (2002) AJCC cancer staging manual, 6th edn. Springer, New YorkCrossRef

6.

Fritz A, Percy C, Jack A (2000) International classification of diseases for oncology, 3rd edn. World Health Organization, Geneva

7.

Myers EN, Suen JY, Myers JN, Ehab HYN (2003) Cancer of the head and neck. Saunders, Philadelphia

8.

Douglass CW, Gammon MD (1984) Reassessing the epidemiology of lip cancer. Oral Surg 57:631–642PubMedCrossRef

9.

Regezi JA, Sciubba JJ, Jordan RCK (2008) Oral pathology: clinical pathologic correlations. Saunders/Elsevier, St. Louis/Edinburgh

10.

Neville BW, Damm DD, Allen CM, Bouquot JE (2009) Oral and maxillofacial pathology. Saunders/Elsevier, St. Louis

11.

Zitsch RP, Park CW, Renner GJ, Rea JL (1995) Outcome analysis for lip carcinoma. Otolaryngol Head Neck Surg 113(5):589–596PubMedCrossRef

12.

Moore SR, Johnson NW, Peirce AM, Wilson DF (1999) The epidemiology of lip cancer. Oral Dis 5:185–195PubMedCrossRef

13.

Lindqvist C (1979) Risk factors in lip cancer: a questionnaire survey. Am J Epidemiol 109:521–530PubMed

14.

Rowe DE, Carroll RJ, Day CL (1992) Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. J Am Acad Dermatol 26:976–990PubMedCrossRef

15.

Haydon RC (1993) Cutaneous squamous carcinoma and related lesions. Otolaryngol Clin North Am 26:57–71PubMed

16.

King GN, Healy CM, Glover MT et al (1995) Increased prevalence of dysplastic and malignant lip lesions in renal transplant recipients. N Engl J Med 332:1052–1057PubMedCrossRef

17.

Penn I (1991) Cancer in the immunosuppressed organ recipient. Transplant Proc 23:1771–1772PubMed

18.

Nolan A, Girdler NM, Seymour RA, Thomason JM (2012) The prevalence of dysplasia and malignant lip lesions in transplant patients. J Oral Pathol Med 41(2):113–118PubMedCrossRef

19.

Lindqvist C (1979) Risk factors of lip cancer: a critical evaluation based on epidemiological comparisons. Am J Public Health 69(3):256–260PubMedCrossRef

20.

Olson JS (1989) The history of cancer: an annotated bibliography. Greenwood Press, New York

21.

Retsas S (1986) Palaeo-oncology: the antiquity of cancer. Farrand, London

Antonia Kolokythas (ed.)Lip Cancer2014Treatment and Reconstruction10.1007/978-3-642-38180-5_2

© Springer-Verlag Berlin Heidelberg 2014

2. Anatomic Considerations of the Lips

Thomas Schlieve¹   and Antonia Kolokythas¹  

(1)

Department of Oral and Maxillofacial Surgery, University of Illinois at Chicago, 801 S. Paulina Street, MC 835, Chicago, IL 60612, USA

Thomas Schlieve (Corresponding author)

Email: [e-mail]

Antonia Kolokythas

Email: [e-mail]

Abstract

The lips are a prominent facial feature and play an important role in communication, both verbal and nonverbal, mastication, deglutition, and providing an oral seal. The American Joint Committee on Cancer defines the lip as the junction of the vermillion border with the skin and includes only the vermillion surface or that portion of the lip that comes into contact with the opposing lip. It is well defined into an upper and lower lip joined at the commissure of the mouth. A thorough understanding of lip anatomy allows the surgeon to confidently perform lip reconstruction following tumor resection, understand the basis for selected neck dissections in lip cancer, and provide a high level of patient care. The anatomy of the lip can be broken down into the surface anatomy, microanatomy, and lymphatic anatomy. The aim of this chapter is to provide a comprehensive review of the anatomy of the lip.

2.1 Introduction

The lips are a prominent facial feature and play an important role in communication, both verbal and nonverbal, mastication, deglutition, and providing an oral seal. The American Joint Committee on Cancer defines the lip as the junction of the vermillion border with the skin and includes only the vermillion surface or that portion of the lip that comes into contact with the opposing lip. It is well defined into an upper and lower lip joined at the commissure of the mouth [1]. A thorough understanding of lip anatomy allows the surgeon to confidently perform lip reconstruction following tumor resection, understand the basis for selected neck dissections in lip cancer, and provide a high level of patient care. The anatomy of the lip can be broken down into the surface anatomy, microanatomy, and lymphatic anatomy. The aim of this chapter is to provide a comprehensive review of the anatomy of the lip.

2.2 Surface Anatomy

The average horizontal length of the vermillion portion of the upper lip is 8.0 cm and the lower lip slightly shorter at 7.5 cm [2]. The vertical width of the lip varies significantly among different ethnic groups and is influenced by skeletal anatomy, dental anatomy, and muscle function. Measured from subnasale to stomion, the upper lip length averages 22 mm and the lower lip averages 44 mm from stomion to soft tissue menton. On repose, the lower lip should be slightly more everted than the upper lip and approximately 2–4 mm of tooth should be displayed. There are several ways to evaluate the anterior-posterior positioning of the lip. Using the E-Line, a line drawn from nasal tip to pogonion, the upper lip should be 4 mm from this line and the lower lip 2 mm from this line. Defined borders include the nasal base and nasal labial fold superiorly and the labiomental crease inferiorly. The upper lip contains a central portion, the philtrum, that is bordered laterally by the philtral columns.

The surface of the lip consists of that portion referred to as the vermillion. Bordering the vermillion are the wet-dry lip line, the transition from vermillion to oral mucosa of the inner lip, and the vermillion border or white line that represents the border with the skin of the face. The vermillion is composed of a modified mucosa and represents a transitional epithelium from that of the skin to that of the oral mucosa. Adjacent skin is composed of keratinized stratified squamous epithelium with sebaceous glands, sweat glands, and hair follicles. Oral mucosa covering the inner surface of the lips and buccal mucosa is composed of nonkeratinized stratified squamous epithelium that is supported by a dense lamina propria and submucosa bound by connective tissue fibers to the underlying skeletal muscle. Numerous minor salivary glands are located within the lamina propria of the inner mucosal lining of the lip. The vermillion consists of a keratinized epithelium that is structurally different from the skin of the face or mucosa of the oral cavity. Its red color is present for several reasons. First, the epithelium of the lip is thin. Second, it contains a high concentration of eleidin, a transparent intracellular protein. Lastly, the presence of elongated vascular connective tissue papillae extending into the papillary layer brings the blood supply into close approximation with the thin and translucent epithelium of the vermillion [3, 4].

2.3 Microanatomy

Sensory innervation of the lips is supplied by separate branches of the trigeminal nerve. The upper lip is supplied by the infraorbital branch of the maxillary division of the trigeminal nerve, while the lower lip is supplied by a branch of the inferior alveolar nerve, the mental nerve, after exiting through its bony foramen in the mandible. This nerve is a branch of the mandibular division of the trigeminal nerve. As the mental nerve exits its foramen, it divides into three branches. A single branch descends to the skin of the chin and two branches ascend to the mucosa of the inner lip, skin, and vermillion. The commissure receives additional innervation from the buccal branch of the mandibular division of the trigeminal nerve [5].

Motor innervation of the classically described muscles of facial expression originates from branches of the facial nerve. Those that effect the upper lip are innervated by the buccal branch and zygomatic branch of the facial nerve, while the marginal mandibular branch of the facial never innervates those muscles involved in lower lip function [5]. For simplicity, the muscular anatomy of the lips can be thought of as a circular sphincter composed of the orbicularis oris muscle. In reality, the orbicularis oris proper comprises only a portion of the sphincter. The remaining portion is a confluence of multiple muscle fiber contributions having varied directions that, when taken as a whole, give the appearance of a circular muscle. One such contributor to the orbicularis oris is the buccinator muscle. As it approaches the corner of the mouth, the uppermost and lowermost fibers pass across the upper and lower lip, respectively. Fibers located more centrally decussate with the lower fibers crossing over to the upper lip and upper fibers crossing into the lower lip. Additional muscle groups that contribute to lip function include the depressor anguli oris and levator anguli oris, the levator labii superioris and depressor labii inferioris, levator labii superioris alaeque nasi, risorius, zygomaticus major and minor, and mentalis [5]. The modiolus is a chiasma of facial muscles held together by fibrous tissue. It is of critical importance in the subtle expressions of the lips and should be preserved or reconstructed if possible during reconstruction of lip defects [6]. A detailed discussion of the anatomic origin and insertion of these muscles can be found in most anatomy textbooks and is beyond the scope of this chapter. It is the complex interaction of the above muscles that allows the lips to perform their varied functions.

The blood supply to the upper and lower lip is derived from branches of the external carotid, mainly the facial artery and its branches. The facial artery crosses the inferior border of the mandible and travels anteriorly towards the lips. As it crosses the inferior border of the mandible, its average diameter is 2.6 mm. In its course, it gives off small branches to multiple muscles of facial expression and mastication while traveling superficial to the buccinator muscle and deep to the risorius and zygomaticus major muscles. It passes on average 15.5 mm lateral to the commissure as it travels in a superomedial direction towards the medial palpebral fissure [7]. The branching of the facial artery that contributes specifically to the upper and lower lip has been extensively studied through cadaver dissection and angiography [7–11].

The lower lip blood supply is provided by three named vessels: the inferior labial artery (ILA), horizontal labial artery (HLA), and vertical labial artery (VLA). All three are branches of the facial artery in most cases (Fig. 2.1). The ILA is the main blood supply of the lower lip and branches from the facial artery at or below the commissure in greater than 80 % of cases with a significant portion originating near the border of the mandible. It runs deep to the depressor anguli oris immediately after branching and begins to travel superomedially, first between the orbicularis oris and buccinator