Buccal Mucosa Cancer

Buccal Mucosa Cancer

Write about etiology, clinical features and treatment of carcinoma of cheek.
Or
Write short note on etiology and treatment of carcinoma of cheek.

Answer. The common carcinoma of cheek is squamous cell carcinoma.

This is also called verrucous carcinoma or tobacco chewers carcinoma of cheek.

“Causes Of Buccal Mucosa Cancer”

Carcinoma of cheek Etiology

• All the ‘S’, i.e. smoking, spirit, syphilis, sharp tooth and spices.
• Premalignant lesions and conditions, i.e. leukoplakia,erythroplakia, OSMF, candidiasis, etc.
• Placing the quid of betel nut and tobacco in cheek mucosa.

Carcinoma of cheek Pathological types

• A non-healing ulcer
• An exophytic growth or verrucous carcinoma
• An infitrative lesion, which involves adjacent structures like tongue, mandible, floor of mouth.

“Symptoms Of Buccal Mucosa Cancer”

Carcinoma of cheek Clinical Features

• Ulcer (painless to begin with) in the cheek which gradually increases in size in a patient with history of chewing pan and smoking is the most common presentation and initially it is painless.
• Pain occurs when it involves the skin, bone or if secondarily infected. Referred pain to the ear signifis involvement of lingual nerve.
• Halitosis which is bad odour breath is common.
• Involvement of retromolar trigone indicates that it is an advanced disease, as the lymphatics here communicate freely with the pharyngeal lymphatics.
• Everted edge, induration are the typical features of the ulcer.
• Mandible is examined bidigitally, for thickening, tenderness, irregularity and sites of fracture.
  Mandible may get involved by direct extension, through mandibular canal or through periodontal membrane.
  Loss of central part of mandible due to destruction by tumor will cause pouting of lower lip with drooling of saliva, i.e.
  Andy Gump deformity.
• Mandibular canal is close to occlusive alveolar surface in elderly and edentulous patients to cause early mandibular spread in carcinoma.
• Trismus and dysphagia signify involvement of pterygoids or posterior extension.
• Occasionally it may extend into the upper alveolus and to the maxilla causing swelling, pain and tenderness.
• Once involvement of soft tissue occurs, it may come out through skin as fungating lesion often with orocutaneous fitulas with saliva dribbling through fitula.
• Submandibular lymph nodes and upper deep cervical nodes are involved which are hard and nodular; initially mobile and later get fied to each other and then to deeper structure.

“Best Ways To Prevent Buccal Mucosa Cancer”

Features of advanced Carcinoma Cheek

• Involvement of retromolar trigone.
• Extension into the base of skull and pharynx
• Fixed neck lymph nodes
• Extension to the opposite side

Carcinoma Cheek Spread

• Local spread: Result in orosubcutaneous fitula and mandibular sinus.
• Lymphatic spread: Enlargement of submandibular lymph nodes.
• Hematogenous spread: Very rare.

“Can Smoking Lead To Buccal Mucosa Cancer”

Carcinoma Cheek Investigation

• Wedge biopsy, usually taken from two sites. Biopsy has to be taken from the edge as it contains active cells; not from the center as it is the area of necrosis.
  Malignant squamous cells with epithelial pearls (keratin pearls) are the histological features.
• FNAC from lymph nodes.
• CT scan is used to assess the extent of tumor into mandible, pterygoid region, in patient with trismus, with neck lymph nodes, with carotid involvement by lymph nodes.
• MRI is very useful in assessing the soft tissues, base of skull and perineural spread.
• Orthopantomogram to look for the involvement of mandible destruction and fracture sites.
  Symphysis menti and lingual plate are not clearly appreciated.
  So often OPG may be supported with dental occlusion and intraoral X-rays.

Carcinoma Cheek Treatment

Treatment should be curative or palliative

• Early growth without bone involvement
• Curative radiotherapy using caesium needles or iridium wires, i.e. brachytherapy.
• Other option is wide excision wire 1–2 cm clearance.
• Often, the approach to the tumor is by raising the cheek flp (outside). After the wide excision, the flp is placed back (Pattrson operation).
• Presently advanced technology in radiotherapy,facilitates the use of external radiotherapy also.
  The incidence of dreaded complication like osteoradionecrosis mandible has been reduced due to bettr radiotherapy methods.
• Growth with mandible involvement: Here along with wide excision of the primary tumor hemimandibulectomy or segmental resection of the mandible or marginal mandibulectomy (using rotary electric saw) is done.

“What Tests Diagnose Buccal Mucosa Cancer”

• Operable growth with mandible involvement and mobile lymph nodes on the same side (confimed by FNAC): Along with wide excision of the primary, hemimandibulectomy and radical neck lymph node dissection is done (commando operation).
  Wide excision of primary lesion, hemimandibulectomy with radical neck node dissection is called as compositeresection.
• Operable growth with mandible involvement; mobile lymph node on same side and opposite side: Along with wide excision of the tumor, hemi-mandibulectomy, radical neck lymph node dissection on same side and functional block dissection on opposite side are done, retaining the internal jugular vein, sternomastoid and spinal accessory nerve.
• Operable primary tumor with mobile lymph nodes on same side but without mandibular involvement: Wide excision of primary tumor and radical neck lymph node dissection on same side are done. Mandible is not removed.
• Fixed primary tumor or advanced neck lymph node secondaries: Only palliative external radiotherapy is given to palli-ate pain fungation and to prevent anticipated to rrential hemorrhage.
• Preoperative radiotherapy is often used in fied lymph node to downstage the disease to make it operative.
• Postoperative radiotherapy is given in T3 and T4 tumors:
  N2 and N3 nodal status to reduce the recurrence and to improve the prognosis.
• Prophylactic block dissection has become popular in N0 diseases
• If growth is extending to upper alveolus: Partial maxillectomy or total maxillectomy is done.

Reconstruction After Surgery

Flaps used for reconstruction after oral surgery:

• Forehead flp based on superfiial temporal artery.
• Deltopectoral flp based on 1, 2 and 3 perforating vessels from internal mammary vessels.
• Pectoralis major myocutaneous flp (PMMF) based on thoracoacromial artery.
• Free microvascular flps may be from radial artery forearm flp.
• For small defects—tongue flap, buccal flap, palatal mucoperiosteal flp.

“Understanding The Causes Of Buccal Mucosa Cancer”

Carcinoma Cheek Chemotherapy

• Drugs used are methotrexate, cisplatin, vincristine,bleomycin, adriamycin.
  Often it is given intra-arterially through external carotid artery using arterial pump or by increasing the height of the drip more than l3 feet, so as to attain a pressure more than systolic pressure. Chemotherapy can also be given IV or orally postoperatively.
• Initial chemotherapy to downstage the tumor followed by surgery and later again end with chemotherapy.
• Chemoradiotherapy is used in unresectable tumors as consecutive therapies.

“Comprehensive Overview Of Buccal Mucosa Cancer Symptoms”

Carcinoma Cheek Radiotherapy

• Early lesions are managed by radiotherapy.
• Radiotherapy is of two types, i.e. external radiotherapy
  and interstitial radiotherapy.
• In external radiotherapy large dose of 6000 to 8000 cGy units are given, i.e. 200cGy units/day Interstitial radiotherapy is indicated in infitrative small lesions.
  Caesium 137 or iridium wires are placed within the tumor.
  Minimal tissue resection is the basic advantage of this procedure.