2. 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.
3. 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
4.
5. 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.
6. 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.[
7. 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.
8. 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
PREMALIGNANT LESIONS
9. 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%)
10. ORAL SUB MUCOUS FIBROSIS (SMF)
4.5 – 7.5 % progress to oral cancer
11. 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
13. 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.
14. 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.
15. 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
16. DIAGNOSTIC WORK UP
History & Clinical examination , including head &
neck examination
Clinical staging
Assessment of performance & nutritional status
Investigations for histological diagnosis – Punch
Biopsy
17. 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
20. 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
21. 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
23. 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.
24. 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
25. 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.
26. 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
27. 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.
28. 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
29. 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
30.
31. 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
33. 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
34. 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
35. 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
36. 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
37. 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.
38. 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
39. 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.
40.
41. 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
42. 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
43. RT DOSE
Doses of 66 Gy in 2-Gy fractions for positive
margins.
60 Gy in 2-Gy fractions or 59.4 to 63 Gy in 1.8-Gy
fractions to high-risk regions.
54 Gy in 1.8-Gy fractions for low-risk regions.
An LAN is often used, treated to either 50 Gy in 2-
Gy fractions or 50.4 Gy in 1.8-Gy fractions.
44. 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 70 Gy
in 5 to 8 days is delivered through a single-plane
or double-plane implant on the thickness of the
lesion.
45. 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.
