Surgical management of squamous cell carcinoma of the lower lip: an experience of 109 cases

Squamous cell carcinoma and basal cell carcinoma of the lips: 25 years of experience in a northeast Brazilian population

BACKGROUND

The lips are the transition zone between the facial skin and the oral mucosa and are the site of alterations related to a broad spectrum of etiologies. Squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) are the most prevalent neoplasms affecting lips. This study evaluated the demographic and clinicopathological features of the SCC and BCC in the lip.

MATERIAL AND METHODS

A retrospective cross-sectional descriptive study (1994-2019) was carried out. Demographic and clinicopathologic data were collected from a hospital's dermatological service and an oncologic hospital. The data were submitted to descriptive analysis and Pearson's chi-square and Fisher's exact tests (p ≤ 0.05).

RESULTS

417 medical records were analyzed, of which 323 corresponded to SCC (77.5%) and 94 to BCC (22.5%). SCC showed more frequency in males (58.8%) and BCC in females (54.3%). The lower lip was significantly affected in male patients (p < 0.0001) and by both neoplasms (70.6% and 56.4%, respectively; p = 0.014). SCC and BCC were mainly treated with surgery (88.3% and 93.2%, respectively). Surgical margin was frequently negative in SCC and BCC (87%; 72.3%, respectively), and no recurrence was observed in 79.9% of SCC and 69.1% of BCC cases.

CONCLUSIONS

SCC was more frequent in male patients, while BCC showed more frequency in female patients. Both neoplasms mainly affect the lower lip. Understanding the epidemiological profile of these lesions in the lip, as well as their etiology and clinical features, is fundamental for appropriate clinical conduct and the creation and/or amplification of preventive measures.

Squamous cell carcinoma of lip: Clinical feature analysis and suggestion of reconstruction algorithm

Reconstruction of lips after squamous cell carcinoma (SCC) removal should restore functional and aesthetic roles; however, it remains a challenge. In this study we describe the clinical features of lip SCC and suggest a reconstruction algorithm. We retrospectively analyzed 34 patients with lip SCC who underwent reconstruction after Mohs micrographic surgery between January 2006 and March 2022. The mean age of the patients was 70.2 years. Seven tumors were on the upper lip and 27 tumors were on the lower lip. Twenty-five defects were located on the mucosal lip, eight defects involved both the mucosal and cutaneous lips, and one defect was confined to the cutaneous lip. Eighteen defects were smaller than 50% of the total lip size, and 16 were larger than 50%. Primary closure was mostly performed for defects smaller than 50% of the lip size (9/18 cases), and local flap, according to the location and size of the defects, was performed for larger defects. Thirteen patients experienced postoperative complications but improved within 1 year after surgery, except for one patient. We suggest a reconstruction algorithm with a 50% cut-off value. Defects smaller than 50% of the lip size could be reconstructed by primary closure. Even larger defects could be reconstructed by creation of a local flap from the remaining adjacent tissue with minimal postoperative complications.

Bilateral Karapandzic Flap, a Saviour for Subtotal Lower Lip Reconstruction

Lip plays an essential role in facial esthetic, food intake, and speech. Lip defect due to trauma or surgical excision needs proper reconstruction to preserve their function. Carcinoma lip is one of the common malignant lesions in the head and neck, which needs wide local excision with proper margin with neck clearance. When the size is more than two-thirds, it becomes a challenge to reconstruct and preserve its functionality and aesthetic issues. Bilateral karapandzic flap plays an important role in this case scenario. We have two cases of subtotal lower lip defect following squamous cell carcinoma of the lower lip excision, which was reconstructed with a bilateral karapandzic flap with reasonable functional outcome and cosmesis. Thus, bilateral karapandzic flap can be an alternative option to free flap in resource-constrained scenarios with acceptable functional outcomes.

Appropriate Surgical Margins for Excision of Squamous Cell Carcinoma of the Lower Lip

Background Squamous cell carcinoma (SCC) is the most common malignancy on the lower lip. Surgical excision, the standard treatment for SCC, requires full-thickness excision. However, no consensus exists about the appropriate surgical margin. Therefore, we investigated the appropriate surgical margin and excision technique by analyzing 23 years of surgical experience with lower-lip SCC. Methods  We reviewed 44 patients with lower-lip SCC who underwent surgery from November 1997 to October 2020. Frozen biopsy was performed with an appropriate margin on the left and right sides of the lesion, and the margin below the lesion was the skin above the sulcus boundary. If the frozen biopsy result was positive, an additional session was performed to secure a negative margin. Full-thickness excision was performed until the final negative margin. In each patient, the total number of sessions performed, final surgical margin, and recurrence were analyzed. Results  Forty-one cases ended in the first session, 2 ended in the second session, and 1 ended in the third session. The final surgical margins (left and right; n  = 88) were 5 mm (66%), 7 mm (9%), 8 mm (2.3%), 10 mm (20.4%), and 15 mm (2.3%). During an average follow-up of 67.4 months (range, 12-227 months), recurrence occurred in one patient. Conclusion  The final surgical margin was 5 mm in 66% (58/88) of the cases, and 97.7% (86/88) were within 10 mm. Therefore, we set the first frozen biopsy margin to 5 mm, and we suggest that a 5-mm additional excision is appropriate when frozen biopsy results are positive.

Distant metastasis from oral cavity-correlation between histopathology results and primary site

OBJECTIVES

Oral cancer is the eighth most common type of cancer worldwide and a significant contributor to the global burden caused by this disease. The principal parameters considered to influence prognosis, and thus treatment selection, are size and location of the primary tumor, as well as assessment of the presence and extent of lymph node and distant metastasis (DM). However, no known report regarding the relationship between the primary site and DM has been presented. For effective treatment selection and good prognosis, the correlation of DM with anatomic site and histopathology results of the primary malignancy is important. In the present study, we performed a systematic review of published reports in an effort to determine the relationship between the anatomic site of various types of oral cavity cancer and DM.

METHODS

A systematic review of articles published until the end of 2018 was performed using PubMed/MEDLINE.

RESULTS

A total of 150 studies were selected for this review. The percentage of all cases reported with DM was 6.3%, ranging from 0.6% to 33.1% in the individual studies. The rate of incidence of tongue occurrence was 9.3%. A frequent DM site was the lungs, with adenoid cystic carcinoma the most commonly involved histopathological factor. Malignant melanoma was most frequent (43.4%) in all histopathology findings, whereas there were no cases with an acinic cell carcinoma or cystadenocarcinoma.

CONCLUSIONS

We found that the occurrence of DM from the primary site as well as rate of incidence was dependent on histopathological factors.

High CD3+ lymphocytes, low CD66b+ neutrophils, and scarce tumor budding in the invasive front of lip squamous cell carcinomas

OBJECTIVE

This study aimed to evaluate tumor budding (TB) and quantify the neutrophilic and lymphocytic infiltration in the invasive front of lip squamous cell carcinomas. In addition, the associations between these features and the histopathological grading in the invasive front were analyzed.

DESIGN

A total of 43 lip squamous cell carcinoma surgical specimens were included and classified in accordance with a histological invasive front grading system. Immunohistochemistry was performed for CD66b and CD3 for the evaluation of neutrophils and T lymphocytes, respectively, in the invasive front of the tumors. Tumor budding was evidenced by AE1/AE3 staining.

RESULTS

Thirty-six (83.7%) of the tumors were well-differentiated tumors. Eleven (25.6%) of the cases exhibited high-intensity tumor budding. There were low neutrophil and high T lymphocyte infiltrations in the invasive front, leading to a low neutrophil/T lymphocyte ratio in the same region. Moreover, we found an association between tumor budding and the pattern of invasion, and between the CD3⁺ cell count and the inflammatory infiltrate (p < 0.05).

CONCLUSIONS

The low neutrophil and high T lymphocyte infiltration in the invasive front, and the few high-intensity tumor budding cases are in accordance with the histopathological features of well-differentiated lip tumors. If these characteristics remain in lip squamous cell carcinomas with more aggressive histopathological features, it deserves to be investigated.

Reconstruction of the Oral Commissure With the Zisser Flap

The aim of this study was to investigate the role of the Zisser flap in the reconstruction of defects of the oral commissure. We describe our personal experience with this method and present some interesting aspects from the relevant literature. We retrospectively evaluated the records, from the period between 2003 and 2017, of all patients with defects of the oral commissure after resection of malignant tumors, traumas, or burns and reconstruction by means of the Zisser flap. We looked for information on the origin of the commissural defect, method of vermillion reconstruction using the lingual or buccal mucosa, functional result, esthetic outcome, and postoperative complications. The functional result of the reconstruction of the oral commissure was assessed regarding postoperative subjective speech integrity, preservation of competence of the oral sphincter, and lip sensation. The esthetic outcome was evaluated regarding limitations in facial expression and scar formation. The study included 13 patients. The follow-up period in the oncologic cases was 63.2 months (range, 10 to 140 months). No tumor recurrences were detected. Vermillion reconstruction was achieved by means of a buccal mucosal flap in 11 cases and a lingual mucosal flap in 2. All patients achieved normal oral competence and mouth opening except for 1 case, in which secondary commissuroplasty with restoration of sphincter function was needed. No cases of blunting or microstomia were detected. Reconstruction of the oral commissure with the Zisser flap is associated with an outstanding functional outcome that is cosmetically very acceptable.

Lower lip squamous cell carcinoma: A Vietnamese case report of surgical treatment with reconstruction by local flap

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Many risk factors including age, sex, chronic exposure to solar radiation, tobacco, alcohol consumption, viral factors autoimmune diseases and using immunosuppressant drugs are associated with developing lip cancer.

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Treatment with tumor excision, lymph node dissection and reconstruction by local flap is primary treatment for patients with lower lip cancer.

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Bilateral V-Y advancement flap can be utilized in the reconstruction of lip cancer in case of large defect, as well as guarantee safety and adequate cosmetic and function for low-income patients.

Introduction

Squamous cell carcinoma (SCC) of lower lip comprises over 25% of oral cancer. Surgical treatment plan for SCC patients includes tumor excision, lymph node dissection and reconstruction.

Case presentation

A 68-year-old patient was admitted with 1-year history of tumor in his lower lip. Examination revealed a large lower lip tumor with expansion to the upper lip and a 2 cm submental lymph node. Biopsy result of the tumor was SCC and fine needle aspiration result of the lymph node was metastasis SCC. He underwent a complete removal of the lower lip and 1/3 external of the upper lip plus dissection of bilateral cervical lymph node plus reconstruction with local flap. After a 4-hour operation and 14-day hospitalization, patient recovered with flap in excellent condition and without any complications.

Conclusion

Treatment with tumor excision, lymph node dissection and reconstruction by local flap is primary treatment for patients with lower lip cancer. Choice of reconstruction method depends on various factors, whereas V-Y advancement flap presents dominant advantage in lower lip cancer treatment.

Diseases of the lips

Heath care providers should be comfortable with normal as well as pathologic findings in the lips, because the lips are highly visible and may display clinical manifestations of local, as well as systemic inflammatory, allergic, irritant, and neoplastic alterations. Fortunately, the lips are easily accessible. The evaluation should include a careful history and physical examination, including visual inspection, as well as palpation of the lips and an examination of associated cervical, submandibular, and submental nodes. Pathologic and microscopic studies, as well as a review of medications, allergies, and habits, may further highlight possible etiologies. Many lip conditions, including premalignant changes, are relatively easy to treat, when the abnormalities are detected early; however, advanced disease and malignancies are challenging for both the patient and clinician. Treatment should be focused on eliminating potential irritants or allergens and treatment of the primary dermatosis. In this paper we review physiologic variants as well as pathologic conditions of the lips.

Stage is a prognostic factor for surgically treated patients with early-stage lip cancer for whom a ‘wait and see’ policy in terms of neck status has been implemented

Objectives:

To determine the locoregional control and survival rates (in terms of risk factors) of patients who underwent surgical resection of early-stage lip cancer and for whom a ‘wait and see’ policy in terms of neck status had been implemented.

Methods:

The sociodemographic data, tumour stage, tumour characteristics and histopathological features of 41 patients with early-stage lip cancer were evaluated. Factors predictive of survival and locoregional recurrence were analysed. The five-year overall survival and disease-free survival rates were determined, and the prognostic risk factors were compared.

Results:

The mean follow-up period was 60.5 months (range, 4–92 months). Age, sex, tumour stage, tumour thickness and volume, and perineural involvement were not predictive of locoregional recurrence or survival. Pathological tumour stage (T1vsT2) was a prognostic factor for both five-year overall survival (87.3vs65.6 per cent,p= 0.042) and disease-free survival (88.6vs65.6 per cent,p= 0.037).

Conclusion:

Tumour stage was clearly a major factor affecting the prognosis of surgically treated patients with early-stage lip cancer for whom a ‘wait and see’ policy in terms of neck status had been implemented.

The role of suprahyoid neck dissection in the treatment of squamous cell carcinoma of the lower lip: 20 years' experience at a Tertiary Center

PURPOSE

To evaluate the efficacy of L1-2ND in the management of the lower lip squamous cell carcinoma and to achieve the highest cure rates with adequate neck dissection.

METHODS

A retrospective review was completed on patients treated between 1994 and 2014. The case histories of 184 patients who were treated with surgical excision of the primary tumor along with neck dissection, and 24 patients who were treated only with surgical excision without neck dissection at another center, were studied. All patients were followed up for evidence of recurrent disease.

RESULTS

In 208 patients (193 men, 15 women) with a mean age of 51 years, 12 were N1, 3 were N2, and 169 were N0; 24 patients had undergone operation at another center without neck dissection. Lymph node metastases were present in 34 patients (18.4%) with dissected necks and occult metastases were detected in 19 patients with clinically N0 necks (11.2%). The median follow-up of each patient was 28 months. Only 1 patient developed neck recurrence, and there was no local recurrence. The overall survival rate (OAS) of patients with clinical N0 disease who underwent neck dissection was 94.7%; the OAS of the patients who were not treated with neck dissection was 29.1%.

CONCLUSION

Level 1-2 neck dissection (L1-2ND) is the treatment of choice for controlling neck disease in patients with lower lip carcinoma, and serves as a staging procedure to detect patients who require adjuvant therapy.

Reconstructive surgery in advanced perioral non-melanoma skin cancer. Results in elderly patients

BACKGROUND

Nonmelanoma skin cancer (NMSC) of the perioral region is not uncommon. Basal cell carcinoma is predominant in the upper lip area and squamous cell carcinoma in the lower lip area. While smaller lesions can be treated by excision followed by primary closure larger defects after tumor surgery can be challenging.

OBJECTIVES

Analysis of outcome after complete surgical excision with micrographical control of excision margins (delayed Mohs surgery) of large NMSC's of the perioral region (lips and chin).

PATIENTS AND METHODS

This is a retrospective, single-center analysis of patients with defects after delayed Mohs surgery of ≥ 3 cm of the perioral region. The study included a total of 25 patients (4 women and 21 men) with a mean age of 83.7 years. Twenty patients were diagnosed with squamous cell carcinoma and five had basal cell carcinoma. The lower lip was affected in 19 patients, the upper lip in 4 patients and the chin in 2 patients. Tumor stage was either T1N0M0 or T2N0M0. The most common procedure for lower lip defect closure was staircase or modified staircase technique. Cheek advancement flaps were used for upper lip defect closure. Inferiorly based nasolabial rotational flap, cheek rotational flap and modified Webster flap were also employed. In one patient Webster flap and unilateral staircase technique were combined.

RESULTS

In all patients the tumor was removed completely with preservation of function and aesthetics. No local recurrence was observed after a median follow-up of 4.9 years.

CONCLUSION

Perioral reconstruction after removal of large NMSC is a complex issue. The age group of over 70 years, frequently with comorbidities, requires a robust surgical technique with short operation times and tailored approaches for defect closure.