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5 Year Experience with Lower Lip Cancer Egils Kornevs, Andrejs Skagers, Juris Tars, Andris Bigestans, Gunars Lauskis, Olafs Libermanis

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5 Year Experience with Lower Lip Cancer Egils Kornevs, Andrejs Skagers, Juris Tars, Andris Bigestans, Gunars Lauskis, Olafs Libermanis SCIENTIFIC ARTICLES Stomatologija, Baltic Dental and Maxillofacial Journal, 7:95-8, 2005 5 year experience with lower lip cancer Egils Kornevs, Andrejs Skagers, Juris Tars, Andris Bigestans, Gunars Lauskis, Olafs Libermanis SUMMARY Retrospective study of 189 cases of lower lip cancer treated from 1996 - 2000 is done. There were 69% males and 31% females. Median age was 66.8 years. 84.4% of patients were with tumors stage I - II. Surgical treatment was performed in 83.6 % of patients . In all operated cases was squamous cell carci- noma as verrucous tumor in 17.4 %, as exophytic in 46% and as ulcerative in 36.6%.There were different methods of local excision, primary reconstruction and neck dissection depending from stage. In the patient group with clinically negative neck at the first attendance (170 patients) delayed cervical metastases developed in 6 patients (3.5%).Recurrence at the primary site developed in 11.3 % of patients and was associated with large tumor size and low cancer differentiation. Survival rate at 5-year follow-up was 95% for patients with I stage, 89.7% for II stage and 37% for III and IV stage patients or mean for all group 83.7%. Diagnosis and treatment of actinic cheilitis also is discussed. Key words: lip, cancer, surgery, outcomes INTRODUCTION Cancer of the lip is relatively common among malig- esis does not seem to be limited to a single agent, but rather nancies of the head and neck region, accounting for 12% of to a complex multistep process of interactions between pu- all head and neck cancers, excluding nonmelanoma skin can- tative risk factors (2) (Fig. 2). cer and for approximately one quarter of oral cavity cancers. The epidemiology of lip cancer supports the proposal 95% occur on the lower lip. Although this form of cancer is that the lip should be considered as a distinct cancer site, generally readily curable compared with malignancies at rather than being included with other forms of intraoral can- other head and neck sites, regional metastases, local recur- cer (4). Althogh the lips play a role in deglutition and articu- rence, and even death from this disease may occasionally lation, one must remember that the major criterion for suc- occur (8, 11-13) (Fig. 1). cessful lip reconstruction is oral competence. Most commonly found in fair - complexioned, white males in their sixth decade of life. Often found in those per- MATERIAL AND METHODS sons having outdoor occupations with prolonged solar ra- diation Other associated factors that have a less certain role The retrospective study included 189 patients with in the etiology of lip carcinoma are tobacco smoking, vi- lower lip carcinoma treated in Latvian Oncological Center ruses, poor oral hygiene, alcoholism. The etiology of the from 1996 to 2000. There were 131males (69%) and 58 fe- disease is far from established. A range of environmental males (31%) with a median age of 66.8 years (range 33-89 and host factors has been identified to explain the etiopatho- years). The majority of cases were stage I and stage II genesis of squamous cell carcinoma of the lip. However, the tumours (158 patients; 84.4%). 27 patients were in stage III definitive pathogenic pathway remains unclear. Carcinogen- and IV. In 4 cases stage was unknown. Actinic exposure appears to be an etiologic factor in 1Department of Oral and maxillofacial Surgery Riga Stradins Uni- squamous cell carcinoma of the lower lip, as evident by versity, Latvia. such risk factors as occupation and geographic location. 2Department of Head and Neck Surgery Latvian Oncological center The history of the patients revealed liver disease associ- 3Latvian Center of Plastic and Reconstructive Microsurgery ated to alcohol consumption in 30.4% of cases and tobacco Egils Kornevs1 - D.D.S., Dr.hab.med.,assoc.professor, Department of used in any form in 78.6%. As regards solar exposure, 53.1% Oral and maxillofacial Surgery Riga Stradins Uni- versity, Latvia. of the men referred open-air professional activities, while Andrejs Skagers1 - M.D., Dr.hab.med.,profesor, Head of Department 90% of the women presented important solar exposure. The of Oral and Maxillofacial Surgery Riga Stradins Uni- versity, Latvia. most frequent clinical manifestations were bleeding and the Juris Tars2 - M.D., Head of Department of Head and Neck Surgery presence of leukoplakia patches; pain was reported in only Latvian Oncological center. 16% of cases. Over 40% of the patients were asymptomatic. Andris Bigestans1 - M.D.,D.D.S.,Lecturer, Department of Oral and maxillofacial Surgery Riga Stradins University, The location of the lesions of actinic cheilitis was in all cases Latvia. on the lower lip. Actinic cheilitis appeared in three forms; Gunars Lauskis1 - M.D.,D.D.S., Lecturer, Department of Oral and maxillofacial Surgery Riga Stradins University, white non-ulcerated lesions (29%), erosions or ulcers of the Latvia. lip (48%), mixed white and erosive (23%). The histopatho- Olafs Libermanis3 - Surgeon, Latvian Center of Plastic and Recon- structive Microsurgery. logic characteristics included increased thickness of keratin layer, alterations of the thickness of spinous cell layer, epi- Address correspondence to Prof. Egils Kornevs, Institute of Stoma- tology, Dzirciema str. 20, Riga, Latvia, LV-1007. thelial dysplasia, connective tissue changes, perivascular E-mail : [email protected] inflammation and basophilic changes of connective tissue. Stomatologija, Baltic Dental and Maxillofacial Journal, 2005, Vol. 7., N. 3. 95 SCIENTIFIC ARTICLES E. Kornevs et al. 31 52.0% 29 28 23 20 32.4% 15 13 14 9 7 9.8% 4.9% 1.0% 1996 1997 1998 1999 2000 I II III IV Unknown Fig. 1. Incidence of the lip cancer in Dept. Head Neck Surg Latvian Fig. 2. Distribution of lower lip cancer according to stage in Dept. Oncological Center Head Neck Surg Latvian Oncological Center In 11 cases (16.9%) the presence of squamous cell carci- these 6 patients underwent therapeutic neck dissection, fol- noma was observed. This case-series highlights varied clini- lowed by radiotherapy in 5 cases. cal presentation of actinic cheilitis among whom a high pro- The selection of the most appropriate procedure for portion developed squamous cell carcinoma. the removal of lip carcinoma obviously depends on the Vermilionectomy is the recommended treatment for ac- clinical assessment. 4 patients refused from offered treat- tinic cheilitis. Operation usually performed on the lower lip ment. Any operation for lip cancer should have as the in which a part or all of the vermilion surface of the lip is primary goal complete, en bloc removal of the tumor with excised. This procedure should be used for premalignant normal tissue margins. Important but secondary consid- lesions of the lip such as severe actinic cheilitis and leuko- erations are the preservation or restoration of lip func- plakia with atypia. tion and cosmesis. Although varied recommendations for Clinically the SCC is seen initially in a wide variety of margins may be found in the literature, in general, a mini- forms - ulcer, wart, sore, scab, blister, fissure, crusting, sun- mum of 8 to 10 mm of normal tissue margin should be burn, tumor, knot, trauma. The differential diagnosis will in- taken with the lesion in order to adequately remove the clude some precursors of squamous cell carcinoma as the tumor (1, 3, 6). A 3 mm margin with excision of early SCCLL chronic actinic changes of hyperceratosis, verruca vulgaris, seems to be appropriate, if the margins are controlled by keratoacanthoma and leukoplakia. Three gross types of SCC systematic use of frozen-section analysis (3). Primary le- have been observed: verrucous (33 patients; 17.4%), exo- sions measuring 1.5 cm or less can be excised with a mar- phytic (87 patients; 46%) and ulcerative. (69 patients; 36,6%). gin of 5 to 7 mm or a total resection of approximately one In addition to squamous cell carcinoma, other histologic third of the lower lip and the edges coapted without un- varieties arising from the mucosa of the lip are: basal cell due tension (5). Resection is accomplished most effica- carcinoma, melanoma and salivary gland tumors. The latter ciously by "V" excision and primary closure. If the exci- three are rare. sion or tip of the "V" will cross the mental crease, a more The usual location on the lower lip is halfway between acceptable scar is obtained by modfying the "V" into a the commisure and the midline. The lesions at the commisure "W", permitting transverse closure of the inferior por- appear to have a poorer prognosis than do the other lower tion at the mental crease. Both the V and W forms of full lip lesions. The vermilion border of the lower lip is a fre- - thickness excisions can be satisfactorily closed prima- quent location of squamous cell carcinoma (SCC), but it is rily if the resultant defect is no more than 30% to 40% of rarely mentioned of basal cell carcinomas (BCCs). In 5 cases, the length of the lip. Careful attention should be directed the neoplasm involved either mainly or exclusively the ver- to repair of the orbicularis muscle for reconstruction of milion border of either the lower (2 cases) or the upper (3 the oral sphincter. As mentioned before, Vermilionectomy case) lip (Fig. 3). was performed to 11 patients. Reconstruction of vermil- The treatment of carcinoma of the lower lip is primarily ionectomy defects was usually done using a mucosal surgical although results for surgery and radiotherapy for advancement flap. "V" or "W" excision were performed smaller lesions are similar. 59 patients with squamous cell to 25 patients. Defects of 30 to 65%. Transfer of upper lip carcinoma of the lower lip were treated by irradiation. There tissue (lip - switch) pedicled on the labial artery can be were 24 T1, 26 T2, 6 T3 and 3 T4 with 56 N0, 2 N1 and 1 N2 accomplished by the Abbe technique (1889), preserving patients.
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