Carcinoma of the lower Lip

Head and Neck Surgery

Carcinoma of the lower Lip Edward A. Luce, M.D. *

This article discusses cancer of the lip and, specifically, epidermoid carcinoma of the lower lip. Malignancies of the upper lip are almost always basal cell carcinoma, although epidermoid carcinoma can occur as well (and tumors of the labial minor salivary glands). In behavior and occurrence, epidermoid carcinoma of the lip lies somewhere between oropharyngeal and skin cancer of squamous cell histology. Mortality figures for carcinoma of the lip have steadily decreased over the past 30 to 40 years,9 and at p,resent the overall survival rate is 85 to 90 per cent. In contrast to oropharyngeal cancer, regional spread evident either at the time of initial presentation or as a delayed recurrence is distinctly uncommon in lip cancer. So, although frequent in occurrence and readily cured, carcinoma of the lip has certain diagnostic and therapeutic pitfalls that should be avoided. This article describes approaches to resection, management of the regional nodes, and formulation of a reconstructive plan. ANATOMY The main function of the lips is oral competence. Although the lips playa role in deglutition and articulation and even are a symbol of beauty and appeal,28 one must remember that the major criterion for successful lip reconstruction is oral competence. That competence is provided by the sphincter muscles, the orbicularis oris, and a supporting cast of paired elevators and depressors. The unreplaced loss of a significant segment of orbicularis precludes competence. 4 The skin of the lips joins the red portion, or vermilion, in a transitional zone, the mucocutaneous ridge, which is an important landmark. In most individuals, the vermilion of the upper lip is thinner and slightly more recessed than the pout-like eversion of the lower lip. Transverse length is *Chief, Division of Plastic Surgery, University of Kentucky Medical Center, Lexington, Kentucky

Surgical Clinics of North America-Vol. 66, No.1, February 1986

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also slightly longer in the upper lip, about 8.0 cm., compared with that of the lower lip, 7.5 cm. Motor innervation is from the buccal and mandibular branches of the facial nerve. Sensation is supplied by the infraorbital (upper) and mental (lower) nerves, both branches of the trigeminal nerve. The mental nerve and its point of exit from the mandible, the mental foramen, are important structures in the spread of lip cancer. Growth of the tumor along perineural lymphatics into the mental foramen permits extension along the inferior alveolar canal proximally and posteriorly and eventually to the base of the skull. The blood supply to the lips is principally by the facial artery that in turn gives rise to the superior and inferior labial arteries. These paired vessels create a circumoral vascular arcade located at the level of the mucocutaneous ridge on the mucosal aspect. 5 They provide the basis for the classic lip-switch procedures as well as the more contemporary myocutaneous methods of reconstruction, but their origin from the facial vessels must be considered when performing a concomitant nodal dissection, an operation that usually sacrifices the facial vessels. Lymphatic drainage is through three to five lymph channels to the submental and submandibular lymph node groups. The median one third of each half of the lower lip drains principally into the submental group, and contralateral drainage is relatively common. The lateral two thirds drain into the submandibular group, and drainage to the contralateral side is uncommon. 10

DIAGNOSIS The pathologic types divide along anatomic lines-basal cell on the upper lip and squamous cell on the lower lip. Actinic exposure appears to be an etiologic factor in squamous cell carcinoma of the lower lip, as evident by such risk factors as occupation and geographic location. I7 The differential diagnosis will include some precursors of squamous cell carcinoma as the chronic actinic changes of hyperkeratosis and leukoplakia. Inflammatory ulcers of cheilitis and stomatitis will heal with symptomatic treatment in 10 to 14 days. Persistent lesions should be biopsied, although the final pathologic diagnosis in smaller lesions may be irrelevant since surgical therapy may be indicated for chronic actinic damage. Three gross types of lesions have been described: verrucous, which is quite rare in occurrence, exophytic, and ulcerative. The ulcerative type appears to have the greatest propensity for infiltration into deeper structures. Histologically, 70 per cent are well differentiated, grades 1 and 2, and only 2 per cent are poorly differentiated, or grades 3 and 4. 13 Staging of the primary lesion by the TNM classification is by size: less than 2 cm (Tl), 2 to 4 cm (T2), and greater than 4 cm (T3).

TREATMENT The treatment of carcinoma of the lower lip is primarily surgicap2 although results for surgery and radiotherapy for smaller lesions are simi-

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lar. 3, 16 Some clinical situations present clear contraindications to the use of radiotherapy,15 These include recurrence following radiotherapy as the primary treatment modality, large lesions (T3) with possible mental nerve or mandibular involvement, and young patients, When extensive precancerous changes afflict the remaining lip, the use of radiotherapy must be seriously questioned. Resection is accomplished most efficaciously by "Y" excision and primary closure. Primary lesions measuring 1.5 cm or less can be excised with a margin of 5 to 7 mm or a total resection of approximately one third of the lower lip and the edges coapted without undue tension. My preferred anesthetic approach is the use of ample preoperative medication, bilateral mental nerve blocks, and some local infiltration. General anesthesia is rarely necessary, Several technical points are worthy of attention. After the mental nerve blocks, the mucocutaneous ridge at each edge of the proposed resection is tattooed with methylene blue to ensure accurate alignment at the time of repair, If the excision or tip of the "Y" will cross the mental crease, a more acceptable scar is obtained by modifying the "Y" into a "W," permitting transverse closure of the inferior portion at the mental crease. Careful attention should be directed to repair of the orbicularis muscle for reconstitution of the oral sphincter. Patients with carcinoma commonly have actinic and degenerative changes of the remaining lip. The frequency of leukoplakia in one series was 60 to 70 per cent.7 In another study of serial sectioning of lip shaves that was performed at the time of excision of the primary carcinoma, the incidence of carcinoma in situ was 12 per cent-a figure that closely parallels the local recurrence rate in small carcinomas of the lip.26 For these reasons, we perform a lip shave in conjunction with a "Y" excision in any patient with the associated clinical findings of actinic changes of the vermilion (Fig. 1). In practice, most patients qualify. We concur with Paletta26 in that our recurrence rate has been reduced considerably since the adoption of this combined procedure. The frequency of local recurrence is directly proportional to the size of the primary lesion, 6, 7 Lesions less than 2 cm recur in 12 to 15 per cent of cases. In carcinomas greater than 4 cm that have involved most of the lip, recurrence is almost a foregone conclusion (55 to 70 per cent), Fortunately, the number of large neglected lesions appears to be a much smaller proportion of the cases of lip cancer than in the past. 13, 22

MANAGEMENT OF REGIONAL LYMPH NODES The management of the regional lymph nodes in carcinoma of the lower lip remains a subject of controversy.21 In contrast to squamous cell malignancies of the buccal and oral cavities, carcinoma of the lower lip has a much lower predilection for regional spread. Yet most of the mortality is the result of uncontrolled disease in the neck. Routine or prophylactic neck dissections for carcinoma of the lip fell into disfavor because of the relatively low yield of nodal metastases, 11, 22 In follow-up of a large series of patients who have had treatment directed toward the primary lesion only, approximately 8 to 10 per cent will subsequently develop lymph node metasta-

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Figure 1. A, A superficially invasive squamous cell carcinoma with actinic changes throughout the remaining lip. 8, Vermilionectomy in conjunction with wedge excision of carcinoma. C, A satisfactory postoperative aesthetic result.

ses. 20, 24 The appropriate treatment for manifest lymph node metastases is surgical. A standard radical neck dissection, a procedure that will yield about a 50 per cent 5-year survival rate, is performed. 2, 24 Although delayed metastases in lower lip carcinoma usually occur within 2 years of the initial primary lesion, we have been impressed by the longer hiatus between initial therapy and manifest regional metastases in lip lesions as compared with the experience with primary lesions of the oral cavities and oropharynx. A small percentage of patients (7 to 8 per cent) will have· regional nodes, mental and/or submandibular, at initial presentation. A significant number of these patients (35 to 50 per cent) will have nodal enlargement on the basis of hyperplastic or inflammatory changes only. 12, 18, 20 This experience also is in contrast to the reliability of the clinical examination of the neck in patients with a primary lesion of the oral cavity or oropharynx, in whom palpable nodes on initial presentation are subsequently determined to be pathologically positive in 90 per cent of the cases. The other clinical problem is the delineation of the small percentage of patients who most likely harbor occult microscopic nodal metastases and would merit treatment directed toward the regional nodes concomitant with management of the primary lesion. Adequately defined significant risk factors are size,6, 7, 30 histologic grading,!' 25 and local recurrence. 8 Of these three risk factors, size is probably the most useful clinically. The risk of nodal metastases in poorly differentiated lesions is probably 50 to 60 per cent versus 5 to 6 per cent in well-differentiated carcinoma, I, 25 but only 2 per cent of all lip cancers are poorly differentiated. In combined recent studies, the incidence of lymph node metastases is 4 per cent in Tl lesions (less than 2 em), 35 per cent in T2 lesions (2 to 4 cm), and 63 per cent in

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T3 lesions (greater than 4 cm). In our experience, T2 lesions can be further subdivided into those 2 to 3 cm and 3 to 4 cm since the risk appears considerably greater in the latter group. In summary, our indications for operative intervention in the neck are palpable nodes on initial presentation, a primary lesion greater than 3 cm, a poorly differentiated or spindle-cell carcinoma, and locally recurrent disease. The initial procedure of choice is a bilateral suprahyoid dissection. If one or more nodes are positive for metastatic disease on final pathologic examination, a complete neck dissection is performed subsequently-that is, conversion to a standard radical neck dissection on the side of the positive node(s). Because of the low morbidity and minimal cosmetic and functional deficit, bilateral suprahyoid neck dissection is a useful procedure for the patient with initially palpable nodes that may only be inflammatory in nature. Our procedure for the patient who develops palpable lymph nodes in follow-up subsequent to treatment of the primary lesion is a standard radical neck dissection. We have limited the use of radiotherapy to the postoperative period and reserved that treatment modality for those patients at risk for failure of surgical control. Extracapsular spread of the tumor on pathologic examination of the radical neck dissection as in other head and neck primary lesions indicates a significant risk for locoregional recurrence. The treatment for massive lesions (T3) and/or mandibular invasion is almost universally followed by failure and recurrence in our and other authors' experience. This group of patients should also receive postoperative radiotherapy as soon as wound healing permits.

RECONSTRUCTION The successful reconstruction of the lower lip must meet certain criteria. The reconstructed lip should be sensate, retain sphincter or muscle function, oppose vermilion to vermilion of the upper lip in a watertight continent seal, allow sufficient opening for food, dentures, etc., and be of acceptable aesthetic appearance. On occasion, particularly in subtotal resections, not all these criteria can be satisfied. One should, however, avoid the postoperative result of the tight, inverted lower lip that, when the mouth closes, dissappears beneath the curtain of the upper lip. These patients in profile have an appearance more like that of a guppy than of a human mouth. Each case requires consideration and planning. With reasonable certainty, the magnitude of the defect can be predicted preoperatively and the appropriate method of reconstruction selected. As previously described, defects of up to one third of the lip can be closed primarily. Larger defects require tissue transfer, and the preferred donor site is adjacent or upper lip.

Defects of 30 to 65 Per Cent If properly planned and executed, most reconstructive techniques utilizing lip tissue will yield an excellent result in moderate-sized defects. Transfer of upper lip tissue (lip-switch) pedicled on the labial artery can be

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accomplished by the Abbe technique, preserving the oral commissure, or rotated
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Figure 2. A, Sixty-five per cent resection of the lip with incisions made for Karapandzic reconstruction. B, Lip segments that developed after identification and dissection of neurovascular supply. C, Postoperative result with some microstomia. D, Excellent orbicularis function.

time and use, and return with a lip-switch procedure to enlarge the oral opening. Total Resection of the Lip Defects larger than 80 to 85 per cent of the lower lip require essentially total resection and the lip cannot be. reconstructed successfully by the methods described previously. If the lesion is large and infiltrative, that is T3, with invasion of chin, I have reconstructed the lip with a full-thickness (including mucosa), inferiorly based nasolabial flap29 or bilateral flaps as needed (Fig. 3). A massive resection of the lip, chin, and mandible must be reconstructed with distant flaps27 and requires reconstruction of the lower lip as a separate unit (Fig. 4). The transfer of composite flaps of skin and bone revascularized by microvascular techniques achieves the most consistent

c Figure 3. A, Large ulcerating invasive carcinoma. B, Full-thickness nasolabial Haps developed after 80 per cent resection of the lip. C, Postoperative result.

Figure 4. A, Large undifferentiated carcinoma with invasion of chin soft tissue and inandible. B, Result after resection and reconstruction with pectoralis osteomyocutaneous Hap for chin reconstruction and bilateral nasolabial Haps for reconstruction of the lip.

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results and allows for institution of radiotherapy in the early postoperative period.

REFERENCES 1. Ashley. F. L.: Carcinoma of the lip: A comparison of five-year results after irradiation and surgical therapy. Am. J. Surg., 110:549, 1965. 2. Backus, L. H., and DeFelice, C. A.: Five year end results in epidermoid carcinoma of the lip with indications for neck dissections. Plast. Reconstr. Surg., 17:58, 1956. 3. Bailey, B. J.: Management of carcinoma of the lower lip. Laryngoscope, 87:250, 1977. 4. Baker, S. R., and Krause, C. J.: Cancer of the lip. In Suen, J. Y., and Myers, E. N. (eds.): Cancer of the Head and Neck. New York, Churchill Livingstone, 1981, p. 280. 5. Brescia, M. J.: Anatomy of the lip and palate. In Grabb, W. C., Rosenstein, S. W., and Bzoch, K. R.: Cleft Lip and Palate. Boston, Little, Brown, 1971, p. 10. 6. Brown, R. G., Poole, N. D., Calamel, P. M., et al.: Advanced and recurrent squamous carcinoma of the lower lip. Am. J. Surg., 132:492, 1976. 7. Creely, J. J., and Peterson, H. D.: Carcinoma of the Lip. South. Med. J., 67:779, 1974. 8. Dickie, W. R., Colville, J., and Graham, W. J.: Recurrent carcinoma of the lip. Oral Surg., 24:449, 1967. 9. Editor: Cancer statistics. CA, 25:7, 1975. 10. Feind, C. R.: The head and neck. In Haagensen, C. D., Feind, C. R., Herter, F. P., et al.: The Lymphatics in Cancer. Philadelphia, W. B. Saunders Company, 1972, p. 95. 11. Figi, F. A.: Epithelioma of the lower lip. Surg. Gynecol. Obstet., 59:810,1934. 12. Heller, K., and Shah J.: Carcinoma of the lip. Am. J. Surg., 138:600,1979. 13. Hendricks, J. L., Mendelson, B. C., and Woods, J. E.: Carcinoma of the lower lip. Surg. Clin. North Am., 57:837, 1977. 14. Jabaley, M. E., Clement, R. L., and Orcutt, T. W.: Myocutaneous flaps in lip reconstruction. Plast. Reconstr. Surg., 59:680, 1977. 15. Jesse, R. H.: Extensive cancer of the lip. Arch. Surg. 94:509, 1967. 16. Jorgensen, Elbrond, 0., and Andersen, J. P.: Carcinoma of the lip. Acta Otolaryngol., 75:312, 1973. 17. Ju, D.: On the biology of cancer of the lower lip. Plast. Reconstr. Surg., 52:151, 1973. 18. Judd, E. S., and Beahrs, O. H.: Epithelioma of the lower lip: Evaluation of dissection of cervical lymph nodes. Arch. Surg., 59:422, 1949. 19. Karapandzic, M.: Reconstruction of lip defects by local arterial flaps. Br. J. Plast. Surg., 27:93, 1974. 20. Lyall, D., and Grier, W. R.: Experiences with squamous carcinoma of the lip with special reference to the role of neck dissection. Ann. Surg., 152:1067, 1960. 21. Marshall, K. A., and Edgerton, M. T.: Indications for neck dissection in carcinoma of the lip. Am. J. Surg., 133:216, 1977. 22. Martin, H., MacComb, W. S., and Blady, J. B.: Cancer of the lip I and II. Ann. Surg., 114:226 and 341, 1941. 23. MacGregor, I. A.: Reconstruction of the lower lip. Br. J. Plast. Surg., 36:40, 1983. 24. Modlin, J.: Neck dissections in cancer of the lower lip. Surgery, 28:404, 1950. 25. Molmar, L., Ronay, P., and Tapolcsanyi, L.: Carcinoma of the lip: Analysis of material of twenty-five years. Oncology, 29:101, 1974. 26. Paletta, F. X.: Treatment of leukoplakia and carcinoma-in-situ of the lower lip. Ann. Surg., 145:74,1957. 27. Parsons, R. W.: Reconstruction of the lower face and lips. Clin. Plast. Surg., 2:551, 1975. 28. Romm, S.: On the beauty of lips. Clin. Plast. Surg., 1:571,1984. 29. Schewe, E. J.: A technique for reconstruction following extensive excision for cancer. Ann. Surg., 146:285, 1957. 30. Wurman, L. H., Adams, G. L., and Meyerhoff, W. L.: Carcinoma of the lip. Am. J. Surg., 130:470, 1975. Division of Plastic Surgery University of Kentucky Medical Center 800 Rose Street, MN 275 A Lexington, Kentucky 40536