|Year : 2021 | Volume
| Issue : 2 | Page : 61-65
Surgical management of carcinoma of buccal mucosa abutting mandible and involving skin of the face: A case report
Gyanendra S Mittal, Tripta Bhagat, Shalabh Gupta, Sagar D Sharma, Nithin R Pillai
Department of Surgery, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India
|Date of Web Publication||6-Dec-2021|
Gyanendra S Mittal
Department of Surgery, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Squamous cell carcinoma (SCC) of the oral cavity is the most common site of head-and-neck carcinoma in India. It grows in the vicinity and penetrates through adjacent anatomical structures; surgical resection of the tumor becomes more challenging in the head-and-neck region. As important anatomical structures are closely packed and to resect the tumor with safe margins being an issue, thus raising specific considerations for reconstruction relative to the extent of resection. The present case describes the management of a 64-year-old man with SCC of the left buccal mucosa, invaded into the skin of the cheek. It was managed surgically, with resection and flap reconstruction in the same sitting done in Santosh Medical College and Hospital, Ghaziabad.
Keywords: Carcinoma buccal mucosa, Commando operation, pectoralis major myocutaneous flap
|How to cite this article:|
Mittal GS, Bhagat T, Gupta S, Sharma SD, Pillai NR. Surgical management of carcinoma of buccal mucosa abutting mandible and involving skin of the face: A case report. Santosh Univ J Health Sci 2021;7:61-5
|How to cite this URL:|
Mittal GS, Bhagat T, Gupta S, Sharma SD, Pillai NR. Surgical management of carcinoma of buccal mucosa abutting mandible and involving skin of the face: A case report. Santosh Univ J Health Sci [serial online] 2021 [cited 2022 Dec 8];7:61-5. Available from: http://www.sujhs.org/text.asp?2021/7/2/61/331783
| Introduction|| |
Buccal mucosa carcinoma is uncommon and represents only about 5% of head-and-neck carcinomas in the western world, whereas in South East Asia, it is the most common site in head-and-neck carcinoma, in which up to 40% of oral cancers reported arise from it, which is in contrast with western countries where buccal mucosa is only about 2%–10% of the total reported cases of oral carcinoma. The causative factors associated with buccal mucosa carcinoma being tobacco chewing, smoking, alcohol abuse, lichen planus, dental trauma, snuff dipping, etc. Cigarette smoking triples the likelihood of developing an oral cavity cancer, while the addition of alcohol synergistically increases the likelihood by around 10–15-fold. The consumption of betel quid is socially and culturally embedded in southeastern countries and is adding on to the site predilection. For many years, it was reported that tobacco alone being the carcinogen in the betel quid whereas areca nut is also a carcinogen becoming an etiological agent in oral carcinoma.
The buccal mucosa is anatomically connected from the gingivobuccal sulcus of the maxilla and mandible to the retromolar trigone and masseter muscle. Buccal mucosa carcinoma in the region of the retromolar trigone is known to grow more rapidly and penetrate well with a higher recurrence rate than other oral squamous cell carcinomas (SCCs) at other sites. Approximately 20% of patients with carcinoma of the buccal mucosa are initially with extension beyond mucosa. Thus, these carcinomas can invade adjacent structures, such as upper and lower jaws, masticatory muscles, and cheek skin, often rendering surgical resection and reconstruction more challenging. It is particularly when the cancer invades the masticatory space; furthermore, it is even more complicated when mouth opening is limited. Lymphatic drainage is to the submandibular group of lymph nodes, however, those tumors raising from the posterior aspect of the buccal mucosa may primarily spread to Level 2 cervical lymph nodes. Earlier for the Stage 1 tumors are treated with excision of the tumor from the local site without proceeding to neck dissection whereas it has been found to have increased incidents of local recurrence so currently these tumors being treated with resection of the tumor with modified radical neck dissection (MRND). Adjuvant radiotherapy has been added if nodes are involved on histopathological examination for early-stage lesions also. Deep invasions into skin require excision of the cheek skin necessitating reconstruction of internal and external linings, usually with a fasciocutaneous pedicle or free flap. Following surgical resection of the tumor, appropriate reconstruction is necessary to minimize functional and esthetic issues.,,
| Case Report|| |
A 64-year-male came to the surgical outpatient department with complaints of nonhealing ulcer in the left buccal mucosa [Figure 1] for the past 6 months. The ulcer was painless and gradually increasing. He also complained of swelling and pain over the left cheek region for the last 1 month. He has a history of tobacco and betel quid chewing for more than 18 years. On examination, there was a diffuse swelling with skin dimpling over the left cheek [Figure 2]. Mouth opening was normal. An ulceroproliferative growth of approximately 3 cm × 4 cm was present in the left buccal mucosa involving the lower gingivobuccal sulcus and abutting the left mandible. Clinically, there was no cervical lymphadenopathy. Punch biopsy was done and showed moderately differentiated SCC of the buccal mucosa (stage: cT4aN0M0).
Further investigations including contrast-enhanced computed tomography (CECT) face and neck, routine blood investigations, and preanesthetic clearance were done, and the patient was taken for surgery after taking proper consent. He underwent left Commando operation (wide local excision of lesion including skin of cheek + segmental mandibulectomy + MRND) with double-paddle pectoralis major myocutaneous flap reconstruction under general anesthesia. Longitudinal incision was given on the left side of the face including the neck. Planes were dissected. MRND was done on the left side with resection of the left sternocleidomastoid muscle. Dissection was advanced superiorly to reach for accessing the tumor from the buccal mucosa involving the gingivobuccal sulcus. The lesion was identified and resected with adequate margins [Figure 3], including the buccinator muscle and skin along with segmental mandibulectomy. Following the surgery, reconstruction was done with regional pectoralis major myocutaneous flap in the same sitting [Figure 4]. The flap was tunneled through the supraclavicular plane and was adjoined with the resected plane in the oral cavity with the skin and mucosa. We tried to place the nipple–areolar complex of the flap at the angle of the mouth for future reconstruction (commissuroplasty) and color match [Figure 5]. Following the surgery, the patient was put on donor site and neck drains which were removed when the drained amount was minimal.
|Figure 4: Pectoralis major myocutaneous flap in setting for reconstruction|
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|Figure 5: Postoperative recipient site with nipple and areola at the angle of the mouth|
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Postoperative recovery was uneventful, started liquids on the 2nd day through Ryle's tube. The patient was discharged on the 4th postoperative day without any major postoperative complication with Ryle's tube, neck, and chest drains in situ. Later, he developed a minor wound infection which was treated with dressings and conservative management. No other surgical complication was noticed on follow-up. The flap was taken up by the recipient site, and adequate mucosalization was attained which was noted on subsequent follow-up [Figure 6].
| Discussion|| |
SCC of the oral cavity is aggressive in nature when compared to any other carcinoma in the head-and-neck region. It has been reported to be having locoregional spread and infiltration to surrounding structures involving the retromolar trigone. It is a surgical challenge in the case of all head-and-neck carcinomas due to the plane of spread as well as structures that can likely be infiltrated from inside out. Thus having a 5-year cause-specific survival rate in early-stage carcinomas compare, with those in the buccal mucosa, tongue, and mouth floor. The recurrence rate of buccal mucosa SCC is 30%–80% in those patients who are treated with only local excision of the lesion without leaving adequate margin from the lesion and not exploring the neck nodes that being commonly done previously for lower stage of disease. Therefore, acquiring an adequate negative margin of 1cm is crucial during surgical resection, let alone it can reduce the rate for recurrence of the disease. In early stages, when the cancer is limited to the buccal mucosa and submucosal region, it is proposed to include the buccinator muscle in the resection margin. If the lesion infiltrates beyond the submucosal region to the buccinator muscle, resection including the buccinator space should be considered. When positive margins are revealed in the subcutaneous tissue, wide resection including the skin should be performed. MRND has to be done even for lower stage tumors, as these have high propensity to have nodal spread to cervical lymph nodes likely being Level 1–3 mostly.
From inside out, the mucosal lesion can spread and infiltrate into the four layers starting with the mucosa, buccinator muscle, subcutaneous tissue, and skin (inside out). The branches of the facial nerve run through the subcutaneous tissue planes over the buccinator muscle. These tumors start from mucosa and easily invade the buccinator muscle. Involvement of the subcutaneous tissue is also common and seen quite early in the disease progress. It is strongly recommended to remove one layer extra to get negative margins at depth. The skin invasion is considered a sign of aggressive biology in conventional thinking. This infiltration of the skin is just because of the close proximity to the mucosa and a natural progression of the disease. If adequately resected, the outcome of these patients has been comparable to other advanced lesions.
In our case, the lesion was evaluated with all the preoperative investigations including clinical examination, imaging, and punch biopsy. Clinically, the lesion was staged T4N0M0 as per the 8th AJCC Oral Cavity Carcinoma staging and confirmed it to be SCC following punch biopsy. On CECT face and neck, no cervical lymphadenopathy was seen. The patient was planned for Commando procedure (wide local excision + segmental mandibulectomy + MRND) with pectoralis major myocutaneous (PMMC) flap reconstruction under general anesthesia. Postoperative histopathological examination revealed SCC of with pT2N0 stage.
Carcinoma of the buccal mucosa mostly presents in stages with deep infiltration to the adjacent structures. Surgical treatment is the treatment of choice for the disease; at the same time, patients are facilitated with and with postoperative radiotherapy and chemotherapy so as to reduce the rate of local recurrence and to improve the disease outcome. Complete resection of the tumor with negative margins confirmed by frozen section histopathology is the goal. Positive margins are associated with increased recurrence and decreased survival rates. Small lesions can be removed via transoral wide local excision, whereas advanced lesions usually require excision via a cheek flap. Composite resection is indicated for lesions impinging to the mandible while maxillectomy is advised in lesions that are having superior alveolar ridge invasion.
Reconstruction being an unavoidable step in the process of surgical treatment of the lesion, the goal is to prevent the contracture in the buccal mucosa that can interfere with the normal functioning of the oral cavity. The type of reconstruction also depends on the size of the lesion excised, mandible excised or not and the defect of the lesion which is left out after the resection. The defect may involve the mucosa, skin, bone, muscle. or combination of any of these. Reconstruction options include primary closure, healing by secondary intention, split-thickness skin graft, local flaps, regional flaps like PMMC flap, trapezius flap or free tissue transfer like radial forearm flap, anterolateral thigh muscle flap, fibular osteocutaneous flap.,
The concept of neoadjuvant chemotherapy being the newest of the treatment modality in which the researches are being undertaken to see its efficacy in the prognosis and the recurrence of the lesion in the postoperative phase. There are many tumor sites where the neoadjuvant chemotherapy will aid in achieving an adequate negative margin postoperatively so as to reduce the recurrence rate of the tumor like in the case of those lesions which are clinically T4a oral cavity lesions with extensive skin edema up to the zygomatic arch or those tumors reaching or involving the pterygoid muscles, etc.
| Conclusion|| |
Buccal mucosa SCC is a rapidly growing tumor and has a high recurrence rate; therefore, careful and multidisciplinary treatment approach is required even if the cancer is at an early stage. Resecting sufficient margins from the lesion will favor local control as it will reduce the rate of local recurrence. Since the site being one among having high cosmetic value, consideration of reconstruction has become an obligatory step during the surgical treatment of the lesion in most cases which furthermore shows good acceptance and outcome of the disease in total.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]