Lip cancer

Lip cancer accounts for about 3% of all malignant tumors (8-9 place). Cancer of the upper lip is much less common than cancer of the lower lip - it is found in 2-5% of cases of lip cancer, but it is characterized by a more aggressive course.

Men suffer from this type of cancer more often than women (more than 76% of cases). The peak incidence is in age over 70 years. Lip cancer is most common in rural areas.

Causes of lip cancer include:

• exposure to smoking
• frequent exposure to high temperature
• frequent mechanical injuries
• smoking (especially pipes), chewing tobacco
• chemical carcinogens: arsenic , mercury , bismuth compounds, anthracite , liquid resins, petroleum distillates
• alcohol
• frequent use of nasvai
• viral infections
• chronic inflammatory processes

Obligatory precancerous conditions include focal dyskeratosis and papilloma , which manifest as hyperkeratosis and leukoplakia . Erythroplasty , diffuse dyskeratosis, keratoacanthoma have a significant propensity for malignant degeneration.

Optional precancerous conditions are cheilitis , chronic ulcers, lip cracks and erosive flat lichen forms.

Cancer of the lip has a squamous keratinizing structure (95%) or non-squaring cancer. Squamous keratinized cancer manifests itself by slow exophytic growth, small infiltration of surrounding tissues, rare metastasis and relatively late ulceration. Squamous non-squamous cancer is characterized by rapid endophytic growth, early ulceration and metastasis, and marked infiltration of surrounding tissues.

Metastases lip cancer mainly lymphogenous in regional lymph nodes - submental, submandibular, in the jugular vein area. At stage I, metastases are observed in 5-8% of cases, in II - 15-20%, in III - 35%, with IV - in 70% of cases.

Hematogenous metastasis is observed much less frequently - in 2% of cases, usually - in the lungs .

Clinically, lip cancer is divided into 3 forms:

1. Papillary
2. Warty (due to diffuse productive dyskeratosis)
3. Ulcerative and ulcerative-infiltrative (developing from erythroplakia) - the most malignant form

According to the TNM-classification of the tumor determine:

Primary tumor:

• T _x - not enough data to assess the primary tumor.
• T ₀ - the primary tumor is not defined.
• T _is a non-invasive cancer (carcinoma in situ).
• T _l - a tumor up to 2 cm in the largest dimension.
• T ₂ - tumor up to 4 cm in the largest dimension.
• T C - a tumor more than 4 cm in the largest dimension.
• T _4a - the tumor invades the cortical plate of the lower jaw, deep (external) muscles of the tongue, maxillary sinus,

skin

• T _4b - the tumor grows into the pterygopulmonary fossa, the side wall of the pharynx or the base of the skull, or affects the internal carotid artery .

N - regional lymph nodes.

• N _x - not enough data to assess the state of regional lymph nodes.
• N ₀ - no signs of metastatic lesion of regional lymph nodes.
• N ₁ - metastases in one lymph node on the affected side up to 3 cm or less in the largest dimension.
• N ₂ - metastases in one or several lymph nodes on the side of the lesion up to 6 cm in the largest dimension or meta

lymphatic stasis of the neck on both sides, or from the opposite side up to 6 cm in the largest dimension.

• N _2a - metastases in one lymph node on the affected side up to 6 cm in the largest dimension.
• N _2b - metastases in several lymph nodes on the affected side up to 6 cm in the largest dimension.
• N _2c - lymph node metastases on both sides or on the opposite side up to 6 cm in the largest dimension.
• N ₃ - metastasis in the lymph nodes more than 6 cm in the largest dimension.

M - distant metastases.

• M _x - not enough data to determine distant metastases.
• M _o - no signs of distant metastases.
• M _l - there are distant metastases.

Grouping in stages.

• Stage 0 - T _is .
• Stage I - T ₁ N ₀ M ₀ .
• Stage II -T ₂ N ₀ M ₀ .
• Stage III - T _1-2 N ₁ M ₀ , T ₃ N _0-1 M ₀ .
• Stage IVA - T _I-3 N ₂ M _O.
• Stage IVb T4b any NM0, any T with N ₃ M ₀ .
• Stage IVc any T, any N with M _l .

Lip cancer always occurs on the background of another lip disease and never from healthy tissue. Sometimes cancer arises from leukoplakia or fissure, sometimes from papilloma or warty dyskeratosis.

Initially, a small seal appears protruding above the surface of the lip. In the center of the neoplasm, erosion or an ulcer occurs with a granular surface and a roller-like edge. Education has fuzzy boundaries and gradually increases in size. The tumor is covered with a film, the removal of which is painful. Under the film visible tuberous growths.

The tumor gradually grows, destroying the surrounding tissue and significantly infiltrating. A secondary infection joins the neoplasm. Infiltration spreads to the cheek, chin, lower jaw. The regional lymph nodes are initially dense, painless and mobile. As the metastases grow, the lymph nodes grow in size, sprout adjacent tissues and lose mobility. In advanced stages, metastases turn into large disintegrating infiltrates.

Nutrition is gradually disrupted, tissue breakdown joins, and cachexia develops.

When diagnosing conduct:

• examination and palpation of the lips, cheeks and gums , the mucous membrane of the alveolar processes of the jaws
• examination and palpation of the submandibular region and neck on both sides
• chest x-ray
• Ultrasound of the lip, neck, abdominal organs (if indicated)
• x-ray of the lower jaw, orthopantomography (by indications)
• cytological smears (for ulceration) or biopsy of the affected area
• biopsy of the lymph nodes of the neck with their increase

In addition, it is necessary to conduct additional differential diagnostics to exclude:

• parakeratosis and acanthosis
• sexually transmitted diseases (hard chancre)
• leukoplakia
• limited hyperkeratosis;
• cheilitis manganotti
• papilloma
• keratoacanthu
• cutaneous horn
• erosive and ulcerative form of systemic lupus erythematosus and lichen planus

Lip cancer treatment is carried out in a combined way and provides for the cure of both the primary focus and the zones of primary metastasis.

• Stage I: surgical and radiation method of treatment. In case of excision of the pathological focus, additional operations are performed by Vanach or Krajl. This is done to prevent the spread of metastases. Lip excision of 1.5-2 cm on both sides of the infiltrate is carried out, or (more often) - short-focus radiotherapy (60 Gy) or interstitial therapy. Lymph nodes take on dynamic observation
• Stage II - radiotherapy of the primary focus, after 2-3 weeks - upper fascial-ciliary excision of the cervical tissue
• Stage III - the primary focus is cured by the radiation method on gamma-therapeutic installations. The remains of the tumor implant needles with a radioactive drug. The residual tumor is removed by resection of the lip. After complete regression, tumors make a simultaneous bilateral fascial-shear excision. In the presence of regional metastases, the operation is preceded by radiation therapy in SOD 30-40 Gy simultaneously with radiation therapy of the primary tumor. This is achieved by reducing the size of the lymph nodes. While limiting lymph node dislocation, Krajl surgery is performed.
• Stage IV - complex treatment: neoadjuvant polychemotherapy, preoperative remote radiation or brachytherapy, widespread excision of the tumor. At the same time, regional zones of the neck and submandibular region are irradiated at a dose of 40–50 Gy on both sides.
• IVC stage - palliative chemoradiation therapy

Treatment of submandibular metastases is performed by the Vanach operation (removal of the submental and submandibular lymph nodes with the submaxillary salivary glands on both sides), with numerous, partially mobile or large metastases to the deep jugular or supraclavicular lymph nodes, the Krajl operation is performed (removal of the internal jugular vein, sternocleum - mastoid muscle , accessory nerve ; the operation is performed on one side or alternately on both sides).

Chemotherapy due to the low efficacy of widespread use is not found. It is used in the treatment of distant metastases. Chemotherapy is carried out with platinum, fluorouracil , methotrexate , bleomycin .

Photodynamic therapy - laser effects on the tumor with the preliminary introduction of a photosensitizing drug into it. Used with limited superficial lesions.

In some cases, in the I — III stages, a cryogenic method is used, in which the use of surgical, radiation and chemotherapeutic treatment can be avoided. It is also used in the treatment of tumor recurrences.

The prognosis of lower lip cancer depends on the stage of the disease, the age of the patient, the degree of differentiation of the cancer cells, and the sensitivity of the tumor to radiation. A complete cure for cancer of the I — II stage of the lip reaches 97-100%, at stage III and limited relapses - up to 67-80%. At stage IV and common relapses, the prognosis is noticeably worse - 55%.

• Fedyaev I. M., Bayrikov I. M., Belova L. P., Shuvalova T. V. "Malignant tumors of the maxillofacial region". - M .: Medical book, N. Novgorod: Publishing house of GPS, 2000. - 160 p.
• Lip cancer Clinical guidelines. Association of Oncologists of Russia (2017).
• Brachytherapy for lip cancer. Per. from English ND Firsova (2017).
• S. Gantsev. Oncology: A Textbook for Medical Students. M .: Medical Information Agency LLC, 2006. - 488 p.
• "Oncology", ed. Chissov V.I., Daryalova S.L. - Moscow: GEOTAR-Media, 2007. - 560 p.