Oral Cavity (Mouth) Cancer
Oral cavity cancer can occur anywhere in the mouth including the palate (roof of the mouth), tongue, cheek, lip or the floor of the mouth. It can be isolated to the lining or grow into the top (maxilla) or bottom (mandible) jaw.
The most common cancer is a squamous cell carcinoma (the same that can grow on the skin), a cancer that starts from the cells that line the mouth. Other less common cancers may start in the small salivary glands that line the mouth. These have many different names but the most common are a mucoepidermoid carcinoma or a carcinoma ex-pleomorphic adenoma.
All cancers typically present in the same way with the most common being an ulcer or sore in the mouth that doesn’t heal. Cancers may also present with a growing lump or mass under the lining of the mouth.
Where can cancers in the mouth begin/be found?
Tongue Cancer
The tongue is the most common site of cancer in the mouth. They will typically present with an ulcer. Larger cancers may cause a decreased feeling (sensation) to the tongue or a change or decrease in taste. Larger cancers may even affect the nerve supplying movement which will result in changes in speech or causes difficulty in swallowing.
Buccal (Cheek) Cancer
The cheek is a common site for cancer in the mouth. Cancers the start in the cheek may cause pain, present with bleeding or a reduction in mouth opening (trismus). Large cancers could present with redness or an ulcer to the outside skin.
These cancers are typically reconstructed with a free flap from the forearm (radial or ulnar artery forearm flap), upper arm (lateral arm flap), groin or upper leg (anterolateral thigh flap). It is less likely that a patient will need a tracheostomy. These cancers may not affect the speech or swallow as much as others, but often the flap can interfere with your chewing in the weeks following surgery. It is common for the flap to swell and this may cause interference with the.
Following surgery, it is important to undertake exercises to maintain the amount of mouth opening. You may be recommended to use a device such as a Restorabite™.
Lip Cancer
The lip is overall the most common location for cancers. Lip cancers can be considered to have started on the outside (skin based) or inside (mouth based). A lip cancer typically presents with an ulcer or area of skin that bleeds and does not heal. This distinction is important as it will change the investigations and surgery that is required.
Skin based cancers may not require as aggressive removal and therefore less likely to need a free flap. A mouth based cancer will require an additional margin to remove the cancer and therefore more likely to need skin transplanted or transferred. Small lip cancers may be treated with moving skin from the bottom lip, top lip or cheek.
For larger cancers, these may need to be reconstructed with a free flap from the forearm (radial or ulnar artery forearm flap) and may require a tendon to be included to prevent the lower lip collapsing. It is less likely that a patient will need a tracheostomy. There is a delicate balance when reconstructing the lower lip between making it too tight or not tight enough. It is normal after surgery for the opening to feel tight as it will often relax with time and as the tissue heals. If the lip is not tight enough it can cause a problem of food spilling out called lip incompetence.
Palate cancer
The palate is the roof of the mouth and is an uncommon site for mouth cancers. The anterior (front) part is made of bone and is known as the hard palate. It is important to seal off the nose and the maxillary sinus from the mouth. The posterior (back) part is made of muscles and is known as the soft palate. The soft palate helps with speech (present a nasally sounding voice) and prevents food regurgitating into the nose.
Large cancers of the nose or sinus may involve the sinus and it may be a common site for a minor salivary gland or lymphoma. These cancers may present with bleeding from the nose (epistaxis), mouth or the presence of an ulcer or swelling on the roof of the mouth. These cancers may be reconstructed in a number of different ways depending on its location.
For cancers involving the soft palate or the posterior aspect of the palate, they are typically reconstructed with a free flap containing skin and muscles from the forearm (radial or ulnar artery forearm flap), upper arm (lateral arm flap), groin or upper leg (anterolateral thigh flap). Larger reconstructions may incorporate a free flap from a bone in the lower leg (fibula), shoulder blade or hip. There is also the option of no immediate reconstruction which would be with an obturator (special denture made to fill in the space between the mouth and sinus). There are a number of reasons why you may be recommended to have one flap chosen over the other. Depending on the thickness of the reconstruction and closeness to the back of the mouth and overall health, it will determine if a tracheostomy tube is required.
It is common during the healing phase for a section of your flap to dehisce (suture to pull through). This may result in slowing down of your return to eating or more regular checks. What is important for reconstructing the top jaw (maxilla) is the replacement of the teeth. This can be achieved through the placement of dental implants which can be placed into the free flap, the remaining jaw bone or cheekbone (known as a zygomatic implant). These implants will support your future teeth and will need the involvement of a Prosthodontist (dental specialist).
Bottom jaw (mandible) cancer
Cancers of the bottom jaw can start on its lining (alveolus) or from within the bone (interosseous) which is much less common. These cancers may present as an ulcer, a swelling, bleeding or change in feeling (pins and needles or numbness). For superficial or small lesions, surgery may involve removing a small amount of the bone underneath the lining (called a marginal mandibulectomy). For cancers that have involved the bone, it is likely to mean a whole section of your jaw (segmental mandibulectomy) will be needed.