Oral Cancer Surgery: Diagnosis, Reconstruction & Factors

• Early diagnosis and precise surgery are critical for improved survival rates.
• Post-operative reconstruction and rehabilitation are vital for restoring quality of life.
• Follow-up care ensures early detection of recurrence and helps manage long-term effects.

Factors Influencing Surgical Approach

• Tumour size and location determine the extent of the resection needed.
• The depth of invasion guides bone removal or soft tissue excision.
• Assessment of mouth opening is carried out to determine surgical accessibility.
• Minor bone invasions may require small rim resections.
• Severe bone invasions may require segmental or total bone resection, often followed by reconstruction.
• Functional and cosmetic outcomes are prioritised to maintain quality of life.
• The surgeon’s experience influences the choice of treatment and its success.

Reconstruction in Oral Cancer Surgery

• Harvest sites for bone and soft tissue reconstruction include the fibula, hip, and scapula.
• Prosthetics, bone grafts, and implants are used to aid facial restoration.
• Segmental Mandibulectomy can be reconstructed using fibular flaps.
• Hemi Maxillectomy requires complex grafting for functional and cosmetic outcomes.

Advanced Surgical Techniques

• Robotic surgery, uses systems such as the Da Vinci System.
• Robots generally have four arms.
• The robotic arms can hold a camera, cutting tools, swabs, and tissue manipulation devices.
• Robotic surgery enables minimally invasive, precise resections.

Key Goals of Surgical Treatment

• Clear margins of at least 10 mm away from the tumour edge must be achieved.
• If margins are positive post-pathology, wide local excision or adjuvant therapy, (radiotherapy/chemotherapy), is considered.
• Organ function and appearance should be preserved to ensure speech, swallowing, and cosmetic integrity.

Neck Dissection

• Neck dissection is indicated when a tumour depth is >4 mm.
• T1 tumours have a 6–25% risk of hidden metastasis.
• T2 tumours have a 20–30% risk of metastasis.
• Elective dissections (Levels 1-3) are performed for tumours >T2.
• A sentinel node biopsy is performed in clinically N0 tumours to check for lymphatic spread.
• Adjuvant treatment post-dissection with radiotherapy or chemo-radiotherapy is determined by:
  • Number of nodes involved
  • Presence of extracapsular spread

Adjuvant Therapies

• Radiotherapy is administered if margins are positive or nodes are involved.
• Advanced techniques like Intensity-Modulated Radiotherapy (IMRT) focus radiation precisely.
• Chemotherapy is often combined with radiotherapy for better outcomes.
• Palliative radiotherapy/chemotherapy is employed when surgery is no longer viable, to improve quality of life.

Salvage Surgery

• Salvage surgery is indicated for recurrence after primary treatment.
• Salvage surgery generally involves radical surgery and complex reconstruction.
• Rehabilitation and palliative care are essential when no further treatments are feasible.

Rehabilitation and Follow-Up

• Post-surgery goals include disease-free survival and improved quality of life.
• Rehabilitation focuses on assisting speech, swallowing, and psychological well-being.
• Advised lifestyle modifications include stopping smoking and alcohol consumption, as well as maintaining a healthy diet and oral hygiene.
• Follow-up should continue for a minimum of 5 years post-treatment.
• Surveillance monitors recurrence or secondary cancers.

Complications of Surgery

• Immediate complications: wound breakdown, flap failure in reconstruction.
• Long-term complications:
  • Functional deficits, such as speech, and swallowing difficulties; trismus (restricted jaw opening).
  • Cosmetic issues such as disfigurement, and scarring and fibrosis.
  • Chronic pain and sensory deficits.

Early diagnosis and precise surgery improve survival rates for oral cancer. Post-operative reconstruction and rehabilitation are vital for restoring quality of life. Tumor size, location, and depth of invasion influence the surgical decisions.