1. DIAGNOSTIC EVALUATION
2. EXAMINATION UNDER ANESTHESIA AND BIOPSY
3. DEFINITIVE TREATMENT
4. ADJUVANT TREATMENT
5. FOLLOW UP
6. BIBLIOGRAPHY

I. DIAGNOSTIC EVALUATION:

Clinical Evaluation:

• Complete history including history of sun exposure and tobacco usage

•  Complete examination of the head and neck.
  
  Includes examination of the lip and skin of the head and neck, entire oral cavity and oropharynx mucosa, indirect laryngoscopy of the larynx and hypopharynx. Evidence of neural involvement of the lower lip musculature (marginal nerve weakness) or hypesthesia of the mental nerve should be documented. The examination includes an assessment of the status of the mandible and the dentition, palpation of the neck bilaterally, recording the location (Group or Level I - VI), size, mobility, and relationship of any palpable node(s) to adjacent structures. The staging of the primary and of the cervical lymph nodes must be documented.
  

Imaging Studies:

• Panorex - Panoramic View
  
  Indicated if evidence of neural or bony involvement is present or when appropriate to evaluate the patient's dentition.

• PA and Lateral Chest Radiograph
  
  Indicated when general anesthesia is planned for removal in individuals who smoke.
  
  CT or MRI of the Neck
  
  In the absence of palpable adenopathy in individuals with an obese or muscular neck, who are at high risk of having metastases (i.e. age under 30, presence of perineural invasion).
  
  Laboratory Tests

• Preanesthesia laboratory test (according to institutional guidelines)

   Consultations

• Radiation Therapy
  In consideration for radiation treatment rather than surgery.

• Dermatology
  As needed in consideration for dermatologic treatment of malignant or premalignant lesions or MOHS surgery for the primary lesion.

• Internal Medicine, Cardiology, or Anesthesiology.
  
  As needed to evaluate existing conditions that may preclude or increase the risk of general anesthesia.

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Examination under anesthesia is generally not appropriate. Biopsy of the lesion can be done in the office with local anesthesia.

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Treatment of Primary Tumor

The choice of treatment depends upon the anticipated functional and cosmetic outcome and the patient's general condition

Surgery

If surgical excision is employed, the tumor and adjacent premalignant tissue should be excised with an adequate margin of normal tissue. Most early lip carcinomas can be excised under local anesthesia.

Reconstruction:

Defects of the vermilion can be closed with mucosal advancement.

Full Thickness Lip Lesion Defects Can Be Repaired By:

• Primary closure utilizing a V-lip or W-lip excision is most appropriate if an acceptable functional and cosmetic result is expected (resection of < 1/3 of the lower lip).
  
• Local flap reconstruction is appropriate for defects involving 1/3 to 2/3 of the lip (Abbe flap, Estlander flap or Karapandzic flap).

Radiation

Radiation therapy as a definitive treatment is a satisfactory alternative for cancer of the lower lip, particularly for patients where the anticipated functional and cosmetic outcome is unsatisfactory with surgery, as well as for those patients medically unfit to undergo surgery. Treatment by external beam, brachytherapy or a combination of the two is employed as dictated by the size and location of the tumor.

Chemotherapy

Not indicated.

Treatment of Neck

Treatment of the regional lymph nodes is generally not indicated for stage I and II lesions with no evidence of adenopathy on clinical and/or radiologic exam.

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Preoperative

Not indicated.

Post-operative

Radiation should be utilized for microscopic positive margins only when re-excision is not feasible, also for patients with extensive perineural invasion or histologically positive nodes.

V.FOLLOW UP:

• Removal of sutures at 5-10 days.
  
  Follow-up appointments are scheduled on an individual basis determined by the risk of recurrence, to survey for the development of second primary tumors, to deal with morbidity from treatment (i.e. speech and swallowing problems as well as wound care), to provide social and psychological support, and to deal with comorbidity not directly related to the cancer itself.
  

• After all treatment is completed a general formula which is modified according to the individual patient's characteristics is:
  
  1st year post treatment: 1-3 months
  
  2nd year post treatment: 2-4 months
  
  3rd year post treatment: 3- 6 months
  
  4th and 5th years: 4- 6 months
  
  After 5 years: Every 12 months

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Lore JM, Kaufman S, Grabau JC, and Popovic DN. Surgical management and epidemiology of lip cancer. Otolaryngologic Clinics of North America. 12:81-95, 1979.

Mehregan DA, Roenigk RK. Management of superficial squamous cell carcinoma of the lip with Mohs micrographic surgery. Cancer. 66:463-68, 1990.

Hosal IN, Önerci M, Kaya S and Turan E. Squamous cell carcinoma of the lower lip. Am J Otolaryngol. 13(6):363-65, 1992.

Baker SR. Cancer of the lip. In Cancer of the Head and Neck, 2nd ed., Churchill Livingston, New York, 383-413, 1989.

Bailey BJ. Management of carcinoma of the lip. Laryngoscope. 87:250-60, 1977.

Stepnick DW. Cancer of the lip. In Current Therapy in Otolaryngology - Head and Neck Surgery, 5th ed., Mosby, St Louis, 257-61, 1994.

Jorgenson K, Elbrond O, Andersen AP. Carcinoma of the lip: A series of 869 cases. Acta Radiol. 12:177, 1973.

Zitsch RP. Evaluation and Surgical Therapy of tumors of the oral cavity: Lip tumors. In Comprehensive Management of Head and Neck Tumors, 2nd ed., W.B. Saunders, Philadelphia, 673-685, 1999.