This document provides information on carcinoma of the buccal mucosa, including its anatomy, epidemiology, risk factors, clinical features, diagnosis, staging, treatment, and prognosis. Carcinoma of the buccal mucosa is most common in India, Malaysia, and Taiwan, where it affects men more than women. Risk factors include tobacco and betel nut chewing. Treatment depends on the stage, with surgery or radiation typically used for early stages and chemoradiation for advanced stages. Prognosis depends on factors like tumor size and nodal involvement.

1. Carcinoma Buccal Mucosa:
Anatomy to management
Dr. Ayush Garg

2. • Anatomy
• Epidemiology
• Risk Factors
• Pre Malignant Lesions
• Clinical Features
• Pathology
• Diagnostic Work Up
• Staging
• Management
• Follow Up

3. ANATOMY
• The buccal mucosa includes the mucosal surfaces of the cheek
and lips from the line of contact of the opposing lips to the
pterygomandibular raphe posteriorly.
• This extends to the line of attachment of the mucosa of the
upper and lower alveolar ridge superiorly and inferiorly.

5. • The muscle of the cheek is the buccinator muscle.
• The buccal fat pad is superficial to the fascia covering the
buccinator muscle and gives the cheeks a rounded contour.
• Branches of the maxillary and mandibular nerves (cranial nerves
V2 and V3) provide sensory innervation to the skin, the cheek,
and the mucous membranes lining the cheeks.
• The facial nerve (cranial nerve VII) provides motor innervation to
the muscles of the cheeks and lips.

7. • The lips and cheeks function together as an oral
sphincter propelling food into the oral cavity.
• If the facial nerve is paralyzed, food tends to accumulate
within the cheek along the affected side so that saliva
and food dribble out of the corner of the mouth.

9. EPIDEMIOLOGY
• After carcinoma of the lip, oral tongue, floor of the mouth, and
lower gum, carcinoma of the buccal mucosa is the fifth most
common carcinoma of the oral cavity.
• It is the most common carcinoma of the oral cavity in India,
Malaysia, and Taiwan.
• It usually occurs in the sixth and seventh decades of life, and is
more prevalent in men than in women.
• Tobacco and betel nut chewing appear to play an important role
in the cause of these tumors.

10. • Carcinomas of the buccal mucosa often occur in association with
pre-existing leukoplakia and tend to have multiple primary sites
and recurrence.
• Excision of the oral leukoplakia may reduce the subsequent
development of carcinoma.
• These tumors usually arise in the area adjacent to the lower
molars along the occlusal line of the teeth.

11. RISK FACTORS

12. PREMALIGNANT LESIONS
• Leukoplakia - A chronic white mucosal
macule which cannot be scraped off,
cannot be given another specific
diagnostic name, and does not disappear
with removal of potential etiologic factors
(excepting tobacco).
• 4-18% progress to invasive carcinoma

13. ERYTHROPLAKIA
• Erythroplakia is the clinical diagnostic
term - A chronic red mucosal macule
which cannot be given another specific
diagnostic name and cannot be
attributed to traumatic, vascular or
inflammatory causes, i.e. it is a
diagnosis of exclusion.
• Higher risk of cancer development
• (approx 30%)

14. Oral Sub mucous fibrosis
4.5 – 7.5 % progress to oral cancer

15. • Clinically, there are three distinct types: exophytic, ulcerative,
and verrucous.
• The patient may present with pain or bleeding, trismus, or
cervical lymphadenopathy.
• Posterior extension may result in involvement of the lingual or
dental nerves, which may cause ear pain.
• Extension behind the pterygomandibular raphe into the
pterygoid muscles or into the buccinator and masseter muscles
may cause trismus.

16. Exophytic Ulcerative
Verrucous

17. • In advanced stages, the tumor may destroy the entire
cheek and invade the adjacent bones and the neck.
Infection is common and mastication becomes difficult.
Death usually occurs as a result of poor nutrition and
general debilitation

18. CLINICAL FEATURES
• Non Healing ulcer
• Pain
• Bleeding
• Dysphagia
• Referred pain to ear
• Hypersalivation
• Trismus

19. Trismus

20. Classification

21. ROUTES OF SPREAD
• Infiltrating lesions of the buccal mucosa can invade the
buccinator muscle, extend to the buccal fat pad, and invade the
subcutaneous tissue.
• Carcinomas of the buccal mucosa frequently spread by direct
invasion into the gingivobuccal sulcus, the upper and lower
alveolar ridges, the hard palate, the maxilla, and the mandible.
• Lymph node metastasis occurs in approximately 9% to 31% of
the patients during the course of the disease.

22. • The risk of subclinical disease is 16%.
• Distant metastases are rare, as patients often die of
uncontrolled local disease before distant metastases are
manifested clinically.

23. PATHOLOGY
• >90 % Squamous cell carcinomas
• Spectrum of diseases from benign
lesions like leukoplakia, lichen planus,
SMF to verrucous carcinoma to well
differentiated squamous carcinoma
• Malignant Minor salivary gland
tumors such as Adenoid cystic,
Adenocarcinoma, Mucoepidermiod
carcinoma (< 10%) are uncommon
• Malignant Melanoma, Lymphoma,
Sarcoma occur rarely.

24. DIAGNOSTIC WORK UP
• History & Clinical examination , including head & neck
examination
• Clinical staging
• Assessment of performance & nutritional status
• Investigations for histological diagnosis – Punch Biopsy

25. Investigations to determine the extent of the disease
• OPG/ Dental examination
• CT Scan / MRI for extent of disease
• USG for N0 neck in select cases

26. Routine Investigations
• CXR
• Routine blood counts
• Blood chemistry profile

27. STAGING
T4a-Moderately advanced local
disease.
• Tumor invades adjacent structures
only (e.g., through cortical bone,
[mandible or maxilla] into deep
[extrinsic] muscle of tongue
[genioglossus, hyoglossus,
palatoglossus, and styloglossus],
maxillary sinus, skin of face)
T4b-Very advanced local disease.
• Tumor invades masticator space,
pterygoid plates, or skull base and/or
encases internal carotid artery

29. • DISTANT METASTASIS (M)
• M0-No distant metastasis (no pathologic M0; use
clinical M to complete stage group)
• M1-Distant metastasis GROUP T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
IVB Any T N3 M0
T4b Any N M0
IVC Any T Any N M1
GROUP T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
IVB Any T N3 M0
T4b Any N M0
IVC Any T Any N M1

30. PROGNOSTIC FACTORS

31. Intent of treatment
• Stage I – IV A : Curative
• Stage IV B-C : Palliative
The aim of treatment:
• Cure
• Loco regional control
• Preservation of anatomy & function
• Reasonable cosmesis
• Quality of life

32. TREATMENT ALGORITHM

33. T1-2 N0
• Excision of primary (preferred) ± unilateral or bilateral selective
neck dissection.
• Neck treatment (dissection or RT) required for lesions >1.5–3
mm thick.
• For +margin only, re-excise if feasible.
• Post-op RT for pT3/T4, close margin, multiple nodes, PNI,
and/or LVSI, or level IV–V nodes
• Post-op chemo-RT indicated for +margin, ECE
• Alternatively, EBRT ± brachytherapy. Salvage surgery for
residual disease

34. T3 N0
• Excision of primary and unilateral or bilateral selective
neck dissection.
• Reconstruction as indicated.
• For +margin only, reexcise if feasible.
• Post-op RT for all; chemo-RT indicated for +margin, ECE

35. T4a or N1-3
• Excision of primary and ipsilateral comprehensive neck dissection
± contralateral selective neck dissection, or bilateral neck
dissection (for N2c).
• Reconstruction as indicated.
• For +margin only, reexcise if feasible.
• Post-op RT for pT3/T4, close margin, multiple nodes, PNI, and/or
LVSI, or level IV–V nodes
• May consider post-op RT for N1 as only risk feature
• Post-op chemo-RT indicated for +margin, ECE

36. Unresectable
• Concomitant chemo-RT (preferred).
• Alternatively, induction chemotherapy followed by
chemo-RT, or altered fractionation RT alone if unable to
tolerate chemo.
• If primary has < CR, salvage surgery controversial.
• If residual neck mass by CT/MRI or PET at 6–12 weeks,
post-RT neck dissection considered

37. VERRUCOUS CARCINOMA
• Perceived risk that the tumor may become more aggressive if it
recurs after RT.
• Many tumors that recur after treatment are biologically more
aggressive. Therefore, it is reasonable to treat these lesions with
irradiation if surgery is not feasible.
• Wang reported a series of patients with verrucous carcinoma
treated with RT; the results were comparable to those for patients
treated for squamous cell carcinoma.

38. SURGERY
• Used as single modality in early disease (Stage I & II )
• Combined with post operative adjuvant radiotherapy in
advanced disease(Stage III & IV)
• Wide excision of tumor in all dimensions with adequate margins
& appropriate neck dissection essential for locoregional control
of disease

39. ADVANTAGES OF SURGERY
• Treatment time is shorter.
• The risk of immediate and late radiation sequel are avoided.
• Irradiation is reserved for recurrence, which may not be
resectable.
• Pathological assessment, accurate staging.
Disadvantage: functional & cosmetic impairment, increased
morbidity when bilateral neck is addressed.

40. • Modified neck dissection is sufficient treatment for the
ipsilateral neck for patients with N1 without PNI.
• Radiation therapy is added for
• N1 with PNI/LVI
• N2,N3 stages, for control of contra lateral subclinical disease
• For invasion through the capsule of the node,
• For multiple positive nodes

41. NECK DISSECTION
• RND : superficial & deep cervical fascia with its enclosed LN
(level I-V) is removed in continuity of SCM, omohyoid muscle,
internal & external jugular veins, spinal accessory N &
submandibular gland
• MND : is finding more acceptance & preference to RND in
managing N0 neck because of severe morbidity related to RND
such as, shoulder dysfunction, poor cosmesis, facial edema
(level I-V LN)

42. • SOHND : least morbid, provides most satisfactory
sampling of the LN at the level I, II, III which are greatest
risk
• Extended SOHND : level I-IV LN dissection

44. NCCN GUIDELINES FOR NECK TREATMENT

45. MANDIBULECTOMY
• Marginal mandibulectomy: partial-thickness (marginal) mandibular
resection
• Segmental Mandibulectomy
For small lesions with minimal bone invasion, a short section of mandible is
removed in continuity with the tumor (e.g., removal of the mandible from
the angle to the mental foramen).
• Hemimandibulectomy
- Removal of the mandible symphysis to the condyle on one side.
- Major cosmetic and functional loss
- Reconstruction is performed with a composite osteomyocutaneous flap

46. MARGINAL MANDIBULECTOMY SEGMENTAL MANDIBULECTOMY

47. HPE REPORT
Gross pathology
1. Morphology
2. Location & extent of the tumor / lesion
3. Tumor dimensions
4. Distance from various margins of excision
5. Nodal dissection

48. Microscopy
1. Histologic type
2. Grade
3. Extent of disease including depth of infiltration
4. Perineural invasion
5. Extracapsular Spread
6. Lymphovascular Invasion
7. Bone / Cartilage / Skin / Soft tissue involvement
8. Margins of excision, submucosal spread, In – situ changes
9. Nodal status – no. & size of nodes, perinodal extension &
level of nodes
10. Status of cut margins

49. Miscellaneous features
1. In RND/ MND status of internal jugular vein
2. Presence of predisposing factors - leukoplakia, SMF
3. Dysplasia/ in situ elements

50. • Unresectable Disease
Primary disease
• Adequate surgical clearance is not achievable
• Extensive Infra Temporal Fossa involvement
• Extensive involvement of base skull
• Extensive soft tissue disease – skin edema / ulceration
Nodal disease
• Clinically fixed nodes
• Infiltration of Internal / Common carotid artery
• Extensive infiltration of prevertebral muscles

51. IRRADIATION
• Better functional and cosmetic outcome
• Elective irradiation of the lymph nodes can be included with
little added morbidity, whereas the surgeon must either observe
the neck or proceed with an elective neck dissection (sometimes
bilateral depending on the primary site),
• The surgical salvage of irradiation failure is probably more likely
than the salvage of a surgical failure.
• The risk of postoperative complications is avoided

52. INDICATIONS OF POST OP RT
Primary:
• Advanced primary – T3 or T4
• Close or positive margins of excision
• Depth of invasion
• High grade tumor
• LVI & PNI
Nodes:
• Bulky nodal disease N2/N3
• Extra nodal extension
• Multiple level involvement

53. INDICATIONS OF POST OP CHEMO RT
• Extracapsular nodal involvement
• Positive Surgical Margin

54. RADIOTHERAPY BORDERS

56. • T3 and T4 lesions
• Patients with significant tumor extension toward the midline are
treated with parallel opposed fields weighted 3 : 2 toward the
side of the lesion.
• The low neck is treated with an anterior field with a 6-MV X-Ray
beam to 50 Gy in 25 fractions once daily

57. 3D CRT TARGET VOLUMES

58. RT DOSE
• Doses of 66-70 Gy in 1.8-2-Gy per fraction is given over 6.5-7
weeks
• Phase 1- 44 Gy is given over 4.5 weeks
• Phase 2-26 Gy is given over 2.5 weeks
• A LAN is often used, treated to either 50 Gy in 2-Gy fractions or
50.4 Gy in 1.8-Gy fractions.

59. ROLE OF IMRT

60. PASSPORT Trial: Numbers not enough to establish non-
inferiority
Conventional
Radiotherapy
IMRT
2 year PFS 80% 78%
Estimated 2 year
OS
76% 78%

62. IMRT TARGET VOLUMES
• GTV
Gross tumor on imaging studies
• CTV
• High risk: GTV
• Intermediate risk: areas with high likelihood of nodal
disease or tumor spread
• Low risk: elective nodal treatment
• PTV
CTV plus 3–5 mm

63. DOSE RECOMMENDATION
• A total dose of 66–70 Gy in 30–33 fractions using
simultaneous integrated boost (SIB) technique with 7–14
coplanar fields can be used according to the shape of PTV:
• High-risk PTV: 70 Gy to high-risk CTV
• Intermediate-risk PTV: 59.4 Gy
• Low-risk elective PTV: 50–54 Gy

64. PRESCRIPTION FOR HEAD & NECK IMRT
• 95 % prescription dose to cover 98% of high dose PTV
• Prescription dose to cover at least 91% of high dose PTV
• 95% dose to cover at least 95% of low risk PTV
• Avoid hotspots > 107%
• Parotid
• PRV Spine
• Mandible

66. BRACHYTHERAPY
• Accessible lesions
• Small (preferably < 3cm ) tumors
• Well defined borders
• Lesion away from bone
• Superficial lesions
• Tumors of the anterior two thirds of the buccal mucosa without
involvement of gingiva are ideally suited for brachytherapy
alone.

67. • Interstitial implants with iridium wires or seeds in nylon
ribbons can be considered for treatment of early, small
lesions that have not invaded the buccogingival sulcus,
the gingiva, or bone.
• Usually a minimum tumor dose of 60 to 70 Gy in 5 to 8
days is delivered through a single-plane or double-plane
implant on the thickness of the lesion.
• The buccal mucosa tolerates high-dose RT with a low
risk of late complications.
• Trismus may develop if the muscles of mastication
receive high doses of irradiation.

68. CHEMOTHERAPY
• Cisplatin
- Used in NACT (T4b and N3 cases)
- Used in CTRT

69. FOLLOW UP

71. Table 1. Re-irradiation for Head and Neck cancer (various sites)
Author Year Site Treatment Radiotherapy Outcome Adverse reaction Bleeding †
Prognostic factors
(Institute) (Pt No.) [Median preRT dose / RT interval (M)] RR/ 2yOS/ 2yLC/ MST
Conventional
6
De Crevoisier 1998 Various rec/2nd (1) Conv. RT 27 (1) RT 65Gy (1) RR 41% / 2y OS 25% / 5y OS 6% / MST 10M Acute G4< 13% 5 /169 (2.9%) Small volume irradiation favorable
(Gustave-Roussy) (169) [65Gy/ 40M] (2) Conv. RT+CTX 106 (2) Voks protocol: HU+5-FU+RT60Gy (2) RR 48%/ 2yOS 24%/ 5yOS 14%/ MST 10M Severe 29%
(3) HfxRT+CTX 36 (3) MMC, 5-FU+1.5 Gy/bid 60Gy (3) RR 63%/ 2y OS 10%/ 5y OS 0%/ MST 11M G2-3 fibrosis 41%, mucosal necrosis 21%,
Higher RT dose favorable
16
Ohizumi 2002 Various rec Conv. RT, HfxRT± CTX 53Gy RR64%/ 2y OS 10% Acute severe 2/44 (4.5%) none Overlapping RT field 40 cc < favorable
(Tokai Univ) (44) [62.1Gy (mean) / 13.5M] Late severe 5 (11%), laryngeal edema etc. NPC, OPC, kkk favorable
18
Salama 2006 Various rec/2nd rec 66： 2nd 49 Micro lesion 60Gy/Macro lesion 66-70Gｙ 3y OS 22%/ 3y LRC 33%/ MST 11M 21 G4< (18%) 6 /115 (5.2%) 2nd (vs. rec) favorable
(Chicago Univ) (115) [67.5Gy/NA] Conv. RT, HfxRT± CTX Conv. RT 2Gy/day or Hfx RT 1.5Gy x 2/day Lethal 19 (16.5%) Carotid blow-out 5 > 1Y interval / CTX(GEM etc) favorable
inOP49/ OP49 inOp 2yOS 11% vs. OP 2yOS 39% OP (vs. inOP) favorable
19
Spencer 2006 Various rec/2nd HfxRT + CTX 60Gy 2y OS 15.2%/ 5y OS 3.8%/ MST8.8M Acute G4 17.7%, G5 7.6% 1 (1%) > 1Y interval favorable
(RTOG96-10) (81) [55-65Gy / 24M] HU +5-FU 1.5 Gy/bid x 5d other weekx4 Lethal 6/81(7%) on treatment
10
Langer 2007 Various rec/2nd HfxRT + CTX 60Gy 2y OS 25.9%/ MST12M Acute G4< 28% 2/81 (2.4%)
(RTOG99-11) (105) [65.4Gy/ 39.6M] cisplatin+paclitaxel+GCSF 1.5 Gy/bid x 5d other weekx4 Lethal 8 (acute 5, late 3)
22
McDonald 2011 Various rec/2nd Various Various Various 1.8-2Gy QD or 1.2Gy bid bleeding 1.3%-1.8% 41/1554 (2.6%) 76% fatal
(Review) (1554) 1.5 Gy bid or delayed accelerating HfxRT bleeding 4.5%
IMRT
20
Sulman 2009 Various rec CTX 26 60Gy 2y OS 58%/ 2y LRC 64% Severe 15 (20%) none Younger favorable
(MDAC) (74) [60Gy/ 46M] platinum based Death 1 (unknown cause) Male favorable
23
Popovtzer 2009 Various rec/2nd HfxRT ± CTX 68Gy 2y OS 40%/ 2y LC 27% Acute G3 26, G4 11 2/66 (3%) Almost recurrence occurred
(Michigan Univ) (66) [64Gy/ 37M] CTX 47 (cisplatin etc.) 1.25Gybidx6wks (1wk interval in midway) Late G3 < 19 (29%) surgically salvaged inside irradiated area
24
Duprez F 2009 Various rec/2nd OP19 69Gy 2yOS 35%/ 2y LCR 48%/ MST13.4M Acute G3< 26 (31%) 2/84 (2.3%) T4, short interval, HPC unfavorable
(Belgium) (84) [61Gy/ 49.5M] CTX17 (cisplatin etc.) Late G3 < 11 (14%)
25
Biagioli 2007 Various rec CTX 60Gy/30fr, each other week RR76%/ 2y OS 48.7% Acute G3< 32% 1/41 (2.5%)
(Miami) (41) [60Gy/ 25M] Cisplatin or CBDCA Late 6
26
Lee 2007 Various rec IMRT 74, nonIMRT 31 59.4Gy RR50%/ 2yOS 37%/ 2yLRPFS 42%/ MST15M Acute G3-4 23% none NPC favorable
(MSK) (105) [62Gy/ 38M] 71% CTX Late G3-4 15 % (severe 11%) > 50Gy favorable
Abbreviations: MSK; Memorial Sloan-Kettering Cancer Center, MDAC; MD Anderson Cancer Center, rec; recurrence, 2nd; second primary, LC; local control, OS; overall survival, RR; response rate, DSS: disease-specific survival, LRC: locoregional control, MST; median survival time
NA; not available, OP; surgery, inOP; inoperative case, QD; once a day, bid; twice a day
RT; radiotherapy, Conv. RT; conventional fractionated radiation, HfxRT; hyperfractionated radiation, CTX; Chemotherapy, HU; Hydroxyurea, 5-FU; 5 fluorouracil, CBDCA.; Carboplatin, GEM; Gemcitabine
†
prognostic factors for overall survival if otherwise stated