Buccal mucosa cancer is a subsite of oral cavity cancers and represents serious diagnostic, therapeutic, and postoperative challenges. It is one of the most prevalent cancers in India, largely due to heavy use of tobacco and betel nut (Singhania et al., 2015) [2]. Although improved surgical techniques and multimodal treatments are imminent, control of complications after surgery is an essential part of patient treatment. Wide local excision, neck dissection, and reconstruction methods are part of surgical treatment of buccal mucosa carcinoma with a preference for oncologic control and the least functional and aesthetic impairment (Nair et al., 2017) [1].

The outcome of buccal mucosa carcinoma is based on a range of factors including the tumor stage, lymph node involvement, perineural invasion, and occult metastasis (El-Naaj et al., 2011). Even in the early stages of disease, T1-T2N0, the presence of micrometastases can influence survival (El-Naaj et al., 2011) [3]. Furthermore, the aggressive behavior of squamous cell carcinoma of the buccal mucosa compared to other oral cavity locations leads to higher locoregional recurrence and distant metastasis (Lubek et al., 2013) [4]. Thus, a systemic treatment regimen with surgical resection and adjuvant treatment for improved disease-free survival is warranted. Postoperative morbidity continues to be a significant problem in surgically managed buccal mucosa carcinoma. The common complications are wound infection, flap necrosis, dehiscence, and orocutaneous fistula formation (Girkar et al., 2019) [5]. These complications indirectly prolong hospital stay along with adversely affecting functional outcomes, i.e., speech, mastication, and quality of life. The etiologic factors are patient comorbidities, extent of resection, and technical reconstruction. Proper knowledge and awareness of such complications and management are therefore necessary for optimizing patient outcomes.

In tertiary centers, management of buccal mucosa carcinoma is a multidisciplinary approach by surgical oncologists, radiation oncologists, medical oncologists, and rehabilitation experts. Induction chemotherapy for borderline resectable tumors is controversial, and evidence is that there are differential degrees of reduction of the tumor and post-resectability (Patil et al., 2013) [7]. Further, the effect of multimodality therapy on long-term survival and patterns of recurrence necessitates individualized treatment regimens (Deo et al., 2004) [6].

This paper will evaluate the morbidity of surgically treated cases of buccal mucosa carcinoma in a tertiary care facility and their treatment protocols. Based on clinical outcomes and postoperative complication evaluation, this research tries to contribute to the literature regarding how patients and surgical management can be optimized.

Study Design and Setting

The present study was a retrospective study carried out in a tertiary care center in patients who underwent surgery for carcinoma of buccal mucosa. Institution records were evaluated in a specific time frame being careful to select cases in which there were complete clinical, surgical, and follow-up records. Ethical approval had been obtained from the institutional ethics committee before data collection and analysis.

Patient Selection

The patients were histopathologically diagnosed and surgically treated with squamous cell carcinoma of the buccal mucosa and were included in the study. Patients with distant metastasis, recurrent, or for whom the clinical history was not complete were not included in the study. The subjects were included in the study population with a mix of ages and gender and with a history of tobacco, betel nut, or alcohol.

 Surgical intervention and reconstruction

All patients underwent primary surgical resection with curative intent. Extent of resection was preoperatively planned with imaging and clinical staging. Neck dissection was performed in clinically or radiologically evident nodal disease and prophylactic neck dissection was planned in well-selected early-stage cases. Reconstruction methods were planned based on the size of the defect and were primary closure, local flaps, or free flap reconstruction. Histopathological examination postoperatively assessed surgical margins, perineural invasion, lymphovascular invasion, and nodal involvement.

Postoperative Complications and Management

Patients were evaluated for early and late postoperative complications such as surgical site infection, flap necrosis, wound dehiscence, orocutaneous fistula, and functional impairment such as trismus and dysphagia. Treatment options were individualized, ranging from conservative wound care and antibiotic therapy to surgery in patients requiring debridement or secondary reconstruction. The impact of complications on hospital stay, functional recovery, and treatment outcome was examined.

Adjuvant Treatment and Follow-Up

Postoperatively, the patients were evaluated to decide on the necessity of adjuvant therapy, either radiation or chemoradiation, based on risk factors like extracapsular spread, positive margins, or multifocal nodal involvements. Regular follow-up was done to assess recurrence, disease-free survival, and long-term functional status. Clinical examination and imaging were utilized to conduct surveillance and observe recurrence patterns.

Data Analysis

Data gathered were analyzed to identify the incidence of postoperative complications and their correlation with clinical and pathological factors. Statistical analysis was applied to evaluate the significance of variables affecting complications and survival. Descriptive analysis was applied to patient demographics, outcome of the surgery, and adjuvant treatment information to provide a holistic assessment of the efficacy of treatment. This approach provides a systematic framework for solving the issues involved in the surgical management of buccal mucosa carcinoma, providing insight into enhancing patient care and enhancing clinical outcomes.

120 patients who had undergone surgical intervention for carcinoma of the buccal mucosa in the tertiary care center were included in the study. The study group consisted of 85 males (70.8%) and 35 females (29.2%), with a mean age of 54.3 years (range: 32–78 years). Most of the patients (62.5%) had a history of tobacco and betel nut chewing, and 28.3% had alcohol consumption as an associated habit. Staging of the tumors at diagnosis was also variable, with 35 patients (29.2%) having early-stage disease (T1-T2) and 85 patients (70.8%) having locally advanced disease (T3-T4).

Surgical Outcomes and Histopathological Findings

Surgical resection with curative intent was carried out in all patients, with 78 patients (65%) undergoing unilateral or bilateral neck dissection. Histopathological examination showed that 47 patients (39.2%) had perineural invasion, and lymphovascular invasion was seen in 32 cases (26.7%). Margin was positive in 19 patients (15.8%), for which additional adjuvant treatment was required. Median hospital stay was 10 days (range: 5–21 days), which was affected by postoperative complications.

Table 1: Clinicopathological Characteristics of Patients

Postoperative Complications

Postoperative complications were seen in 42 patients (35%), of which the most frequent was surgical site infection in 15 patients (12.5%). Flap necrosis was seen in 9 cases (7.5%), and orocutaneous fistula formation was seen in 8 patients (6.7%). Wound dehiscence was seen in 6 cases (5%), and functional deficits like trismus and dysphagia were seen in 10 patients (8.3%). The grade of complications was significantly increased in patients having more extensive tumor resections and those needing major reconstructive surgery.

Table 2: Postoperative Complications and Their Incidence

Postoperative complications were observed in 42 patients (35%). These complications are classified below according to site and timing:

Table 2A: Postoperative Complications Classified by Site and Timing

Association Between Complications and Hospital Stay

The occurrence of complications also extended the length of stay in the hospital, with patients having significant complications taking a median of 15 days to recover, as opposed to 8 days for those without complications.

Figure 1: Graphical Representation of Hospital Stay in Patients With and Without Complications

Adjuvant Treatment and Follow-Up

Of the entire cohort, 72 patients (60%) were treated with adjuvant radiotherapy, and 28 patients (23.3%) were treated with concurrent chemoradiation. With a median follow-up of 18 months, 98 patients (81.7%) were disease-free, and 22 patients (18.3%) had recurrence, either locoregionally (14 cases) or at distant sites (8 cases).

Figure 2: Recurrence-Free Survival in the Study Population

More specific grouping of postoperative complications is listed in the table below, according to site, timing of onset, and clinical course. Complications were designated as immediate (within 1–3 days), intermediate (4–10 days), or late (>10 days) postoperatively.

Table 3: Classification of Postoperative Complications by Site, Timing, and Clinical Course

These results emphasize the range of complications seen after surgery for buccal mucosa carcinoma and highlight the need for careful surgical planning, prompt management of complications, and thorough follow-up to enhance patient outcomes.

The results of this research give vital information on the complications and outcomes of surgical treatment of buccal mucosa carcinoma in a tertiary care center. The postoperative complication rate in the current study was 35%, with orocutaneous fistula, flap necrosis, and surgical site infections being the most frequently seen complications. These complications considerably extended the length of stay in the hospital, making strict perioperative management important. In comparison, the same rates of complications have been reported in past research, citing the aggressive pattern of buccal mucosa carcinoma and surgery (Anand et al., 2017). The existence of perineural invasion and lymphovascular spread, both noted in 39.2% and 26.7% of samples respectively, continues to validate earlier studies that cited these as decisive prognostic indicators of recurrence and survival (Anand et al., 2017) [9].

The large percentage of patients who report advanced-stage disease (70.8%) is in accordance with the findings of earlier studies, where a delay in diagnosis is still a major problem in the management of oral cancer (Iype et al., 2001) [8]. The aggressive nature of buccal mucosa carcinoma, in relation to other oral cavity subsites, has been extensively reported. Camilon et al. (2014) [10] documented worse survival in patients with buccal cancer, which they attributed to aggressive locoregional progression and high recurrence. In the present study, even with a high rate of surgery and adjuvant therapy, recurrence was seen in 18.3% of patients at a median follow-up of 18 months. This is consistent with previous reports that local recurrence is still a significant issue despite multimodal treatment modalities (Lyu et al., 2014) [11].

Multimodal therapy, such as adjuvant chemotherapy and radiotherapy, has been highlighted by various studies. Among the cohort in this study, 60% of the patients underwent postoperative radiotherapy, whereas 23.3% had concurrent chemoradiation. This aligns with current literature, where adjuvant therapy in high-risk pathological features like extracapsular spread and positive margins has been shown to be beneficial (Pai et al., 2013) [12]. The optimal sequencing and intensity are, however, areas of continued debate. Lyu et al. (2014) [11] had better three-year results with a sequential therapy strategy, further necessitating the need for tailored treatment approaches.

The nodal metastasis patterns that were seen in this study are also worth discussing. Narendra and Tankshali (2010) [13] reported a high incidence of nodal involvement in pT4 gingivobuccal cancers, making extensive neck dissection procedures imperative. Likewise, in this study, neck dissection was carried out in 65% of patients, reflecting the need for aggressive surgical intervention to attain locoregional control. In spite of all these, the occurrence of positive margins in 15.8% of cases is still a cause for concern, and incorporation of improved intraoperative evaluation methods like frozen section analysis is warranted.

Using outcomes between populations, Pathak et al. (2008) [15] emphasized differences between India and the West regarding management of buccal cancer, with Indian patients being presented in more advanced stages because of a lack of early detection programs. This research further supports that there is a necessity for increased screening and early intervention mechanisms to enhance survival. Moreover, socioeconomic conditions and access to healthcare still remain influential factors in outcomes of treatment, as emphasized by Noronha et al. (2019) [14].

By and large, this study adds evidence to the prevailing body of findings on the nuances of buccal mucosa carcinoma management. The high rates of complications demonstrate the imperative need for careful perioperative management, while the nature of recurrence provides a basis for the need to use adjuvant treatment on high-risk scenarios. Future work should aim to improve surgical maneuvers, standardize adjuvant therapy protocols, and develop efficient early detection pathways to further increase patient outcomes.

Surgical management of buccal mucosa carcinoma continues to pose a problem owing to the high rate of postoperative complications and high risk of recurrence, especially in those patients who have advanced-stage disease. The current study draws attention to the importance of careful surgical planning, aggressive nodal disease management, and incorporation of adjuvant treatments to maximize treatment results. In spite of multimodal treatment, recurrence was noted in a significant percentage of patients, highlighting the virulent nature of this neoplasm. The results reaffirm the necessity of early diagnosis, enhanced intraoperative evaluation, and complete postoperative management to maximize survival and functional recovery. Refining treatment protocols and investigating new therapeutic modalities should be the focus of future studies to optimize long-term prognosis in patients with buccal mucosa carcinoma.

1. Nair D, Singhvi H, Mair M, et al. Outcomes of surgically treated oral cancer patients at a tertiary cancer center in India. Indian J Cancer. 2017;54(4):616-620. doi:10.4103/ijc.IJC_445_17
2. Singhania V, Jayade BV, Anehosur V, Gopalkrishnan K, Kumar N. Carcinoma of buccal mucosa: A site specific clinical audit. Indian J Cancer. 2015;52(4):605-610. doi:10.4103/0019-509X.178383
3. El-Naaj IA, Leiser Y, Shveis M, Sabo E, Peled M. Incidence of oral cancer occult metastasis and survival of T1-T2N0 oral cancer patients. J Oral Maxillofac Surg. 2011;69(10):2674-2679. doi:10.1016/j.joms.2011.02.012
4. Lubek JE, Dyalram D, Perera EH, Liu X, Ord RA. A retrospective analysis of squamous carcinoma of the buccal mucosa: an aggressive subsite within the oral cavity. J Oral Maxillofac Surg. 2013;71(6):1126-1131. doi:10.1016/j.joms.2012.12.006
5. Girkar F, Thiagarajan S, Malik A, et al. Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center. Head Neck. 2019;41(12):4121-4127. doi:10.1002/hed.25951
6. Deo S, Kumar S, Shukla NK, et al. Patient profile and treatment outcome of rectal cancer patients treated with multimodality therapy at a regional cancer center. Indian J Cancer. 2004;41(3):120-124.
7. Patil VM, Noronha V, Joshi A, et al. Induction chemotherapy in technically unresectable locally advanced oral cavity cancers: does it make a difference? [published correction appears in Indian J Cancer. 2013 Apr-Jun;50(2):153. Joshi, Amit [added]]. Indian J Cancer. 2013;50(1):1-8. doi:10.4103/0019-509X.112263
8. Iype EM, Pandey M, Mathew A, Thomas G, Sebastian P, Nair MK. Oral cancer among patients under the age of 35 years. J Postgrad Med. 2001;47(3):171-176.
9. Anand AK, Agarwal P, Gulia A, et al. Significance of perineural invasion in locally advanced bucco alveolar complex carcinomas treated with surgery and postoperative radiation ± concurrent chemotherapy. Head Neck. 2017;39(7):1446-1453. doi:10.1002/hed.24792
10. Camilon PR, Stokes WA, Fuller CW, Nguyen SA, Lentsch EJ. Does buccal cancer have worse prognosis than other oral cavity cancers?. Laryngoscope. 2014;124(6):1386-1391. doi:10.1002/lary.24496
11. Lyu J, Li C, Wu Y, Wang R, Ren G, Guo W. Sequential therapy of advanced buccal mucosa squamous cell carcinoma: three-year outcome. J Oral Maxillofac Surg. 2014;72(3):606-610. doi:10.1016/j.joms.2013.09.009
12. Pai PS, Vaidya AD, Prabhash K, Banavali SD. Oral metronomic scheduling of anticancer therapy-based treatment compared to existing standard of care in locally advanced oral squamous cell cancers: A matched-pair analysis. Indian J Cancer. 2013;50(2):135-141. doi:10.4103/0019-509X.117024
13. Narendra H, Tankshali RA. Prevalence and pattern of nodal metastasis in pT4 gingivobuccal cancers and its implications for treatment. Indian J Cancer. 2010;47(3):328-331. doi:10.4103/0019-509X.64720
14. Noronha J, deSouza A, Patil P, et al. Management of colon cancer at a tertiary referral center in India - Patterns of presentation, treatment, and survival outcomes. Indian J Cancer. 2019;56(4):297-301. doi:10.4103/ijc.IJC_379_18
15. Pathak KA, Nason RW, Talole SD, Abdoh AA. Are buccal cancers in India and Canada any different?. J Surg Oncol. 2008;97(6):529-532. doi:10.1002/jso.21002