Lip Cancer: Early Signs, Actinic Cheilitis and Surgical Treatment — A Comprehensive Guide

Lip cancer represents 20-30% of all head and neck cancers and 5-10% of all skin cancers. Incidence is higher in sunny countries (Türkiye included); more common in agricultural/fishing populations. Annual incidence 1-15 per 100,000 (geography- and ethnicity-dependent).

Location: 88-95% lower lip, 3-7% upper lip, 2-3% commissure. UV affects the lower lip more (upper lip shaded by the nose).

Histology: >90% squamous cell carcinoma (SCC). Others: basal cell carcinoma (BCC — more common on the upper lip), melanoma (rare, in the vermilion or skin transition, aggressive), minor salivary gland carcinomas.

Risk factors: Sun (UV) exposure — strongest factor, especially UVB. Cumulative outdoor exposure (fishermen, farmers, construction workers, postal workers, street vendors). Fair skin, blue/green eyes, light hair (Fitzpatrick I-II) predispose. Smoking — independent risk factor; the contact zone on the lower lip is especially vulnerable. Pipe and waterpipe carry higher risk than cigarettes. Alcohol — synergistic with smoking. Chronic trauma (ill-fitting dentures, broken tooth, inadequate occlusion). HPV (especially HPV-16) — rare cases on the upper lip. Immunosuppression (organ transplant, bone marrow transplant, HIV). Other: rare genetic conditions like xeroderma pigmentosum, dysplastic naevus syndrome.

Sex and age: 10:1 male-to-female — male predominance reflects higher smoking and outdoor work. Peak incidence 50-70 years. Female incidence is rising (smoking patterns and outdoor recreation changes). Related service: our head and neck cancer surgery programme.

Actinic cheilitis (AC) — cumulative damage to the lower lip vermilion epithelium and subepithelial stroma from chronic UV exposure. Most lip cancer cases have underlying AC; estimated transformation risk 0.5-10% (depending on degree of epithelial atypia).

Clinical appearance: dryness, whitish plaques (leukoplakia-like), red erosions (erythroplakia), crusting, fissures, blurred vermilion border, areas of hypertrophy or atrophy. Usually diffuse on the lower lip.

Histology: epithelial keratosis, parakeratosis, atypical keratinocytes (mild → moderate → severe dysplasia), basement membrane thinning, dermal solar elastosis.

Diagnosis: clinical + biopsy. Multiple punch biopsies from suspicious areas. Early: non-invasive dysplasia; advanced: carcinoma in situ (CIS) or invasive SCC.

Treatment: as the entire field is sun-damaged, "field cancerisation" — local lesion treatment alone is inadequate; whole-lip treatment is required. Options:

1. Topical: 5-fluorouracil (5-FU) cream, imiquimod, diclofenac. Applied for 2-4 weeks; effective during inflammation/erosion. Good for mild-moderate cases.

2. Photodynamic therapy (PDT): topical photosensitiser (ALA or MAL) followed by red light. Effective and cosmetically friendly.

3. Laser ablation: Er:YAG or CO2 laser superficial epithelial removal. Effective for severe cases.

4. Vermilionectomy: surgical removal of the entire vermilion epithelium with mucosal advancement flap reconstruction. Gold standard for diffuse AC and carcinoma in situ; definitive.

Prevention: even after field treatment, renewed UV exposure causes recurrence — lifelong sun protection (high-SPF lip balm, wide-brimmed hat).

Early clinical features: non-healing sore, fissure, crusting, white/red plaque, tender area, induration. Advanced disease: destructive ulcer, bleeding, invasion of surrounding tissues (bone, mucosa, skin), growing mass. Lymph node findings: ipsilateral submental (lower lip midline), submandibular (lateral lower lip). Upper lip drains to parotid and preauricular nodes.

Diagnosis: detailed history (duration, bleeding, pain, spread, smoking, sun exposure), complete head and neck examination (inspection and palpation of upper and lower lip — irregular borders, induration, ulcer; systematic palpation of bilateral cervical nodes). Punch biopsy of the suspicious lesion (3-4 mm, definitive diagnosis) or wide excisional biopsy for small lesions.

Imaging: not routine for superficial <2 cm lesions. >2 cm, clinical invasion, suspected bone involvement, or nodal findings — neck CT or MRI (MRI better for soft tissue and bone). PET-CT for suspected distant metastasis.

Staging (AJCC 8th edition — TNM):

T1: tumour ≤2 cm and depth ≤5 mm; T2: 2-4 cm or depth 5-10 mm; T3: >4 cm or depth >10 mm; T4a: invasion of bone, inferior alveolar nerve, floor of mouth or facial skin; T4b: masticator space, pterygoid plates or skull base.

N: regional lymph nodes. N0: none; N1: ipsilateral single ≤3 cm; N2a: ipsilateral single 3-6 cm; N2b: ipsilateral multiple ≤6 cm; N2c: bilateral or contralateral; N3: >6 cm. Extranodal extension is an additional prognostic factor (N3b).

M: distant metastasis (lung, bone, liver — rare, advanced cases).

Clinical stage: I (T1N0), II (T2N0), III (T3N0 or N1 any T), IV (T4 any N, or N2-3 any T, or M1). For the related clinical reference, see oral cavity cancer page.

Surgical resection is the mainstay of lip cancer treatment. Goal: en-bloc resection with negative margins (≥5 mm). Reconstruction depends on defect size:

Small (<1/3 of lip): primary closure (V or W incision).

Medium (1/3-2/3 of lip): local flaps (Abbe, Estlander, Karapandzic). Karapandzic preserves vermilion and is highly successful on the lower lip.

Large (>2/3 of lip): large flaps (Bernard, Webster, nasolabial), free tissue transfer (radial forearm, anterolateral thigh).

Neck dissection: observation for T1N0 small lesion; elective neck dissection (levels I-III) for T2-T3 advanced and large lesions or tumour depth >4 mm. Therapeutic selective neck dissection (levels I-V or modified radical) for N+ cases.

Radiotherapy (RT): surgical alternative or adjuvant. Curative RT is an option in cosmetically sensitive cases (large lesion preserving commissure). Adjuvant RT: close or positive margins, extracapsular nodal extension, perineural invasion, lymphovascular invasion, T3-T4, multiple positive nodes. Total dose 50-66 Gy over 5-7 weeks.

Chemoradiotherapy (CRT): in advanced disease (locoregional advanced, extracapsular extension, positive margin) adjuvant platinum-based (cisplatin 100 mg/m² every 3 weeks or weekly) with RT. Individualised by medical fitness.

Immunotherapy: PD-1 inhibitors (nivolumab, pembrolizumab) for recurrent/metastatic disease. Clinical trials ongoing.

Reoperation and recurrence: local recurrence typically within 1-2 years; annual follow-up critical. Recurrence is managed multidisciplinarily by tumour board.

Survival: 5-year overall — Stage I 90-95%, Stage II 80-90%, Stage III 50-65%, Stage IV 30-40%. Early-stage lip cancer has one of the best prognoses among head and neck cancers.

Poor prognostic factors: advanced T stage (>4 cm or >10 mm depth), nodal positivity (especially with extranodal extension), perineural invasion, lymphovascular invasion, inadequate surgical margin, poor differentiation, immunosuppression, upper lip (parotid spread), poor treatment adherence.

Close follow-up: first 2 years every 3 months for head and neck examination (peak recurrence period). Years 3-5 every 6 months. After 5 years yearly. Screen for local, regional (neck) and distant recurrence and second primary cancers (especially head/neck and skin).

Imaging follow-up: individualised — in high-risk (T3-T4, N+, adverse features) CT or MRI every 6 months for the first 2 years; standard-risk yearly or symptom-driven.

Second cancer risk: 10-15% of lip cancer patients develop a second primary cancer within 5 years (skin — face, ear, head and neck — oral cavity, larynx, pharynx). Annual skin examination and head/neck screening.

Prevention: lifelong.

Sun protection: SPF 30+ lip balm (reapply every 2 hours), wide-brimmed hat (especially 10:00-16:00), prefer shade outdoors, limit exposure on high-UV days.

Smoking cessation: especially in patients with diagnosed lip cancer. Cessation improves treatment outcome and reduces recurrence in all head/neck cancers.

Alcohol moderation: synergistic risk with smoking is high.

Regular lip and head/neck examination: all outdoor workers >40, current and former smokers should have annual ENT or head and neck surgical exam. Patients with treated actinic cheilitis followed every 3-6 months.

Repair of ill-fitting dentures or broken teeth: reduces chronic mechanical trauma risk. Related reading: our multidisciplinary tumour board.