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TONGUE CARCINOMA-CLINICAL

FEATURES AND MANAGEMENT

CHAIRPERSONS
Prof. D.ROY
Dr.A.MUKHOPADHYAY

SPEAKER-DR. WASHIM MOLLAH

INTRODUCTION:

The tongue is a muscular structure with overlying nonkeratinizing


squamous epithelium.

Tongue is devided into anterior 2/3 (oral) and posterior 1/3


(pharyngeal) by sulcus terminalis.

Due to the extensive lymphatic drainage of the tongue, nodal


metastases are common (37-58%) at the time of diagnosis.

Significant lymphatic drainage occurs across the midline, and thus


the nodes of both sides of the neck need to be carefully examined
for presence of nodal metastases.

Sites of tongue carcinoma:


1. Lateral margincommonest47-50%.
2. Posterior third20%.
3. Dorsum6.5%.
4. Ventral surface9%.
5. Tip10%.

Histologically
1. Squamous cell carcinomacommonest (Approximately 75% of all
tongue SCCs arise from the anterior two thirds of the tongue).
2. Adenocarcinoma- from minor salivary glands or mucous glands.
3. Melanomas.
4. Transitional cell carcinoma and lymphoepithelioma rarely in
posterior 1/3rd of tongue.

SYMPTOMS

A sore in the tongue that does not heal (most common


symptom)
Pain in the tongue that does not go away (also very common)
A persistent red painless patch/ulcer/swelling which may later
become painful in the tongue.
A sore throat or a feeling that something is caught in the throat
that does not go away.
Increased salivation

Difficulty and pain on swallowing (CA of post.1/3 of tongue)


Dysphagia ( CA of post 1/3 of tongue)
Voice changes (CA of post 1/3 of tongue)
Inability to articulate
Difficulty moving the jaw or tongue
Swelling of the jaw that causes dentures to feet poorly or
become uncomfortable
A lump or mass in the neck
Weight loss
Persistent bad breath
Features of bronchopneumonia-duo to aspiration

PATIENT WORK-UP

HISTORY
CLINICAL EXAMINATION
INVESTIGATIONS

INVESTIGATIONS
Primary:
Punch biopsy
FNAC of neck lymph nodes
Indirect and direct laryngoscopy-post.1/3 growth
CXR
Orthopantomogram
ECG
Routine blood investigations

Investigations for staging:


CT scan - Face + Neck + Chest
MRI
USG of neck or primary + USG guided FNAC of suspicious
lymphadenopathy
PET scan

Investigations for
reconstruction:

Allens test of vascular supply to hand if a radial forearm flap


anticipated.
MRA of leg vessels if composite fibular reconstruction
anticipated.
Colour doppler of chest and abdomen if DCIA (deep
circumflex iliac artery) free flap anticipated.

TNM STAGING FOR


ORAL CAVITY CARCINOMA
Primary Tumor
TX Unable to assess primary tumor
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor is < 2 cm in greatest dimension
T2 Tumor > 2 cm and < 4 cm in greatest dimension
T3 Tumor > 4 cm in greatest dimension
T4 (lip) Primary tumor invading cortical bone, inferior alveolar nerve, floor of
mouth, or skin of face (e.g., nose or chin)
- T4a (oral) Tumor invades adjacent structures (e.g., cortical bone,
into deep tongue musculature, maxillary sinus) or skin
of face
- T4b (oral) Tumor invades masticator space, pterygoid plates, or
skull
base and/or encases the internal carotid artery

Regional lymphadenopathy

Nx Unable to assess regional lymph nodes


N0 No evidence of regional metastasis
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
- N2a Metastasis in single ipsilateral lymph node >3 cm and < 6
cm
- N2b Metastasis in multiple ipsilateral lymph nodes, all nodes <
6 cm
- N2c Metastasis in bilateral or contralateral lymph nodes, all
nodes < 6 cm
N3 Metastasis in a lymph node > 6 cm in greatest dimension

Distant metastases

MX Unable to assess for distant metastases


M0 No distant metastases
M1 Distant metastases

TREATMENT
Treatment goals:

To eradicate primary tumour and LN metastasis


To maintain function
Cosmetic reconstruction

Factors affecting choice of treatment:

Tumour factor
Patient factor
Resource factor

TREATMENT MODALITIES

Surgery
Radiotherapy
Chemotherapy

According to stage:

T1 and T2: RT and surgery equally acceptable.


Larger lesions are best managed by combined modality
treatment.

Comparative highlights between surgery and RT:

Early lesions:5 year survival for RT or surgery ranges 80%90%


Local necrosis and bone exposure more with RT.

SURGERY

Wide excision with 1cm clearance in margin and depth-in <


1cm tumour or in ca in situ.

Partial glossectomy with 2cm clearance with removal of ant.


1/3 of tongue-in 1-2 cm tumour

Hemiglossectomy in tumour >2 cm size

Larger tumour preoperative radiotherapy followed by


hemiglossectomy done.

If mandible involved-hemimandibulectomy is done.


Procedure involving hemiglossectomy+
hemimandibulectomy+radical neck dissection called as
COMMANDO OPERATION
Reconstruction of tongue and other area after surgery: By
deltopectoral flap, forehead flap, pectoralis major muscle flap, skin
grafting.

Management of neck:

Treatment of cervical lymphatics is recommended for virtually


all patients.

When the primary site is addressed surgically, modified


radical neck dissection (MRND) or selective neck dissection
(SND) is performed.

Depth of invasion of the primary tumor can direct the need


for elective lymph node dissection with early stage lesions.

Carcinoma of posterior 1/3 of


tongue:

Lesion may remain asymptomatic for long time & Clinically


may be missed easily.

Referred pain in the ear, bleeding from mouth, visible mass in


posterior third of tongue is late local features.

Induration on palpation in posterior third tongue is diagnostic


of the carcinoma.

Lymph node spread is common (70%). Bilateral nodal spread


is common.

Carcinoma posterior third of the tongue is often poorly


differentiated and so carries poor prognosis.

Blood spread can occur into bones, liver and lungs in posterior
third cancers.

T1, T2, N0 and N1 diseases are treated by surgical wide


excision or often by total glossectomy using midline
mandibulotomy incision (mandible split) with neck dissection
on both sides (MRND one side).

Post surgery radiotherapy is needed if it is a poorly


differentiated type or nodal status is more than N1.

Advanced lesions need palliative radiotherapy or


chemotherapy.

T4 lesions are often treated by total glossectomy with


laryngectomy and neck dissection but overall outcome is not
good.

TAKE HOME MESSAGE:

Any complain of sore throat or lesion over tongue


should properly examined to exclude premalignant
condition or malignancy of tongue..............

If not than the patient may lose his/her tongue as well


as life.....