Carcinoma tongue

DR . ARCHANA CHILAKALA
 anatomy

 The oral tongue consists of 4 anatomic regions: the

tip, the lateral borders, the dorsum, and the
undersurface.
 Posterior to the circumvallate papillae, the base of
the tongue is anatomically part of the oropharynx.

 It is covered by squamous epithelium composed of

circumvallate, filiform, and fungiform papillae.
 anatomy

 The oral tongue is a muscular structure with

overlying nonkeratinizing squamous epithelium.
 The tongue is composed of four intrinsic and four
extrinsic muscles separated at the midline by the
median fibrous lingual septum
 anatomy

 The lingual artery provides blood supply to the

tongue( branch of the external carotid artery)
 The hypoglossal (cranial nerve XII) to the muscles
 The lingual branch of the mandibular nerve (cranial
nerve V3) provides the sensory nerve supply to the
mobile tongue.
 Taste is provided by the chorda tympani, a branch of
the facial nerve, traveling with the lingual nerve.
 Etiology

 Synergistic carcinogenic effects of tobacco and

alcohol.
 Poor orodental hygiene
 Chronic irritation from ill-fitting denture or jagged
teeth.
 Gastroesophageal reflux
 Viral infection HPV Human papillomavirus
infection most commonly types 16 and 18
 Plummer-Vinson syndrome, characterised by
atrophy of the upper alimentary tract
 Pathology

 Tumors of the tongue begin in the stratified

epithelium of the surface and eventually invade into
the deeper muscular structures.
 Tumors on the tongue may occur on any surface, but
are most commonly seen on the lateral tongue
(50%)tip (10%) the ventral surfaces(9%)
 pathology

 more than 90% of oral cavity cancers are squamous

cell carcinomas
 Most of the other are of minor salivary gland origin.
 Lymphomas, melanomas, and sarcomas rarely occur
in the tongue
 Primary tumors of the tongue musculature include
 Leiomyosarcoma
 Rhabdomyosarcoma
 Neurofibromas
 Verrucous carcinoma
 Gross pathology

 The presentation is commonly an ulcerated or

exophytic mass
 Direct spread

 Anterior third (tip) lesions usually are diagnosed

early.
 Advanced lesions invade the floor of the mouth and
root of the tongue, producing ulceration and fixation
 lingual nerve and the hypoglossal nerve may be
invaded directly by tumors
 Their involvement produces the clinical findings of
loss of sensation of the dorsal tongue surface and
deviation on tongue protrusion, fasciculations, and
atrophy
 Lymphatic spread

 The regional lymphatics of the oral cavity are to the

submandibular space and the upper cervical lymph
nodes
 skip metastases to the level III or IV nodes without
involvement of levels I and II in 16% of patients.
 35% have clinically positive nodes on admission
 5% are bilateral.
 The incidence of positive nodes increases with T
stage.
 TNM classification

 Primary tumour (T)

 TX Primary tumour cannot be assessed
 T0 No evidence of primary tumour
 Tis Carcinoma in situ
 T1 Tumour < 2 cm in greatest dimension
 T2 Tumour > 2 but < 4 cm
 T3 Tumour > 4 cm but < 6 cm
 T4 Tumour invades adjacent structures, e.g.
mandible, skin
 TNM classification

 Regional lymph nodes (N)

 NX Regional lymph nodes cannot be assessed
 N0 No regional lymph node metastasis
 N1 Metastasis in a single ipsilateral lymph node < 3 cm in
 greatest dimension
 N2a Metastasis in a single ipsilateral lymph node > 3 cm but not
 more than 6 cm
 N2b Metastasis in multiple ipsilateral lymph nodes, none > 6 cm
 in greatest dimension
 N2c Metastasis in bilateral or contralateral lymph nodes, none
 greater than 6 cm in greatest dimension
 N3 Metastasis in any lymph node > 6 cm
 TNM classification

 Distant metastases are relatively uncommon but

sites involved
 include lung, brain, liver, bone and skin.
 Clinical Picture

 Mild irritation of the tongue is the most frequent

complaint.
 As ulceration develops, the pain worsens and is
referred to the external ear canal.
 Extensive infiltration of the muscles of the tongue
affects speech and deglutition
 foul odor
 Painless neck lump
 Trismus
 Examination

 Extent of disease is determined by visual

examination and palpation.
 The tongue protrudes incompletely and toward the
side of the lesion as fixation develops.
 While most cancers have either an ulcerative or an
exophytic appearance, many can have only subtle
visually detectable changes.
 On palpation, the involved area is usually firm and
indurated.
 A bimanual examination of the floor of mouth is
mandatory for a complete exam.
 The mass should be manipulated to discern
mobility.
 Oral cavity cancers can invade the mandible quite
readily, and immobility should raise concern for
bone invasion
 Lymphnodes
 INVESTIGATIONS

 Magnetic resonance imaging

 Computerised tomography
 Fine-needle aspiration cytology
 Ultrasound
 Treatment

 Selection of Treatment Modality

 Both surgery and irradiation result in cure rates that
are similar for similar stages
 Excisional Biopsy (TX)

 Excisional biopsy of a small lesion may show

inadequate or equivocal margins. An interstitial
implant or re-excision will produce a high rate of
local control
 Early Lesions (T1 or T2)

 A partial glossectomy with primary closure or a skin

graft may be done transorally and is usually the
preferred therapy.
 Depending on the depth of invasion, an elective neck
dissection may be indicated.
 The carbon dioxide laser may be used for excision of
early tongue cancers or for ablation of premalignant
lesions.
 Moderately Advanced Lesions (T2 or T3)

 The preferred treatment for the majority of these

patients is partial glossectomy, neck dissection, and
postoperative radiotherapy.
 The flap reconstruction can be either a pedicled flap
(such as pectoralis major flap) or a free flap (radial
forearm and fibular being common flap harvest
sites).
 Advanced Lesions (T4)

 Combined treatment with surgery and radiation

therapy will cure very few patients. Most patients in
this category will receive palliative therapy.
 The COMMANDO Operation or COMMANDO
Procedure (COMbined MAndibulectomy and
Neck Dissection Operation) is a complicated
operation for 1st degree malignancy of the tongue.[1]
It comprises glossectomy (total removal of the
tongue) and hemimandibulectomy together with
block dissection of the cervical nodes. The operation
is so named because of its extensive nature
 Reconstruction

 Small defects of the lateral tongue can be managed

by primary closure or allowed to heal by secondary
intention.
 Larger defects,require formal reconstruction to
 encourage good speech and swallowing.
 A radial forearm flap either with skin and/or fascia,
utilising microvascular anastomosis, gives a good
functional result.
 Large-volume defectsincluding total glossectomy
require more bulky flaps such as the rectus
abdominus free flap.
 Irradiation Technique

 Interstitial radiation therapy or by intraoral cone

 Superficial T1 tumors may be treated with 192Ir
brachytherapy alone using the plastic tube
technique.
 Larger lesions that have an increased risk for
subclinical neck disease may be treated with external
beam radiotherapy and a brachytherapy boost or
with brachytherapy combined with an elective neck
dissection.