Carcinoma tongue

1. Dr.P.Viswakumar,
Assistant professor,
Dept. of General surgery,
PSGIMSR,
Cbe-04
Carcinoma Tongue

2. Anatomy of Oral cavity
 Extends from skin- vermilion junction of lips to
junction of hard and soft palate above
 Below it is limited to circumvallate papilla of tongue.

3. Structures included
 Lips, Buccal mucosa, Upper and lower alveolar
ridges,the retromolar trigone,anterior two thirds of
tongue,floor of mouth and the hard palate.
 Again it is divided into external compartment
vestibule and inner oral cavity proper by alveolar
ridges and teeth.

4. Buccal mucosa

6.  Sensation :
2nd and 3rd branch of Trigeminal
nerve.
 Motor :
Facial nerve
 Lymphatics : Parotid and level 2 lymph nodes
of neck

7. Hard Palate

8.  Importance of hard palate :
-Mucosa and periosteum are closely
adherent.
-These foraminas are potential route of
spread of malignancies anteriorly to nasal cavity
and posteriorly to skull base.
-Lymphatic drainage through level II if in
posterior hard palate and both primary hard
palate drains into level I nodes.
-Sensation is by V 2

9. Retromolar trigone

11. Importance of Retromolar trigone
 Mucosa is closely adherent to the ascending
ramus of the mandible.
 Carcinoma in this region often invades mandible.
 Referred otalgia results from innervation by
V3,lesser palatine nerve, and the
glossopharyngeal nerve.
 Lymphatic into Level II nodes.

12. Floor of the Mouth

13. Tongue

14. Salient features
 Sulcus terminalis divides the tongue into anterior
2/3rd and posterior 1/3rd.
 Anterior 2/3rd is part of oral cavity and posterior
1/3rd part of oropharynx.
 Anterior part is derived from lateral lingual
swellings of first branchial arch and got lingual
nerve as sensory supply.

15. Muscles of Tongue
Broadly divided into
1) Extrinsic and
2) Intrinsic group

16. Muscles of Tongue
 Extrinsic : 3 pairs
1) Styloglossus
2) Hyoglossus
3) Genioglossus
 Intrinsic : 3 groups
1) Vertical.
2) Longitudinal.
3) Transverse.

17. Innervation and Drainage
Motor : Hypoglossal nerve
Sensory : Lingual/Taste by Chorda tymphani via facial
nerve.
V3 also supplies EE,EAC,TM Tongue malignancy has
referred pain over ear.
Arterial : Lingual artery
Lymphatic : Tip – Level I A
Lateral aspect @ Level II nodes
Medial aspect into Level III nodes
Lateral drains only in Ipsilateral nodes
Medial can drain in both ways.

18. Incidence of Oral malignancy
 India continues to report the highest prevalence
of oral cancers globally with 75,000 to 80,000
new cases of such cancers reported every year.
 57.5 % of global head and neck cancer occurs in
Asia esp in India.
 Head and neck cancer accounts 30% of all
cancers in Male and 11-16% of females in India.
 Nearly 2/3rd of oral cancer in India occurs in
Gingivo-buccal sulcus and hence it is popularly
called “Indian oral cancer”.

20. Distribution of cancer in Oral
cavity

22. Etiology

23. Etiology

24. Etiology

25.  Tobacco use in dose dependent fashion.
 Alcohol has synergistic effect.
 It takes 20 years for a smoker or tobacco chewer
who abstained from above to clear of their risk of
developing tumor.
 In India tobacco along with betel nut chewing
contributes 25 % of cancers in oral cavity.
 75% of Squamous cell carcinoma occurs only in 10
% of mucosal areas.
 Those are Gingivobuccal sulcus,lateral border of
tongue to retromolar trigone and the anterior tonsillar
pillar.
 This is due to flow and pooling of carcinogen
contaminated saliva in these regions.

26.  Human papillomaviruses (HPVs) have been
associated with a risk for oral cavity .
 These carcinomas may carry a better prognosis and
may respond better to therapy such as radiotherapy.
 A nested case-control study suggested that the risk
may be with the HPV-16 serotype, with 50% and
14% of oropharyngeal and oral tongue carcinomas,
respectively, containing HPV-16 DNA.
 The EBV is a human herpesvirus that has been
implicated in a number of human malignancies,
including nasopharyngeal carcinoma (NPC).

27. Premalignant lesions

29. Pathology
 Squamous cell carcinoma accounts for 95% of all
malignant tumors in the oral cavity.
 Other malignancies involving the oral cavity
include malignant salivary gland lesions, mucosal
melanoma, lymphoma, and sarcoma.
 In the earliest recognizable stage, squamous cell
carcinoma appears as firm, pearly plaques or as
irregular, roughened, or verrucous areas of
mucosal thickening.

31. Clinical presentation
 Non healing ulcer
 Other tell-tale sign of head and neck malignancy
1) Otalgia
2) Odynophagia
3) Bleeding
4) Dysphagia
 Pertaining to tongue : Restriction of movement of
tongue,difficulty in pronounciation.

32. Pretreatment evaluation
 Complete head and neck examination
 Examination under anaesthesia if necessary.
 Biopsy(Wedge biopsy) of primary lesion or
suspicious ones.
 FNAC of suspicious/enlarged/palpable
lymphnodes.
 CT/MRI of primary and neck.
 X-ray chest to rule out synchronous primary.

33. Other important things
 Dental evaluation
 Examination under anaesthesia
1) Direct laryngoscopy and pharyngoscopy
2) Esophagoscopy.
3) Bronchoscopy.
4) Palpation of tongue and oropharynx.
 Councelling about speech loss and therapy.

34. STAGING

36. Treatment Options
Dr.Haris PS/ OMR36
T1N0, T2N0 Surgery ± RT
RT -External Beam
-Brachytherapy
T3N0, T4N0 Surgery and Post op RT
N+ ± Chemotherapy
T4b, N3, M+ PALLIATION
- Primarily RT ± Chemo
CURATIVE

37. Management
 T1-2 => Either Surgery or Radiotherapy.
 T3-4 => Combination of chemoradiotherapy
and Surgery.

39. Dr.Haris PS/ OMR39
Advantages
 Short time – compliance
 Specimen available for HPE
 Helps in planning adjuvant treatment
 No radiation sequelae
Disadvantages
 Tissue & functional loss
 Disfigurement
 Infection
 Bleeding
 Mortality

40. Radiation Therapy
 They have equal success in controlling T1
lesions.
 They are part of treatment
Curative.
Combination of therapy.
Palliative.

41. Pros and Cons of Radiotherapy
 Provide better functional result with superior
speech and swallowing.
 Disadvantage of altered taste,xerostomia and the
protracted nature of treatment course.
 Requires atleast 6 weeks of treatment.
 Osteonecrosis of mandible.
 Newer technique of IMRT and brachytherapy
reduces above side effects.

42. Chemotherapy
Dr.Haris PS/ OMR42
Curative
- Neoadjuvant (Induction)
- Adjuvant
- Concurrent: to treat micromets
Palliative
- Recurrence
- Metastatic disease
Drugs - Cisplatin, Methotrexate, 5 FU

43. Neck Dissection
 Selective neck dissection.
Supraomhyoid neck dissection
Central compartment neck dissection
Posterior triangle dissectio
 Comprehensive neck dissection.
Radical and modified radical neck
dissection.

46. Prognostic factors
Predictors of Poor prognosis:
Increasing tumor thickness(>4mm)
Poorly differentiated
High grade tumors
Perineural,Vascular and lymphatic invasion.
DNA ploidy status such as aneuploid carry
worst prognosis
Verrucuous Ca has better one

47. Prognosis
Stage 1: 80 – 90 %
Stage 2: 70 – 80 %
Stage 3: 30 – 50 %
Stage 4: 20 – 30 %