Download Carcinoma of Tongue

Carcinoma of Tongue (Oropharyngeal)
Dr. Ahmed Khan Sangrasi,
Assistant Professor, Dept. of Surgery,
LUMHS, Jamshoro
 In oncology squamous cell cancers of the head and neck are
often considered together because they share many
similarities - in incidence, cancer type, predisposing factors,
pathological features, treatment and prognosis
 Up to 30% of patients with one primary head and neck
tumour will have a second primary malignancy
 Tobacco when kept in mouth leaches out carcinogens,
which act on oral mucosa causing neoplastic changes.
Habit of smoking is also equally dangerous
 Tobacco contains potent carcinogens
including Nitrosamines (nicotine),
polycyclic aromatic hydrocarbons,
Nitrosodiethanolamine,
Nitrosoproline, and polonium.
Tobacco smoke contains carbon
monoxide, Thiocyanate, hydrogen
cyanide, nicotine and metabolites of
these constituents.
 Tobacco in Pakistan most commonly
consumed in the form of gutka, quid
pan or smoking in the form of bidi
of cigarette.
 Gutka is a flavored tobacco
mixture with betel nut lime, and
harmful additives like magnesium
carbonate. It is extremely
addictive and is apparently
targeted at youngsters.
 Quid is the mixture of tobacco and
lime and extensively consumed.
Precancerous lesions
 There are three most common precancerous lesions
seen in the mouth and they are
1.Oral leucoplakia
 It is characterized by white patch on
the buccal mucosa or any place in the
mouth and is adjacent to the place where
the tobacco quid is kept. The less
likely place is floor of the mouth and
tongue although 93% of leucoplakia at
this sites turn malignant.
ORAL LEUCOPLAKIA PATCH
2. Erythroplakia
 This is characterized by red velvety patch which is not
associated with any trauma or inflammation. It may
present with or without leucoplakia. This lesion is easily
missed out but is considered to have great malignancy
potential.
Erythroplakia
3.Oral sub mucous fibrosis.
 This condition is characterized by
limited opening of mouth and burning
sensation on eating of spicy food.
This is a progressive lesion in
which the opening of the mouth
becomes progressively limited, and
later on even normal eating becomes
difficult.
Oral Sub Mucous Fibrosis
This patient of SMF has so much of limitation in opening
of mouth that it is difficult to put even 2 fingers in the
mouth
Smf is equally common in gutka eating
ladies
 Professor Newell Johnson an expert
oral surgeon said, ”we know this
condition, oral sub mucous
fibrosis has highest rate of
transferring to malignancy of any
of the so called pre-malignant
lesions in the mouth. It is a very
serious condition.”
 The next stage after the precancerous lesion
is the Cancerous lesions.
 The most common form of cancer is
Squamous cell carcinoma.
 It normally starts from any of the
precancerous lesion in the mouth.
Common sites of oral cancer
 The most common sites of the oral cancer is the
tongue and the floor of the mouth. The other
common sites are buccal vestibule, buccal
mucosa, gingiva and rarely hard and soft palate.
Cancer of bucco-pharyngeal mucosa is common
in smokers.
Cancer of Gingiva and Buccal mucosa
 The lesion is usually painless in early stages
and only when it becomes ulcerated and
secondarily infected or invades adjacent nerve,
pain is the noticeable feature. The tumor is
usually at the level of the occlusal plane or
below it. They may be proliferative warty
exophytic growth with little fixation or deeply
ulcerative invasive lesion. The proliferative
lesion though it looks dangerous is easily
treatable and long-term prognosis is good as
the metastasis to the local lymph nodes is
relatively late. Whereas the ulcerative lesion
is not so easily noticeable in the early stages
but is more dangerous because of their invasive
nature and the metastasis to the local lymph
nodes is very early
Cancer Of Cheek after tobacco quid
habit
SAME PATIENT WITH THE CANCER
LESION COMING EXTRA ORALLY
Cancer of buccal mucosa after tobacco habit going
extra-orally
CANCER STARTING FROM BUCCAL VESTIBULE
FOLLOWING HABIT OF PAN WITH TOBACCO
Cancer of Buccal mucosa invading extra-oral
tissues following tobacco quid habit
Cancer of labial mucosa invading extra-oral
tissues following tobacco quid habit
CANCER OF CHEEK FOLLOWING
EATING OF GUTKA
Cancer of labial mucosa after tobacco
quid habit
Same patient with Cancer Of Gums
CANCER OF GUMS FOLLOWING EATING
OF GUTKA
Carcinoma of the lip
 Carcinoma of the lip usually starts
at the vermilion border of the lower
lip. 95% of lip cancer affects the
lower lip. It is in the form of a
nodule, which ulcerates and forms a
small scab, which fail to heal
completely. It is often misdiagnosed
as a cold sore. Eventually the
margins of the lesions become
proliferative and an extensive
exophytic lesion with central
ulceration develops.
CANCER OF LOWER LIP
 Cancer of palate
 It is usually an ulcerative lesion and may spread extensively
before involving underlying bone.
Cancer of Palate after habit of smoking
Cancer of Palate after habit of smoking
CANCER OF MAXILA AFTER SMOKING
HABIT
CANCER OF PALATE
Alveolar carcinoma
 Alveolar carcinoma is common in
mandible that maxilla. The lesion is
warty nodular and proliferative,
although it may rarely present as
erosive lesion. Unfortunately it
mimics apical or periodontal disease
and their diagnosis is often
delayed. Often the neoplastic nature
is recognized when socket fails to
heal following dental extraction for
a supposedly periodontal abscess.
Alveolar cancer after tobacco quid habit
Alveolar cancer after tobacco quid
habit
Relapse case
He was operated for cancer of lower jaw in oct ‘00
Relapsed cancer in upper jaw in July 04
 This cancer is extremely malignant
and even if there is slight delay
it spreads to lymph nodes of the
neck. Once it spreads the
prognosis becomes poor and death
is inevitable and is because of
erosion of major blood vessels and
erosion of the base of the skull,
Cachexia and secondary infection
of the respiratory tract.
Carcinoma of the Tongue
 It may start as a small ulcer, usually on the lateral border
of the anterior two third of the tongue.
 It may have varied presentation like a small papillary
exophytic lesion, a flat nodule, ulceration within a pre
existing fissure or may occur in the absence of frank
ulceration in an atrophic tongue.
 Once ulceration has occurred, the lesion becomes
painful, making speech and swallowing difficult.
 Tongue cancer rapidly extends to involve the floor of the
mouth and lower alveolus, which makes treatment
difficult.
Statistics on Tongue Cancer
 It is relatively common, with 3% of all malignancies arising
within the oral cavity
 common than all forms of oral cavity cancer except those of
the lip and occurs with increasing age
 uncommon before the age of 40 and the highest incidence of
the disease is in the 6th and 7th decades with sex incidence
being a 3:1 male predominance
 The disease occurs with highest incidence in Indian
populations.
Progression of Tongue Cancer
 tumour spreads by local extension and through the
destruction of adjacent tissue
 Lymphatic invasion with spread to the cervical lymph nodes
is common at diagnosis
 Haematogenous spread to distant sites such as the liver, bones
and lungs may also have occurred at the time of diagnosis
How is Tongue Cancer Diagnosed?
 General investigations may show anaemia or abnormal liver
function tests if the disease is very advanced
 In the early stages of tongue cancer general investigations
tend to be normal.
 when clinical diagnosis of oropharyngeal carcinoma is
suspected a comprehensive protocol of investigations should
be instituted
Investigations
 Blood tests :Evaluate the patient's general health and
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suitability for surgery, if considered
Imaging studies :
Dental X-rays: periapical dental films provide fine details
and are the most useful for detecting minimal invasion of the
mandible, an orthopantomograme of the jaws is helpful to
assess the bony invasion.
Chest X-ray: this may be the only useful X-ray in the
evaluation for distant metastases because the incidence of
distant metastases at presentation is low.
Ultrasound: Done to assess metastases of the liver.
 CT scan and MRI scan: because of the higher soft tissue
resolution with an MRI scan (investigation of choice)
Involvement of the extrinsic tongue musculature and direct
extension in the submandibular glands and the base of tongue
can be revealed with MRI scan.
 Tumour biopsy :
The vast majority of biopsy findings reflect the presence of
SCC. In fewer instances, minor salivary gland malignancies and
sarcomas are discovered.
 An incisional biopsy should be carried out in all cases.
 Fine needle aspiration cytology (FNAC):
 Is useful for the assessment and pathological diagosis of enlarged
cervical lymph nodes.
 Procedure:
 Yield is dependent not only on quality of aspirate but also on skill of
cytologist.
Cancer of Tongue following tobacco
consumption
Cancer of Tongue
Squamous cell carcinoma of the base of the tongue.
Squamous cell carcinoma of the tongue in a 32
year-old chronic smoker.
Cancer classification and Staging
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The American joint committee on cancer has developed the Tumor (T),
Node (N), and Metastasis (M) system of cancer classification. The TNM
classification is basically a clinical description of the disease, but
can also involve imaging in classification. T is the size of the tumor
and T1 is <2 cm, T2 is >2 but < 4 cm, T3 is >4 cm and T4 is >4 cm with
invasion of adjacent structures.
N0 is no lymph node
N1 is single ipsilateral node < 3 cm
N2a single ipsilateral node > 3 cm but < 6 cm
N2b multiple ipsilateral node < 6 cm.
N2c bilateral or contra lateral nodes < 6 cm
N3a ipsilateral node > 6 cm
N3b bilateral nodes > 6 cm
M0 is no metastasis and M1 is metastasis present.
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Staging
Stage I
T1 N0
Stage II T2 N0
Stage III T3 N0
Stage IV T4 ANY
M0
M0
M0; any T1 T2 T3, N1 M0
N, M0; any T, N2 or N3; ANY T OR N WITH M1
Treatment
General Principles for oropharyngeal Caner
1. Surgery
2. Radiotherapy
Small tumours: either by primary radiotherapy or surgery
Advanced tumors: requires combination of surgery and
radiotherapy
 Nowadays chemotherapy is being used for advanced tumors but
patient needs to be fit to tolerate the toxicity.
 Factors to be considered include:
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Site
Stage
Histology
Concomitant Medical Disease
Social Factors
Treatment When Tumour Invades Bone
(Mandible)
 Surgery is deemed appropriate as radio therapy is less
effective.
 Surgery is also more appropriate for bulky, advanced disease
followed by post operative radio therapy.
 Tumour of intermediate size eg: T2 and T3 are more
problematic and regimes are controvertial hence need multi
diciplinary team.
 Cervical Node Involvement:
 Single modality is preferred to deal simultaneously with
lymphnode disease and primary tumor.
Histology
 Degree of differentiation of SCC does not normally influence
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management of tumor alone.
Management of verrucous carcinoma, a variant of SCC is
identical to that of any other SCC.
Malignant tumor of minor salivary gland require primary
surgery.
Lymphoma is managed by radiotherapy, or chemotherapy +
radiotherapy.
Post operative radio therapy for minor salivary gland tumor
is often indicated to reduce risk of locoregional recurrence.
Age
 Modern Anaesthesia and post operative critical care facilities
now allow major head and neck surgery to be carried with
significant medical comorbidity and old age.
 Young patients should not be denied radio therapy for fear of
inducing second malignancy eg: Sarcoma later.
Previous Radiotherapy
 Second course of radiotherapy to previously irradiated site is
contraindicted as tumor is likely to be radio resistant.
 Re-irradiation will result in extensive tissue necrosis.
 Field Change:
 Surgery is preferred when multiple tumors are present or there
is etensive premalignant change of the oropharyngeal mucosa.
 Radiotherapy is unsatisfactory as the entire oral cavity requires
treatment, causing severe morbidity.
Management of premalignant conditions
 Elimination of associated etiological factors
 Cessation of smoking, elimination of the areca nut/pan habit
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and reduction in alcohol consumption
A photographic record is useful for long term follow-up
All erythroplakia and speckled leucoplakia should undergo
incisional biopsy (multiple)
Severe epithelial dysplasia and carcinoma in-situ should be
ablated by surgical excision or laser vaporization.
Small lesions, particularly on lateral border of tongue or
buckle mucosa are managed with surgical excision and
primary closure by undermining adjacent to mucosa
 Large defects can be managed with laser vaporization and
allowed to epitheliaze spontaneously
 With mild to moderate epithelial dysplesia treatment is
facilitated by elimination of causative agents
 Patients who continue to smoke should be managed as for
severe dysplasia and carcinoma in-situ
 Patients who cease smoking and nut-pan maybe followed up
closely at three monthly interval
 Localised disease (T1-T2) lesions are treated with curative
intent by surgery or radiation. Small lesions that are well
lateralised should be excised (partial glossectomy).
 Larger lesions where excision would compromise speech and
swallowing ability should be treated with radiotherapy
 Patients treated with local or regionally advanced disease are
treated most succesfuly with a combined modality therapy of
surgery, radiation therapy and chemotherapy
 Up to 30% of patients with T1 (<2cm) have occult metastasis at
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presentation and should undergo simultaneous treatment of neck by
either elective neck dissection or radiotherapy.
When performing surgical excision of primary tumor, 2cm margin in all
plains should be achieved to ensure a wide, complete excision.
Resection resulting in partial or hemiglossectomy can be performed
with either a cutting dithermi or laser.
Advanced tumors (T3 and T4) often encroach upon the floor of the
mouth and occasionally the mandible. In these circumstances a major
resection of the tongue and floor of mouth and mandible is required.
T4 tumors of oral tongue often cross midline, for which total
glossectomy is the only option to achieve adequate tumor clearance.
When a patient undergoes simultaneous neck dissection the resection of
primary tumor should preferably be in continuity with the neck node
specimen
Prognosis of Tongue Cancer
 Early diagnosis is the key prognostic factor in tongue cancer -
influencing both tumor size and the likelihood of metastatic
deposits
 The 5 year disease free rate is approximately 70% in early
disease, falling to less than 30% in more advanced cases
 Tumors at the base of the tongue are associated with the
worst prognosis due to the increased likelihood of them
being diagnosed at a later stage
THANKYOU