This document discusses the management of tongue cancer. It begins by describing the blood supply and types of carcinoma that can occur on the tongue. The main causes are identified as smoking, alcohol, poor oral hygiene, and viruses. Pre-malignant conditions are discussed. Typical presentations and examinations used in diagnosis are explained. A variety of treatment options are then outlined, including surgery, radiation therapy, and reconstruction techniques. Factors associated with poor prognosis are also identified.

1. MANAGEMENT OF TONGUE
CANCER
MODERATOR: Dr. S. B. Choudhury (Asst.Proff)
PRESENTER: Dr. Bashab Bijoy Roy

4. TONGUE

7. BLOOD SUPPLY:
The tongue receives its blood supply primarily
from :
LINGUAL ARTERY a branch of the External
Carotid Artery.
LINGUAL VEINS drain into the Internal jugular vein.
There is also a secondary blood supply to the root of
tongue from the tonsillar branch of the facial
artery and the ascending pharyngeal artery.

13. CARCINOMA OF TONGUE

14. ETIOLOGY:
7’ S OF TONGUE CANCER :
 SMOKING
 SPIRIT
 SPICES
 SHARP TOOTH
 SUNLIGHT
 SEPSIS
 SYPHILIS

15. TOBACCO-
 90% of tongue cancer patients has history of tobacco use.
 Risk of carcinoma increases with amount of tobacco used &
duration of habit.
 Exposure to tobacco causes progressive sequential morphologic
changes of mucosa leading to neoplastic transformation.
 Such changes may be reversible if tobacco exposure is
eliminated early.
 40% of patients who persisted smoking after presumable cure of
tongue cancer developed second cancer as compared to 6% of
those who stopped smoking.
Agents like - Chewable tobacco, cigarette smoking, pan
masala,etc
ALCOHOL
 70-75% patients with tongue cancer consume alcohol
 6 times more risk in drinker
 Alcohol itself is a carcinogen & act as a direct irritant

17. ETIOLOGY CONTD…
 Poor oral & dental hygiene.
 Fanconi’s anemia.
 Vitamin A deficiency.
 Viruses- HSV -1 … HPV-11 & 16.
 Fresh fruits and vegetables are
protective.

18. PRE-MALIGNANT CONDITIONS
High risk lesions- definite risk of malignancy
1. Leukoplakia :
2. Erythroplakia : 17 -20 times more malignant than
leukoplakia.
3. Chronic hyperplastic candidiasis.
Medium risk lesions-
1. Oral submucosal fibrosis.
2. Syphillitic glossitis
3. Plummer-vinson syndrome-( sideropenic dysphagia due to
iron deficiency)
Equivocal risk lesions-
1. Oral lichen planus
2. Discoid lupus erythematosus
3. Dyskeratosis congenita

20. TYPICAL PRESENTATION:
 A middle aged man coming to OPD -holding
an handkerchief over his mouth to control
the excessive saliva which may be blood
stained (due to chronic non healing ulcer
of tongue) &
has a improper speech (disarticulation -
due to restriction of tongue movement)

22. MOST COMMON VARIETY OF TONGUE CARCINOMA –
Squamous cell carcinoma

23. LOCAL INVASION –OF CA TONGUE
It may spread anteriroly – involving the mandible
Inferiorly – involving the floor of mouth

26. OTHER IMPORTANT EXAMINATIONS

27. CA TONGUE- CT IMAGE & PET SCAN IMAGE

28. MRI IMAGE OF CA TONGUE

33. TREATMENTS AVAILABLE

34. AIMS OF SURGERY:
 Complete excision of primary tumor 3
dimensionally with R0 resection (microscopically
clear margin).
 Removal of Neck lymph nodes.
 Reconstruction of tissue loss-( for rapid healing
, restoration of function & appearance to improve
quality of life.)

35. ACCESS :
 For tumor clearance to be achieved access of oral
cavity is very important:
 Mainly 3 different access techniques are used:
1. TRANSORAL APPROACH- for small tumors.
2. LIP SPLIT TECHNIQUE- through mandible .
3. VISOR INCISION.

37. FOR LYMPH NODE CLEARANCE -

40. INCISIONS FOR NECK DISSECTION

41. FOR SMALL TUMORS <2 CM
 Tumor located at tip of tongue / lateral border of anterior
2/3rd of tongue that are approachable : PER ORAL
RESECTION with 1cm tumor free margin & primary
closure.
 LASER EXCISION can also be used- minimal bleed/ scar &
rapid healing.

42. T1 & SMALL T2 TUMORS :
For T1 /small T2 tumors of anterio- lateral tongue
 Can be treated by BRACHYTHERAPY.
 By using IRIDIUM wire implants
 Can increase the risk of local osteoradionecrosis
of adjacent mandible.
 Should be combined with elective neck radiation if
tumor size exceeds 3 cm.

43. BRACHYTHERAPY

44. FOR LESIONS TOO LARGE FOR LOCAL EXCISION
 Small superficial well differentiated lesions of oral
tongue which are too large for local excision &
tumor not involving the mandible - PARTIAL
GLOSSECTOMY with SPARING OF MANDIBLE is
done along with +
Block dissection of Neck nodes .
Even If no nodes (N0) involved – Selective neck
dissection
is must.
Tongue defect covered with- free skin graft OR
pectoralis major myocutaneous flap OR with radial
forearm free flap (best flap)

46. MANDIBULECTOMY
 Marginal mandibulectomy- it is done in
cancer involving lower gingival or extending
to mandible without clinical or radiological
involvement or with minimal cortical
invasion.
 Segmental mandibulectomy- when
cancer directly invades the mandible

47. FOR LARGE TUMORS / CA TONGUE BASE
 TOTAL GLOSSECTOMY- indicated for massive local
carcinoma of tongue.
 Approach- either lip split technique OR visor’s
approach
 Floor of mouth, mandible up to ascending rami , some
tissue of pharyngeal & laryngeal mucosa along with the
tongue is removed.
 Reconstruction- can be done by PMMF/ radial
forearm free flap.
 If defect is very large – ALT FLAP( Anterio-lateral
thigh flap).
 Mandibular reconstruction- by K-wires OR
titanium plates/ iliac crest bone graft.

48. MANDIBULAR TITANIUM IMPLANT

49. CA POSTERIOR 1/3RD OF TONGUE
 As this site is anatomically difficult for surgery, so
TELE THERAPY / EBRT is useful .
 Median translingual pharyngotomy can be done.
 A temporary tracheostomy is necessary for
patients with flap reconstruction & nasogastric /
gastrostomy tube feeding upto 2 weeks.

52. AT A GLANCE-

53. POOR PROGNOSTIC FACTORS-
 Increasing Tumor thickness >4mm
 High grade tumors
 Poorly differentiated tumors
 Vascular/lymphatic invasion
 Level III & IV has poor prognosis
 B/L or contralateral nodes
 Nodes involved >3 in number
 Nodal size>3cm
 Nodal extracapsular spread

54. THANK YOU