Tongue Cancer and it's Management

1. CA Tongue and its
management
ASST PROF DR AZWAN
HALIM

2. Scenario
63yo Malay Male
P/w right lateral border of tongue swelling in 5/12
Started as ulcer, claimed due to friction of right lower molar tooth against the tongue
Painful associated with odynophagia and slurred speech
Ulcer persist despite extraction of the right lower molar tooth
+LOW (15kg in 3/12), +LOA
No numbness over right lower jaw/lip
No PMHX
Non smoker and non alcoholic drinker

3. Examination
 Patient comfortable, not cachexic, pink no stridor
 Intra oral:
 No trismus, 4x2cm fungating mass at right lateral tongue, anteriorly confined to anterior
2/3 of tongue, not involving the tip, posteriorly involve the post 1/3 of tongue with anterior
pillar involved, laterally involving the floor of the mouth, medially crossed midline
 Limited tongue movement seen, tongue deviated to the right on the tongue protrusion, no
fasciculation seen
 Right retromolar trigone and gingivobuccal sulcus clear.

4. Examination
 Neck : 2x1cm right level 1b node palpable
 Flexible scope:
 Base of tongue, vallaculae, epiglottis clear, larynx normal
 Investigation
 Incisional biopsy: dorsum – well differentiated SCC, ventral moderated diff. SCC

5. An ulcerative squamous cell
carcinoma of the undersurface
of the tongue.
Squamous cell carcinoma of
the tongue associated with
hyperkeratosis.

6. History taking
 When did the ulcer or growth started
 Is the size increasing
 Is it painful – is it local or radiating
 Is it affecting the speech – slurred
 Mobility of the tongue
 Is it affecting oral intake- dysphagia/ odynophagia
 Bleeding from the ulcer?
 Any neck lump
 Any sign of distant metastasis

7. History taking
We need to established history of smoking, tobacco
chewing, vaping, Alcohol drinking
Betel nut chewing
Dietary deficiency. Eg Plummer Vinson syndrome( due to
iron deficiency) increased the risk of oral cancer
Dental problem – jagged sharp teeth and ill fitting
dentures

8. examination
 Thorough ENT examination has to be done.
 Otalgia suggests perineural or deep invasion
 Oral cavity examination must include
 bimanual examination
 Look for leukoplakia and erythroplakia
 Size of the tumor, location of the tumor- ventral/base of tongue or lateral, mobility
of the tongue. Endophytic or exophytic lesion
 Deviation of tongue suggests deep infiltration of muscularity of the tongue.
 Examination of the teeth and alveolus
 Trismus present/-
 Neck examination-To palpate for cervical lymph node metastasis.

9. Examination
Endophytic lesion ( above)
This lesion tend to metastasis
more due to deeper and more
infiltrating nature
Exophytic lesion ( Below)

11. Differential diagnosis
 Benign tumor
Solid
Cystic
Premalignant lesion
Malignant lesion
Carcinoma
Non squamous malignant lesion

12. Benign tumor
Hemangioma of the
tongue Lymphagioma of the
tongue

13. premalignant
Erythroplakia of the lateral
border of tongue
Leukoplakia of the lateral
border of the tongue

14. Malignant
Melanoma of tongue Leiomyosarcoma of tongue
Liposarcoma of tongue

15. DIAGNOSIS
 All ulcerated lesions of the tongue and floor of mouth that last for longer than two to three
weeks require an incisional biopsy to confirm the underlying diagnosis
 All areas of leukoplakia and erythroplakia require a biopsy
 Excisional biopsy will leave a risk of having positive margin at the deep margin

16. imaging
 Ultrasound
 Lodder et al, US thus seems to be the optimal technique in patients with no limited mouth
opening or base of tongue involvement. US measurement is more reliable than MRI for the
measurement of tumour thickness, especially in superficial lesions.
 CT Scan
 Ong et al, It is used if there is suspicious of cortical bone involvement, notably the
mandible which is able to be diagnosed with a higher level of certainty
 MRI
 Ong et al, Tumour invasion of the floor of the mouth is particularly well seen on coronal
images. Sagittal images provide information on tongue base involvement and the extent of
pharyngeal infiltration that cannot be seen on CT. MRI provides valuable information both
within and without the tongue hence it is imaging modality of choice for evaluation of
tongue carcinomas

17.  OPG can be used to assess the state
of dentitation and potential gross
mandibular invasion
 Positron emission tomography (PET)
is useful in improving the detection
of head and neck cancer, especially
recurrent disease, but lacks
anatomical detail

19. Staging
Oral cavity, lips, hypopharynx, major
salivary gland
Lip Oral cavity Hypopharynx clinical/ pathological Major salivary gland
clinical/pathological
Cutaneous
TX Cannot assess Cannot assess Cannot assess Cannot assess Cannot assess
Tis In situ In situ In situ In situ In situ
T1 Size < 2cm
DOI < 5mm
Size < 2cm
1 subsite
Size < 2cm
No extraparenchymal extension
Size < 2cm
T2 2 < size < 4cm
5 < DOI < 10mm
2 < size < 4cm
> 1 subsite
2 < size < 4cm
No extraparenchymal extension
2 < size < 4cm
T3 Size > 4cm
DOI > 10mm
Size > 4cm
Hemilarynx fixation
Esophagus
Size > 4cm
Extraparenchymal extension
Size > 4cm
Minor bone erosion
Perineurial invasion
Deep invasion
T4 Moderately advanced/ very advanced Moderately advanced/ very advanced Moderately advanced/ very advanced
a Bone
Skin
FOM
Nerve
Bone
Sinus - maxillary
Skin
Neck soft tissue - central
Cricoid cartilage
Thyroid cartilage - outer cortex
Hyoid bone
Thyroid gland
Skin
Mandible
EAC
Nerve - facial
Gross cortical/marrow infiltration
b Pterygoid plate
BOS
Masticator
Carotid artery - internal encased
Prevertebral - invade
Carotid artery - encased
Mediastinal structure - invade
Pterygoid plates
Carotid artery
BOS
BOS & foramen

21. Depth of invasion
Spiro, et al. : proposed that the increasing depth of tumor thickness, rather than
tumor staging have the best correlation with treatment failure of survival
Pentenero et al. tumour thickness was shown to be an important parameter for
predicting nodal metastases and for surviva

22. Goal of treatment
 The goals of the treatment of cancer of the oral cavity are:
1. Cure of the cancer
2. Preservation or restoration of speech, mastication,
swallowing, and external appearance;
3. Minimization of the sequelae of treatment such as dental
decay, osteonecrosis of the mandible, and trismus.

23.  Factors that influence the choice of surgical treatment for a primary
tumor of the oral cavity are tumor factors such as:
1. Size and site of the primary tumor (i.e., anterior versus posterior
location)
2. Its depth of infiltration
3. The proximity of the tumor to the mandible or maxilla, or
involvement of mandible or maxilla.
4. Cervical nodes metastasis

24. Tumour
thickness (mm)
Recommended management
>3 Partial glossectomy alone
4-9 Partial glossectomy +/- elective, ipsilateral
level I –IV, selective neck dissection
>9 Partial glossectomy, neck dissection and
post operative radiotherapy to primary site
and neck
Management of cancer of the oral tongue according to tumour
thickness

25. Types of glossectomy
 Partial glossectomy 1/3 or less of tongue
 Hemiglossectomy 1/3 to ½ of the tongue
 Near total glossectomy ½ to ¾ of the tongue
 Total glossectomy or greater of tongue

26.  For T1/T2 lesion, a transoral partial glossectomy
provided adequate margins of resection.
 This maintains articulation and swallowing function.
 However, even early stage cancer may be associated with
rates of nodal metastasis of 30%.
 Also, an increase in loco-regional and disease free
survival after elective neck dissections for clinically
tumor negative necks mandates aggressive treatment.

27.  For T3/T4
 Partial to subtotal glossectomy:
1. modified radical neck dissection type III of N positive neck;
2. ipsilateral selective level I–IV for N0 neck;
3. postoperative radiotherapy of oral cavity and neck.

28. Total glossectomy
This patient we will have to do a near total
glossectomy with radical/modified neck dissection on
the ipsilateral side with selective neck dissection on
the contralateral side
Post operatively radiotherapy should be given

29. Total glossectomy
The surgical approach for total glossectomy with
preservation of the larynx is selected after consideration of
several factors:
1. The size and location of the tumor
2. Invasion of the mandible and the need for
mandibulectomy
3. The need for neck dissection

30. Neck dissection
 Neck dissection should be done first prior to incision of
the primary tumor
 For this case:
 A Modified radical neck dissection on the ipsilateral side
 A selective supraomohyoid neck dissection on the contra lateral
side.
 Rationale for selective or elective neck dissection

31. COnsideration
Bilateral neck dissections should be considered in tumours
that extend to or beyond the midline.
Elective neck dissection or elective neck radiotherapy should
be considered for:
1. Tumours thicker than 3–4mm.
2. T2 or greater in dimension
3. T1 tumours that demonstrate poor histological features
(poor differentiation, double DNA aneuploidy or degree
of differentiation at the advancing front)

32. Modified radical neck dissection
 MRND is divided into 3 types:
1. Type 1 (Preservation of SAN)
1. Clinically obvious neck lymph nodes metastasis and SAN not involved
by tumor. Usually is an intraoperatively decision
2. Type 2 (Preservation of SAN and IJV)
1. Intra operatively decision when tumor is found to be adherent to SCM
but away from IJV and SAN
3. Type 3 (Preservation of SAN, IJV and SCM)
1. Indicated for N1 mobile nodes and not greater than 2.5 – 3.0 cm
2. Contra indicated in the presence of node fixation

33. Supra-omohyoid neck dissection
En Block removal of cervical lymph node
and fibrofatty tissue in regions of I to III,
including submandibular gland
Posterior limit is the cutaneous branches
of the cervical plexus and posterior
border of SCM
Inferior limit is the superior belly of the
omohyoid where it cross IJN

34. Surgical appoach
Oral cavity tumours can be accessed via :
1. Transoral - T1 and small T2 without mandibular involvoment
2. Pull through technique - For more extensive anterior and
lateral floor of mouth cancers without mandibular
involvement
3. Mandibulotomy and mandibular swing

35. Transoral approach
 As long as the tumour is small and easily accessible, ( T1 –
T2 lesions )
 Patients with limited mouth opening, constriction of the
oral commissure and previous radiotherapy causing
fibrosis, may not be suitable .

36. Pull through technique
 Pull-through technique is indicated for large tumors
of the BOT when the surgeon needs wide exposure
but does not want to split the mandible or lip

37. Pull through

38.  Visor flap.
 The superior flap is raised in
the subplatysmal plane up
to the submandibular level.
 Intraoral mucosal cuts are
then performed transorally
with cautery along the
lingual surface of the
mandible

40. MANDIBULOTOMY
 Mandibulotomy or mandibular osteotomy is an excellent
mandible-sparing surgical approach designed to gain access
to the oral cavity or oropharynx for resection of primary
tumors otherwise not accessible through the open mouth
approach.
 3 types of mandibulotomy:
1. Lateral (through the body or angle of the mandible)- rarely do
(posterior)
2. Midline (anterior)
3. Paramedian. (anterior)

41. Comparison of mandibulotomy
Lateral Median Paramedian
Site of osteotomy Body or angle of mandible Midline Between lateral incisor
and canine
Exposure Limited Good Good
Dental extraction May be required One central incisor Not required
Inferior alveolar nerve
and vessel
Have to be transected Spared Spared
Division of geneal
muscle
Not required Inevitable Not required only the
mylohyoid needs division
Mechanical stability Poor because of the
unequal muscle pull on the
2 mandibular segment
Good Good
Fixation of osteotomy May required intermaxillary
fixation
Compression
miniplates or stainless
steel wire
Compression miniplates
or stainless steel wire
Postoperative RT Osteotomy lies within the
lateral portal increased risk
Lies outside the
lateral portal. Safe
Lies outside the lateral
portal. Safe

42. Midline
labiomandibulotomy with
paralingual extension.

43. Midline labiotomy,
paramedian
mandibulotomy.

45. Lip split incision Paramedian mandibulotomy and
a mandibular swing

46. The mandibulotomy site is
exposed.

47. Four drill holes are made prior to
bone division.

48. The mandible is
divided and its
two segments are
retracted laterally.

51. Reconstruction
 Tissue reconstruction in
oropharyngeal defects
follows the standard
‘ladder’ approach, as
with other tissue sites.

52. Aim of reconstruction
 The aim of reconstruction of the oral tongue following
resection is to ensure maximum function of the residual
tongue tissue

53. Reconstruction
 Small defects (<1/4) may be closed primarily with
maximum preservation of tongue mobility and function.
 Larger defects, such as a hemiglossectomy defect, are best
reconstructed with a thin fasciocutaneous flap, such as a
radial forearm or thin anterolateral thigh flap.
 Defects larger than a hemiglossectomy will require more
tissue bulk, and less muscle is left to move the
reconstructed tongue.

54. Reconstruction
 Why is tissue bulk important??
1. It is needed to help the tongue touch the palate
to produce better speech and push food toward
the hypopharynx.
2. The tissue bulk diverts saliva and food to the
lateral gutters during swallowing to minimize
aspiration

55.  The skin paddle of the chosen
free flap should be fashioned
so as not to restrict residual
tongue function and should
hopefully augment swallowing.
 The free flap should be the
same size, or slightly smaller
than the defect created by the
resection

56. Post op Radiotherapy
1. T3/T4 primary cancer
2. Positive surgical margins
3. Poor differentiation
4. Perineural invasion
5. Positive lymphnodes
6. Extracapsular spread of nodal disease
7. Perivascular invasion

58. recurrence
 Recurrence rates for oral tongue carcinoma are 10–50 per cent,
usually being locoregional.
 Similar to other sites, recurrence usually occurs within the first two
years.
 Factors that influence local recurrence include:
 Tumour thickness : due to difficulty in assessing deep clearance
intraoperatively
 The presence of perineural spread.
 Patients younger than 40 years have been demonstrated to be significantly
more likely to develop locoregional failure
10% of patients who have developed a tongue tumour will
develop metachronous second tumours of the oral cavity.

59. reference
 Jatin shah 4th edition
 Stell and Maran 5th edition
 Scott Brown 7th edition
 Lodder WL, Teertstra HJ, Tan B, Pameijer FA, Smeele LE, van Velthuysen ML, van den Brekel
MW. Tumour thickness in oral cancer using an intra-oral ultrasound probe. European
radiology. 2011 Jan 1;21(1):98-106.
 Ong CK, Chong VF. Imaging of tongue carcinoma. Cancer imaging. 2006;6(1):186.
 Spiro RH, Huvos AG, Wong GY, Spiro JD, Gnecco CA, Strong EW. Predictive value of tumor
thickness in squamous carcinomas confined to the tongue and floor of the mouth. Am J
Surg. 1986;152:345–350.

60.  Pentenero M, Gandolfo S, Carrozzo M. Importance of tumor thickness and depth of invasion
in nodal involvement and prognosis of oral squamous cell carcinoma: a review of the
literature. Head Neck. 2005;27:1080–1091.
 Yu P, Robb GL. Reconstruction for total and near-total glossectomy defects. Clinics in plastic
surgery. 2005 Jul 31;32(3):411-9.
 Bertolin A, Ghirardo G, Lionello M, Giacomelli L, Lucioni M, Rizzotto G. Lateral
pharyngotomy approach in the treatment of oropharyngeal carcinoma. European Archives
of Oto-Rhino-Laryngology. 2017 Jun 1;274(6):2573-80.
 Sakamoto K, Matsuzaka K, Yama M, Kakizawa T, Inoue T. A case of leiomyosarcoma arising
from the tongue. Oral Oncology Extra. 2005 Mar 31;41(3):49-52.
 Dubin MR, Chang EW. Liposarcoma of the tongue: case report and review of the literature.
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 Huang SH. Oral cancer: Current role of radiotherapy and chemotherapy. Medicina oral,
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