Ca tongue by dr sharmin farzana

1. Presented by:
Dr. Sarmin Farzana
Resident (Phase B)
Dept. of Radiology & Imaging
BSMMU

2.  Mr. Ripon Ahmed 52 yrs old male hailing
from Narayanganj presented at dept.of
Otolaryngology ,BSMMU with the
complaints of ulcerative lesion on right side
of the tongue which is non healing,
painless,bleeds on mastication with lumpy
feeling on mouth & difficulty in
deglutition.He was evaluated & diagnosed as
a case of squamous cell carcinoma on
histopathology. MRI was suggested for
staging.

5.  Oral cavity- most ventral portion of aerodigestive
tract , continuous posteriorly with oropharynx.
 Anatomic subdivisions of the oral cavity are :
1.Oral mucosal space: including lip ,upper & lower
alveolar ridge mucosa, buccal mucosa, floor of
mouth, hard palate mucosa & tongue mucosa.

6. 2.Root of the tongue.
3.Sublingual space: includes hyoglossus,
lingual- artery,vein,nerve,sublingual & deep
part of submandibular gland.
4.Submandibular space : Includes ant. belly of
digastric, submandibular gland, 1a, 1b LN &
facial artery,vein.

8. a)Coronal graphic b) MR image shows myelohyoid
separating sublingual & submandibular space ,also
neurovascular bundle(lingual artery, vein & nerve)
within sublingual space.

10. Tongue is the muscular organ of the oral
cavity that is situated in the floor of
mouth.
 It helps in mastication, speech and
deglutition.
 Taste is the special sensory function of
tongue due to presence of taste buds.

11.  Tongue has 3 parts
1. Tip
2. Body
3. Root/Base
The body has two surfaces…
1. Upper surface or dorsum
2. Inferior or ventral surface

12.  The dorsum is divided by a V shaped Sulcus
terminalis & circumvallete papillae into 2 parts:
1. Oral part(anterior 2/3)
2. Pharyngeal part(posterior 1/3).

13.  A median fibrous septum divides the tongue into
right and left halves.
 Each half contains 4 intrinsic and 4 extrinsic muscles.
 The intrinsic muscles change the shape of the tongue.
 The extrinsic muscles change the position of the
tongue.

14. Intrinsic muscles
1. Superior
longitudinal
2. Inferior longitudinal
3. Transverse muscle
4. Vertical muscle
Extrinsic muscles
1. Genioglossus
2. Hyoglossus
3. Styloglossus
4. Palatoglossus

17. 1. Tip of tongue: Drains bilaterally to the submental nodes.
(Level 1 A)
2. Anterior 2/3 of the tongue: Drains unilaterally to sub
mandibular nodes (Level 1B)
3. Posterior 1/3 of tongue: Drains bilaterally to
jugulodigastric nodes.
All lymphatic channels finally drains into jugulo-
omohyoid nodes.

18.  In western countries it’s a rare condition (2-4% of all
cancers)
 In our sub-continent, it is about 40% .
 Most common malignancy is squamous cell
carcinoma.
 Most common sites are buccal mucosa, tongue, floor
of mouth, palate, gingiva and oropharynx.

19.  Tongue is one of the most common sites of oral
cancer.
 Most common sites are:
1. Lateral border of tongue
2. ventral surface of tongue
3. Base of the tongue
 Male –female ratio is = 3 : 2

20. Types :
 Squamous cell carcinoma : Most common type.
 Adenocarcinoma : Those arise from minor salivary
glands of tongue.
 Lymphoma: Those arise at the posterior most part of
the tongue particularly around the lymphoid organs.
 Metastatic carcinoma: These are the secondary tumour
of other primary sites.

21. Predisposing factors:
Smoking
Betel nut chewing
Tobacco consumption
Alcohol consumption
Chronic irritation by sharp teeth or denture
Virus : Human Papilloma Virus.
Spice foods.

22. Types of the lesion:
1. Ulcer : Most common type of lesion . Commonly
found in lateral border of tongue.
2. Exophytic growth : This type exibits as cauliflower
like appearance.
3. Erosive plaque : Premalignant lesions
 Erythroplakia
 Erosive lichen plannus

23. Fig 1 : Ulcer type Fig 2 : Exophytic type
Fig 3 : Erosive type

24.  Clinical features:
1. History of the lesion more then 3 weeks
2. Painless non healing ulcer or growth
3. Increased salivation
4. Difficulty in swallowing, speech.
5. Reduced taste sensation
6. Bleeding from ulcer during mastication
7. Cervical lymphadenopathy

25.  Local spread : By infiltration into adjacent structures (
mucosal surface,muscles,bone,retromolar trigone).
• Lymphatic spread:
Anterior 2/3rd: Level 1a nodes.
Lateral surface: Level 1b & 2 nodes.
Posterior 1/3rd: Level 2 nodes.
• Extension along neurovascular bundle (into floor of
mouth).

27. CT /MRI is used to assess :
 The size of tumor & tumor thickness.
 Extension across the midline.
 Extension beyond intrinsic muscles.
 Involvement of adjacent structures-
neurovascular bundle, submandibular gland
,mandible.

28.  Lesions usually appear as soft tissue
attenuation & enhance following contrast
administration.
 Cortical bone(maxilla,mandible)
involvement can be well assessed by CT.

30. Indicated when apposition of buccal mucosal
surface & gingival mucosal surface hinders exact
location & when demonstration of extent of a
tumor of oral cavity is needed.
Method: Puffed cheek CT is performed by having
the patient blow uniformly through pursed lips.
The scanning range is from hard palate to inferior
edge of mandible.

33.  MRI is the preferred modality in the evaluation &
staging of tongue carcinoma.Tumor invasion of
floor of mouth is well seen on coronal
images.Sagittal images provide information on
tongue base involvement & extent of pharyngeal
infitration.
 T1WI: Intermediate to low
 T2WI: intermediate to high
 T1+C with fat sat: Enhancement occurs

36. Primary tumor (T):
Tx: Primary tumor can’t be assessed.
Tis: Carcinoma in situ.
T1: Tumour <2 cm in diameter with DOI < 5 mm
T2: Tumour <2 cm & DOI >5mm but <10mm /
Tumour >2cm & <4cm with DOI <10mm.
T3: Any tumour with DOI >10mm/
Tumour >4cm with DOI <10mm

37.  T4: Moderately or very advanced.
T4a: Moderately advanced local disease
Tumour >4cm with DOI >10mm/
Tumour invades adjacent structures(mandible).
T4b: Very advanced local disease
Tumour invades masticator space ,pterygoid
plates/skull base. &/
Tumour encases ICA

38. Nx: Nodes can’t be assessed.
N0: No regional node metastasis
N1: Ipsilateral palpable node less than 3 cm diameter
,no extranodal extension.
N2: N2a: Metastasis in single ipsilateral
node,>3cm&<6cm ,no ENE
N2b:Metastsis in multiple ipsilateral nodes,all
<6cm,no ENE

39.  N2c: Metastasis in bilateral /contralateral nodes ,all
<6cm, no ENE
 N3: N3a: Metastsis in a node,>6cm & no ENE
N3b: Metastsis in a node with clinically ovart ENE

40. Distant Metastases (M):
M0: No evidence of metastasis.
cM1: Distant metastasis.
pM1: Distant metastasis,histopathologically confirmed.

42. Treatment principle:
Stage 1 : Surgical treatment and Radiotherapy
Stage 2 : Surgical treatment and Radiotherapy
Stage 3 : Surgery + Radiotherapy + Chemotherapy
Stage 4A : Surgery + Radiotherapy + Chemotherapy
Stage 4B and 4C : Palliative treatment