The document discusses carcinoma of the tongue. It begins by describing the anatomy of the oral cavity and structures included. It then discusses the tongue's muscles and functions. Risk factors for oral cancer include tobacco, alcohol, poor oral hygiene, and HPV infection. Premalignant lesions of the tongue include leukoplakia and erythroplakia. Treatment options depend on the stage and size of the tumor and include surgery, radiation therapy, chemotherapy, and neck dissection. Prognosis depends on stage, with earlier stages having better survival rates.

1. 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. Tongue

5. Muscles of Tongue
Broadly divided into
1) Extrinsic – genioglossus, palatoglossus,
styloglossus, hyoglossus
2) Intrinsic group- upper longitudinal, lower
longitudinal, horizontal, vertical

6.  Functionally, the oral cavity can be divided into two units:
an inferior portion that is constantly exposed to saliva and
an upper portion that is relatively dry.
This difference also implies a different exposure of the
mucosa to potential carcinogens present in the saliva.
In addition, this division has surgical implications on
postoperative complications, such that surgery on the
inferior subsites have a higher risk of salivary fistula
formation and superior portions may be complicated by
postoperative wound contracture and resultant deformity

7. 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.

9. 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.

11. 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”.

14. cavity

16. Etiology

17. Tobacco and Alcohol
 Tobacco contains many carcinogenic molecules,
especially polycyclic hydrocarbons and
nitrosamines.
 The risk of developing an oral cancer is directly
proportional to the years of exposure and amount
of tobacco use.
 The simultaneous use of alcohol has a synergistic
effect increasing the mucosal absorption of
tobacco carcinogens, improving the solubility of
these carcinogens compared with aqueous
saliva.
 At a molecular level, tobacco and alcohol use is
associated with a high frequency of p53

18. Alcohol
 Most probably because of a topical effect, the
mucosal areas exposed to prolonged contact with
alcohol are at increased risk
 The precise mechanism by which alcohol causes
cancer is not clearly defined as alcohol itself is not a
carcinogen
 Non-alcohol constituents of various alcoholic
beverages may have carcinogenic activities

19. Other Factors
 Poor oral hygiene
 SMF
 Painful or loose fitting dentures
 Wood dust exposure
 dietary deficiencies
 red meat and salted meat intake.
 herpes simplex virus
 xeroderma pigmentosum, Fanconi anemia, and
ataxia telangiectasia

20.  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.
Key points

21.  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.

22. PRE MALIGNANT CONDITION
 Most of these lesions are characterized by the
presence of hyperplasia and dysplasia
 Hyperplasia represents an increased number of
cells in any layer of the squamous epithelium
 Dysplasia represents changes in the epithelium
architecture and cytology
 Dysplasia catogorized into mild, moderate and
severe and carcinoma Insitu

23. white, mucosal-based
keratotic plaque that cannot
be wiped free from the
underlying tissue. It is a
clinical term without a
histologic definition.
Leukoplakic lesions may
demonstrate parakeratosis,
hyperkeratosis, and
acanthosisParadoxically, an increased risk of malignant
transformation of leukoplakic lesions is seen
more commonly in nonsmokers compared with
smokers
1. Leucoplakia

24.  Leucoplakia of 2 types –
homogenous and non
homogenous
Homogenous- uniform flat
white patch with dysplastic
changes. Chances to get
malignant transformation is
less when compared to Non
homogenous type
 Non Homogenous -
irregularly flat,nodular, or
verrucous, with white and
red patch coexisting.
 It is commonly associated
with severe epithelial
dysplasia and carcinoma in
situ and can develop

25. Erythroplakia
 “Bright red velvety patch
that cannot be
characterized clinically or
pathologically as being
caused by any other
condition”.
May present with severe
dysplasia with aneuploidal
cells. And carcinoma Insitu
More potential for
malignant transformation
Treatment by wide surgical
excision

26. Oral submucous fibrosis
 frequently encountered in individuals who chew betel nut
and is associated with poor oral hygiene, advanced
periodontitis, and the potential development of oral
carcinoma.
 The most common oral cancer subsite was the buccal
mucosa in more than 50% of cases, followed by the oral
tongue.
 Patients with oral cancer associated with OSF were
typically younger men (mean age, 45.11 years) with
better histologic differentiation, lower rates of
regional metastasis, and less extra nodal metastasis

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
Most commonly as a ulcerated exophytic mass or can
be a endophytic
Exophytic mass present as a Verrucus or a cauliflower
like growth
Endophytic – Fixed hard lump with little surface change
History of smoking or alcoholism is present
Pre existing leucoplakia or erythroplakia in adjacent
areas
Most commonly seen in postrolateral area ( ventral)

32.  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

33. Local invation
Ca tongue - Medially to central raphae to
opposite side
Posteriorly to tongue base
Inferiorly to suprahyoid muscle
Nerves - Lingual nerve – loss of general sensation
Hypoglossal nerve – Deviation of tongue on
protution
Fasciculation
Atropy
Reffered otalgia

34. Lymph node metastasis
 At presentation
 Primary metastasis is to level 1,2 and 3
 Primary echelon is level 2
 25% present with bilateral metastasis
 3% only with contralateral metastasis
N0 – High risk metastasis to level 1 to 3
N+ - High risk of metastasis to level 4
Skip metastasis to level 4 present in ca anterior
tongue
Skip metastasis to level 5 rare

35. Investigations
 Ulcerated lesion for 3-4 weeks – incisional biopsy
 Suspecious lesion – first incisional biopsy later
excisional (if excisional is done first then margins may be left behind)
 Leucoplakia and erythroplakia – Biopsy (to study grade of
diaplasia and DNA ploidity)
 Mobile ant tongue – B wave USG
 CT for T1 and T2 lesions
 MRI with fat supression
 PET
 FNAC for lymph nodes
 CXR

36. 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.

37. STAGING

39. Treatment Options
 As per thickness without node

40. Brachytherapy
 Limited to the anterior two-thirds of the mouth
 The technique works best on the lateral aspect of
the mid tongue
 The high dose of local radiotherapy can increase
the risk of osteoradionecrosis in the adjacent
mandible
 Brachytherapy should be combined with elective
neck irradiation when the tumour exceeds 3 cm

41. STAGE III–IV ORAL TONGUE
CARCINOMA
 Larger primary tumours have a higher risk of nodal
metastases
 Partial to subtotal glossectomy:
 – modified radical neck dissection type III of N
positive neck;
 – ipsilateral selective level I–IV for N0 neck;
 – postoperative radiotherapy of oral cavity and neck.

42. Surgical technique of tongue cancer
resection
 Transoral resection and primary closure is the
treatment of choice for small tumours of the mobile
tongue, mainly of the lateral border and floor of
mouth.
 A resection margin of 1.5 cm is recommended for
tumours
 less than 4 cm in largest diameter and less than 1 cm
thick
 lesions, although the margin should be increased to 2
cm for larger or thicker tumours.
 The deep musculature can be approximated using
interrupted resorbable sutures and a second layer of

43.  Partial glossectomy - upnto half of the tongue
when there is no resulting tension on the wound
or decreased mobility of the tongue primary
closure will be adequate. Rest need tongue
reconstruction
 Most commonly used flaps are –
Pectoralis major myocutaneous flap
free radial forearm fasciocutaneous flap
anterolateral thigh flap

45.  The free radial forearm fasciocutaneous flap is a
suitable choice of thin flap for resurfacing of the
tongue and has a 96 percent survival rate
 If one looks at the quality of speech following
significant tongue reconstruction, then it is
significantly worse six and twelve months after
treatment than before treatment

46.  The reconstruction of subtotal glossectomy defects is
controversial.
 Some authers consider that the quality of life outcome
following total glossectomy and free flap reconstruction is
so poor that this treatment option should not be offered
when the patient’s main concern of outcome are speech
and function rather than cure and survival
 others have shown that swallowing and speech can be
maintained without aspiration following microvascular
reconstruction of sub-total glossectomy defects

47.  A temporary tracheostomy is necessary for
patients with flap reconstruction and nasogastric
or gastrostomy tube feeding for up to a week
 Brachytherapy using iridium wire implants is an
effective alternative treatment for T1/small T2
lesions of the lateral anterior tongue

48. Dr.Haris PS/ OMR48
Advantages
 Short time – compliance
 Specimen available for HPE
 Helps in planning adjuvant treatment
 No radiation sequelae
Disadvantages
 Tissue & functional loss
 Disfigurement
 Infection
 Bleeding
 Mortality

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

50. 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.

51. Chemotherapy
Dr.Haris PS/ OMR51
Curative
- Neoadjuvant (Induction)
- Adjuvant
- Concurrent: to treat micromets
Palliative
- Recurrence
- Metastatic disease
Drugs - Cisplatin, Methotrexate, 5 FU

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

53. Management of the
clinically positive neck
 a comprehensive neck dissection should be carried
out. This involves removal of levels I–V,
 although the extent of level V dissection should be
tailored to the location and extent of the nodal disease
 The need for more radical resection including
structures such as the spinal accessory nerve,
sternocleidomastoid muscle, or internal jugular vein
depends on the extent of disease in each individual
patient
 However, the spinal accessory nerve should not be
sacrificed unless it is directly involved by tumor.
 MRND Type 1

54. Management of the clinically
negative neck
 supraomohyoid neck dissection is usually
adequate for managing the cN0 neck in most oral
cancer patients.

57. 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

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