Carcinoma tongue

Carcinoma tongue

1. Dr . SUNDARPRAKASH SIVALINGAM A SSOCIATE PROFESSOR IN SURGERY 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. Buccal mucosa

5. Sensation : 2 nd and 3 rd branch of Trigeminal nerve. Motor : Facial nerve Lymphatics : Parotid and level 2 lymph nodes of neck

6. Hard Palate

7. Importance of hard palate : -Mucosa and periosteum are closely adherent. -These foraminas are potential route of s p read of m a lign a n c ies a n teriorly t o n a s a l c a vity and posteriorly to skull base. -Lymphatic drainage through level II if in h a rd posterior hard palate and both primary palate drains into level I nodes. -Sensation is by V 2

8. Retromolar trigone

9. Importance of Retromolar trigone Mucosa is closely adherent to the ascending ramus of the mandible. Carcinoma in this region often invades mandible. Referred otalgia results from innervation by V3,lesser palatine nerve, and the glossopharyngeal nerve. Lymphatic into Level II nodes.

10. Floor of the Mouth

11. T ongue

12. Salient features Sulcus terminalis divides the tongue into anterior 2/3 rd and posterior 1/3 rd . Anterior 2/3 rd is part of oral cavity and posterior 1/3 rd part of oropharynx. Anterior part is derived from lateral lingual swellings of first branchial arch and got lingual nerve as sensory supply.

13. Muscles of Tongue Broadly divided into Extrinsic and Intrinsic group

14. Muscles of Tongue Extrinsic : 3 pairs Styloglossus Hyoglossus Genioglossus Intrinsic : 3 groups Vertical. Longitudinal. Transverse.

15. 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.

16. 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 2/3 rd of oral cancer in India occurs in Gingivo-buccal sulcus and hence it is popularly called “Indian oral cancer”.

17. Distribution of cancer in Oral cavity

18. Etiology

19. Etiology

20. Etiology

21. 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.

22. Human papillomaviruses (HPVs) have been associated with a risk for oral cavity . T h e s e c a rcin o mas may c a rry a b e t t er pro g n o sis 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. The EBV is a human herpesvirus that has been implicated in a number of human malignancies, including nasopharyngeal carcinoma (NPC).

23. Premalignant lesions

24. Path o logy 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.

25. Clinical presentation Non healing ulcer Other tell-tale sign of head and neck malignancy Otalgia Odynophagia Bleeding Dysphagia Pertaining to tongue : Restriction of movement of tongue,difficulty in pronounciation.

26. Pretreatment evaluation Complete head and neck examination Examination under anaesthesia if necessary. Biopsy(Wedge biopsy) of primary lesion or suspicious ones. FNAC of suspicious/enlarged/palpable lymphnodes. CT/MRI of primary and neck. X-ray chest to rule out synchronous primary.

27. Other important things Dental evaluation Examination under anaesthesia Direct laryngoscopy and pharyngoscopy Esophagoscopy. Bronchoscopy. Palpation of tongue and oropharynx. Councelling about speech loss and therapy.

28. S T AGING

29. Treatment Options Dr.Haris PS/ OMR 36 T 1 N 0, T 2 N Surgery ± RT RT -External Beam -Brachytherapy T 3 N , T 4 N N + Surgery and Post op RT ± Chemotherapy T 4b , N 3 , M + PALLIATION - Primarily RT ± Chemo CURATIVE

30. Management T1-2 => Either Surgery or Radiotherapy. T3-4 => Combination of chemoradiotherapy and Surgery.

31. 39 Advantages Short time – compliance Specimen available for HPE Helps in planning adjuvant treatment No radiation sequelae Disadvantages Tissue & functional loss Disfigurement Infection Bleeding Mortality Dr.Haris PS/ OMR

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

33. 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.

34. Che m otherapy Dr.Haris PS/ OMR 42 Curative Neoadjuvant (Induction) Adjuvant Concurrent: to treat micromets Palliative Recurrence Metastatic disease Drugs - Cisplatin, Methotrexate, 5 FU

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

36. 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

37. Prog n osis Stage 1: 80 – 90 % Stage 2: 70 – 80 % Stage 3: 30 – 50 % Stage 4: 20 – 30 %