Tongue Carcinoma- basic surgical knowledge

Tongue Ca medical officer presentation

1. TONGUE CANCER
KHOO SHU JIUN
Department of Otorhinolaryngology,
Head and Neck Surgery, Hospital Taiping
Version 2022

2. TONGUE ANATOMY
•covered by stratified squamous
epithelium with varying degrees
of keratinization
•Ventral and lateral surfaces –
non keratinizing (in continuity
with FOM)
•Dorsum and tip – specialised
gustatory mucosa with
keratinized squamous
epithelium
•Divided into anterior 2/3 (oral)
and posterior 1/3 (pharyngeal)
by sulcus terminalis

3. LINGUAL PAPILLAE

4. RELATION
•Anterior - teeth
•Superior - hard and soft palates
•Inferior - mucosa of the floor of the oral
cavity, sublingual salivary glands,
posterior wall of oropharynx
•Posterior - epiglottis, pharyngeal inlet
•Lateral - palatoglossal and
palatopharyngeal arches

5. INTRINSIC MUSCLES

6. EXTRINSIC MUSCLES

7. INNERVATION
•Motor - hypoglossal nerve CNXII,
except palatoglossus (Vagus nerve
CNX, Pharyngeal plexus)
•Anterior 2/3 –
•TASTE: chorda tympani (CN VII)
•SENSATION: lingual nerve (CN V3)
•Posterior 1/3-
•TASTE & SENSATION –
glossopharyngeal nerve (CN IX)

8. ARTERY SUPPLY
LINGUAL ARTERY
principal artery supplying the tongue, sublingual gland, gingiva and oral mucosa of the floor of the mouth.
Within the tongue, it is located deep to the hyoglossus muscle.
branches: suprahyoid branch, dorsal lingual arteries, sublingual arteries, deep lingual artery.

9. VENOUS DRAINAGE
1. The deep lingual vein is the largest and the principal vein of the tongue.
originates from tips of tongue paired(2 vena comitantes accompany 1 artery) →
sublingual vein → lingual vein/ internal jugular vein
2. dorsal lingual vein follows the path of the dorsal lingual arteries.

11. LYMPHATIC DRAINAGE
●Anterior 2/3 – initially into the submental and submandibular
nodes, which empty into the jugulo omohyoid lymph nodes.
●Posterior 1/3 – directly into the jugulodigastric lymph nodes
●central/ tip/ base of tongue- lymph vessels decussating to
contralateral lymph nodes as well.

12. EPIDEMIOLOGY
90% of oral ca is Squamous Cell Ca
Others: minor salivary tumour, other rare tumors
Most common @ middle 1/3, lateral aspect
Male > female(increasing trend)
90% Age > 40 y.o
Risk factors: smoking, alcohol, HPV

13. PRESENTATION
•symptoms including pain, ulceration or lump in the tongue
•Lesions in the oral tongue likely to be symptomatic than
lesions in the base of tongue
•Majority of anterior 2/3 tongue ca presented with stage I/II
disease, whereas base of tongue usually at stage III/IV
•Cervical lymphadenopathy at presentation ~21-34%
•function loss: speech, mastication, swallowing

14. EXAMINATION

16. INVESTIGATIONS
•Diagnostic:
•All ulcerated lesions of the tongue and floor of mouth that last for
> 2 to 3 weeks require an incisional biopsy
•Biopsies should include deep margin of the tumor and normal
mucosa at the periphery
•+/- FNAC of suspicious LN
•Pre-operative/ Baseline Investigations

17. IMAGING
•STAGING OF DISEASE:
•Ultrasound (NOT ROUTINELY DONE)
-optimal technique in patients with no trismus or base of tongue
involvement.
-more reliable than MRI for the measurement of tumour thickness,
especially in superficial lesions.
•CT Scan
•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
-choice for evaluation of locoregional involvement, mainly soft tissue
imaging, bone marrow infiltration
-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.

18. TNM STAGING

19. TUMOUR (T)

20. DEPTH OF INVASION
Inclusion of depth of invasion (DOI) in the recent AJCC/UICC TNM staging for oral cancer has incorporated the concept of
tumor third dimension and its prognostic importance. However, for more practical reasons, radiological tumor thickness (rTT) is
a simple and practical measurement which can be used as a clinical predictor of pDOI.

24. 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 function
(speech, mastication, swallowing), and external
appearance;
3.Minimization of the sequelae of treatment
such as dental decay, osteonecrosis of the
mandible, and trismus.

25. CHOICE OF SURGICAL TX
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.depth of infiltration (DOI)
3.The proximity of the tumor to the mandible or maxilla, or involvement of
mandible or maxilla.
4.Cervical nodes metastasis

27. TYPES OF GLOSSECTOMY
•TYPE I GLOSSECTOMY (MUCOSECTOMY)
•TYPE II GLOSSECTOMY (PARTIAI GLOSSECTOMY)
•TYPE III GLOSSECTOMY
•Type IIIa glossectomy (hemiglossectomy)
•Type IIIb glossectomy (compartmental hemiglossectomy)
•TYPE IV GLOSSECTOMY
•Type IVa glossectomy (subtotal glossectomy)
•Type IVb (near‐total glossectomy)
•TYPE V GLOSSECTOMY (TOTAL GLOSSECTOMY)
Shah JP. Classification of GLOSSECTOMIES: Proposal for tongue cancer resections. Head Neck. 2019 Mar;41(3):821-827. doi:
10.1002/hed.25466. Epub 2019 Jan 2. PMID: 30600861; PMCID: PMC6590454.

29. TYPE I GLOSSECTOMY (MUCOSECTOMY)
Indication: Precancerous, superficial suspicious lesions, limited to the epithelium of the
tongue without previous biopsy.

30. TYPE I GLOSSECTOMY (MUCOSECTOMY)
Definition: Incision of the mucosa in healthy tissue & submucosa up to the intrinsic muscle
fibers of the tongue
safety margin 1.0-0.5 cm depending on whether or not the lesion is well defined.
wound: heal by secondary intention / may be partially closed primarily or covered with a skin
graft.
Aim of surgery :remove all the lesion with adequate margins up to the healthy tissue with both
diagnostic and curative intent

31. TYPE II GLOSSECTOMY
(PARTIAL GLOSSECTOMY)
Indication: Lesions infiltrating submucosa and superficially into intrinsic muscles, but
not extrinsic muscles, or DOI< 10 mm deep

32. TYPE II GLOSSECTOMY
(PARTIAL GLOSSECTOMY)
Definition :incision of the lesion and adjacent normal mucosa, submucosa, and the
intrinsic muscles up to the surface of the extrinsic muscles (when the
directions of the muscle fibers change),
include: terminal branches of the lingual artery ligated
the lingual nerve is usually preserved.
safety margins :approximately 1.5 cm
wound: usually is diamond shaped on the surface, while more deeply with the
intrinsic muscles as the apex.
Closure may be partial or total (aim to prevent bleeding, post op edema,
and fibrosis)
** supraomohyoid neck dissection dt probability of occult mets

33. TYPE III GLOSSECTOMY
HEMIGLOSSECTOMY/ COMPARTMENTAL GLOSSECTOMY

34. TYPE III GLOSSECTOMY
HEMIGLOSSECTOMY/ COMPARTMENTAL GLOSSECTOMY
IIIA- HEMIGLOSSECTOMY IIIB- COMPARTMENTAL GLOSSECTOMY
Indication: lesions infiltrating the intrinsic and
minimally extrinsic muscles or DOI > 10 mm but
confined within the ipsilateral tongue
Definition: incision of the mucosa, submucosa, and
intrinsic and extrinsic muscles ipsilateral to the
lesion with base of the tongue preserved
include: the lingual artery ligated & removed en
bloc with the lingual and hypoglossal nerves
safety margins > at least 1.5 cm
Indication: Lesions massively infiltrating the
intrinsic and extrinsic muscles but confined to
the ipsilateral tongue
Definition: incision of mucosa, submucosa, intrinsic
and extrinsic muscles includig base of the tongue
ipsilateral to the lesion
include: similar to hemiglossectomy PLUS extrinsic
muscles
midline raphe is included in the resection.
safety margins > at least 1.5 cm
woud: may not be able to closed primarily or if closed primarily, would cause significant restriction
of the tongue. Therefore a split thickness skin graft may be performed.
** primary tumour, nodes, neck dissection should be done en bloc

35. TYPE IV GLOSSECTOMY
SUBTOTAL/ NEAR-TOTAL GLOSSECTOMY

36. TYPE IV GLOSSECTOMY
SUBTOTAL/ NEAR-TOTAL GLOSSECTOMY
IVA-SUBTOTAL GLOSSECTOMYIVB- NEAR-TOTAL GLOSSECTOMY
Definition: This is an anterior subtotal glossectomy
with preservation of both sides of the base of the
tongue, posterior hyoglossus muscle, and
hypoglossal and lingual nerves, from the less
involved side.
Indication: Lesions that arise in the anterior portion
of the mobile tongue and exceed the hemilingual
area of origin involving the contralateral
genioglossus muscle but limited to mobile tongue
Definition: Type IVa glossectomy with extension to
the ipsilateral base of the tongue. The following
contralateral functional unit of the base of the
tongue are preserved: (hyoglossus and styloglossus
muscles, hypoglossal and lingual nerves, and lingual
artery)
Indication: Massive lesions that exceed the border
of the hemilingual area of origin infiltrating the
ipsilateral base of the tongue and the contralateral
genioglossus muscle

37. TYPE V GLOSSECTOMY
(TOTAL GLOSSECTOMY)

38. TYPE V GLOSSECTOMY
(TOTAL GLOSSECTOMY)
Definition: all of the mobile tongue and the base of the tongue transected at the level of the
vallecula; it includes intrinsic and extrinsic muscles, both lingual arteries, hypoglossal, lingual
nerves, and the floor of the mouth.
Indication: Massive infiltrating lesions, for instance, those of the anterior ventral surface of the
tongue, dorsum of the tongue, or the tongue base, which bilaterally involve the extrinsic
genioglossus, hyoglossus, and styloglossus with impairment of the mobility of the tongue

39. “ Depending upon the extent of the lesion, type III‐V glossectomies
can be extended to some of the adjacent structures such as the
geniohyoid muscle, digastric muscle, the epiglottis, all the
larynx,etc… . In such cases, the type of resection should be termed
“glossectomy type extended to…”
When, however, the structure is preserved, the terminology should
be “glossectomy type…with preservation of…”

40. NECK DISSECTION
•Tongue cancers usually metastasize to levels I and II LN
•It is not unusual for nodes in level IV to be involved,
•in general, type I glossectomy should not require prophylactic neck
dissection.
•In type II glossectomy, supraomohyoid neck dissection should be
carried out based on the probability of occult metastases
• From the type III glossectomy onward, the dissection of the neck
should be done as an en bloc procedure.
•In the type IV and V glossectomies, the en bloc resection should be
performed with bilateral neck dissection.

41. POST OP RADIOTHERAPY
1.T3/T4 primary cancer
2.Positive surgical margins
3.Poor differentiation
4.Perineural invasion
5.Positive lymph nodes
6.Extracapsular spread of nodal disease
7.Perivascular invasion

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

43. TRANSORAL APPROACH
•The tumour is small and easily accessible, ( T1 – T2 lesions )
•
•not suitable for Patients with limited mouth opening,
constriction of the oral commissure and previous radiotherapy
causing fibrosis
•
•Advantage : -no external scar -fast
•Disadvantage: only limited to anterolateral based tumors

44. 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
•Advantage : - no facial incision
- bilateral neck disection can be performed
•Disadvantage:
-injuries to lingual and hypoglossal
nerves
-greater functional deficit
-mental nerve is sectioned
-poor swallowing->quality of life

45. PULL THROUGH

46. •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

48. Surgical Approach
Soft tissue Bone

49. MANDIBULOTOMY
•Mandibulotomy is a mandible-sparing surgical
approach designed to gain access to the oral cavity
or oropharynx for resection of primary tumors
which are not accessible through the transoral
approach.
•3 types of mandibulotomy:
1.Lateral (through the body or angle of the
mandible)- rarely do (posterior)
2.Midline (anterior)
3.Paramedian (between lateral incisor and canine)

51. The mandibulotomy site
is exposed.

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

53. Mandible is retracted to
expose the mylohyoid
muscle.
The proposed site of
resection is marked.

55. Mandible fixation with titanium plate and screws

58. AIM OF RECONSTRUCTION
•The aim of reconstruction of the oral tongue
following resection is to ensure maximum
function of the residual tongue tissue

59. 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.

60. 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

62. •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

63. Fascia cutaneous flap
-in

64. RECURRENCE
•Locoregional recurrence rates is 10-50 per cent, usually in 1
st
2 years.
•Factors that influence local recurrence include:
–Tumour thickness/DOI : 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 (but not
survival)
10% of patients who have developed a tongue tumour will develop
metachronous 2nd tumours of the oral cavity.

66. REFERENCES
•Scott Brown 7
th
edition
•JStell and Maran 5
th
edition
•atin Shah 4th edition
•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.