Dr. Ahmed Khan Sangrasi, Assistant Professor, Dept. of Surgery, LUMHS, Jamshoro Carcinoma of Tongue(Oropharyngeal)

In oncology squamous cell cancers of the head and neck are often considered together because they share many similarities - in incidence, cancer type, predisposing factors, pathological features, treatment and prognosiscancers of the head and neck Up to 30% of patients with one primary head and neck tumour will have a second primary malignancy

Tobacco when kept in mouth leaches out carcinogens, which act on oral mucosa causing neoplastic changes. Habit of smoking is also equally dangerous

Tobacco contains potent carcinogens including Nitrosamines (nicotine), polycyclic aromatic hydrocarbons, Nitrosodiethanolamine, Nitrosoproline, and polonium. Tobacco smoke contains carbon monoxide, Thiocyanate, hydrogen cyanide, nicotine and metabolites of these constituents.

Tobacco in Pakistan most commonly consumed in the form of gutka, quid pan or smoking in the form of bidi of cigarette.

Gutka is a flavored tobacco mixture with betel nut lime, and harmful additives like magnesium carbonate. It is extremely addictive and is apparently targeted at youngsters. Quid is the mixture of tobacco and lime and extensively consumed.

Precancerous lesions There are three most common precancerous lesions seen in the mouth and they are 1.Oral leucoplakia It is characterized by white patch on the buccal mucosa or any place in the mouth and is adjacent to the place where the tobacco quid is kept. The less likely place is floor of the mouth and tongue although 93% of leucoplakia at this sites turn malignant.

ORAL LEUCOPLAKIA PATCH

2. Erythroplakia This is characterized by red velvety patch which is not associated with any trauma or inflammation. It may present with or without leucoplakia. This lesion is easily missed out but is considered to have great malignancy potential.

Erythroplakia

3.Oral sub mucous fibrosis. This condition is characterized by limited opening of mouth and burning sensation on eating of spicy food. This is a progressive lesion in which the opening of the mouth becomes progressively limited, and later on even normal eating becomes difficult.

Oral Sub Mucous Fibrosis

This patient of SMF has so much of limitation in opening of mouth that it is difficult to put even 2 fingers in the mouth

Smf is equally common in gutka eating ladies

Professor Newell Johnson an expert oral surgeon said, ”we know this condition, oral sub mucous fibrosis has highest rate of transferring to malignancy of any of the so called pre-malignant lesions in the mouth. It is a very serious condition.”

The next stage after the precancerous lesion is the Cancerous lesions.

The most common form of cancer is Squamous cell carcinoma. It normally starts from any of the precancerous lesion in the mouth.

Common sites of oral cancer The most common sites of the oral cancer is the tongue and the floor of the mouth. The other common sites are buccal vestibule, buccal mucosa, gingiva and rarely hard and soft palate. Cancer of bucco-pharyngeal mucosa is common in smokers.

Cancer of Gingiva and Buccal mucosa The lesion is usually painless in early stages and only when it becomes ulcerated and secondarily infected or invades adjacent nerve, pain is the noticeable feature. The tumor is usually at the level of the occlusal plane or below it. They may be proliferative warty exophytic growth with little fixation or deeply ulcerative invasive lesion. The proliferative lesion though it looks dangerous is easily treatable and long-term prognosis is good as the metastasis to the local lymph nodes is relatively late. Whereas the ulcerative lesion is not so easily noticeable in the early stages but is more dangerous because of their invasive nature and the metastasis to the local lymph nodes is very early

Cancer Of Cheek after tobacco quid habit

SAME PATIENT WITH THE CANCER LESION COMING EXTRA ORALLY

Cancer of buccal mucosa after tobacco habit going extra-orally

CANCER STARTING FROM BUCCAL VESTIBULE FOLLOWING HABIT OF PAN WITH TOBACCO

Cancer of Buccal mucosa invading extra-oral tissues following tobacco quid habit

Cancer of labial mucosa invading extra-oral tissues following tobacco quid habit

CANCER OF CHEEK FOLLOWING EATING OF GUTKA

Cancer of labial mucosa after tobacco quid habit

Same patient with Cancer Of Gums

CANCER OF GUMS FOLLOWING EATING OF GUTKA

Carcinoma of the lip Carcinoma of the lip usually starts at the vermilion border of the lower lip. 95% of lip cancer affects the lower lip. It is in the form of a nodule, which ulcerates and forms a small scab, which fail to heal completely. It is often misdiagnosed as a cold sore. Eventually the margins of the lesions become proliferative and an extensive exophytic lesion with central ulceration develops.

CANCER OF LOWER LIP

Cancer of palate It is usually an ulcerative lesion and may spread extensively before involving underlying bone.

Cancer of Palate after habit of smoking

CANCER OF MAXILA AFTER SMOKING HABIT

CANCER OF PALATE

Alveolar carcinoma Alveolar carcinoma is common in mandible that maxilla. The lesion is warty nodular and proliferative, although it may rarely present as erosive lesion. Unfortunately it mimics apical or periodontal disease and their diagnosis is often delayed. Often the neoplastic nature is recognized when socket fails to heal following dental extraction for a supposedly periodontal abscess.

Alveolar cancer after tobacco quid habit

Relapse case He was operated for cancer of lower jaw in oct ‘00

Relapsed cancer in upper jaw in July 04

This cancer is extremely malignant and even if there is slight delay it spreads to lymph nodes of the neck. Once it spreads the prognosis becomes poor and death is inevitable and is because of erosion of major blood vessels and erosion of the base of the skull, Cachexia and secondary infection of the respiratory tract.

Carcinoma of the Tongue It may start as a small ulcer, usually on the lateral border of the anterior two third of the tongue. It may have varied presentation like a small papillary exophytic lesion, a flat nodule, ulceration within a pre existing fissure or may occur in the absence of frank ulceration in an atrophic tongue. Once ulceration has occurred, the lesion becomes painful, making speech and swallowing difficult. Tongue cancer rapidly extends to involve the floor of the mouth and lower alveolus, which makes treatment difficult.

Statistics on Tongue Cancer It is relatively common, with 3% of all malignancies arising within the oral cavity common than all forms of oral cavity cancer except those of the lip and occurs with increasing age uncommon before the age of 40 and the highest incidence of the disease is in the 6th and 7th decades with sex incidence being a 3:1 male predominance The disease occurs with highest incidence in Indian populations.

Progression of Tongue Cancer tumour spreads by local extension and through the destruction of adjacent tissue Lymphatic invasion with spread to the cervical lymph nodes is common at diagnosis Haematogenous spread to distant sites such as the liver, bones and lungs may also have occurred at the time of diagnosis

How is Tongue Cancer Diagnosed? General investigations may show anaemia or abnormal liver function tests if the disease is very advancedanaemia In the early stages of tongue cancer general investigations tend to be normal. when clinical diagnosis of oropharyngeal carcinoma is suspected a comprehensive protocol of investigations should be instituted

Blood tests :Evaluate the patient's general health and suitability for surgery, if considered Imaging studies : Dental X-rays: periapical dental films provide fine details and are the most useful for detecting minimal invasion of the mandible, an orthopantomograme of the jaws is helpful to assess the bony invasion. Chest X-ray: this may be the only useful X-ray in the evaluation for distant metastases because the incidence of distant metastases at presentation is low. Ultrasound: Done to assess metastases of the liver. Investigations

CT scan and MRI scan: because of the higher soft tissue resolution with an MRI scan (investigation of choice) Involvement of the extrinsic tongue musculature and direct extension in the submandibular glands and the base of tongue can be revealed with MRI scan. Tumour biopsy : The vast majority of biopsy findings reflect the presence of SCC. In fewer instances, minor salivary gland malignancies and sarcomas are discovered. An incisional biopsy should be carried out in all cases. Fine needle aspiration cytology (FNAC): Is useful for the assessment and pathological diagosis of enlarged cervical lymph nodes. Procedure: Yield is dependent not only on quality of aspirate but also on skill of cytologist.

Cancer of Tongue following tobacco consumption

Cancer of Tongue

Squamous cell carcinoma of the base of the tongue.

Squamous cell carcinoma of the tongue in a 32 year-old chronic smoker.

Cancer classification and Staging The American joint committee on cancer has developed the Tumor (T), Node (N), and Metastasis (M) system of cancer classification. The TNM classification is basically a clinical description of the disease, but can also involve imaging in classification. T is the size of the tumor and T1 is 2 but 4 cm and T4 is >4 cm with invasion of adjacent structures. N0 is no lymph node N1 is single ipsilateral node < 3 cm N2a single ipsilateral node > 3 cm but < 6 cm N2b multiple ipsilateral node < 6 cm. N2c bilateral or contra lateral nodes < 6 cm N3a ipsilateral node > 6 cm N3b bilateral nodes > 6 cm M0 is no metastasis and M1 is metastasis present. Staging Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0; any T1 T2 T3, N1 M0 Stage IV T4 ANY N, M0; any T, N2 or N3; ANY T OR N WITH M1

Treatment General Principles for oropharyngeal Caner 1. Surgery 2. Radiotherapy Small tumours: either by primary radiotherapy or surgery Advanced tumors: requires combination of surgery and radiotherapy Nowadays chemotherapy is being used for advanced tumors but patient needs to be fit to tolerate the toxicity. Factors to be considered include: Site Stage Histology Concomitant Medical Disease Social Factors

Treatment When Tumour Invades Bone (Mandible) Surgery is deemed appropriate as radio therapy is less effective. Surgery is also more appropriate for bulky, advanced disease followed by post operative radio therapy. Tumour of intermediate size eg: T2 and T3 are more problematic and regimes are controvertial hence need multi diciplinary team. Cervical Node Involvement: Single modality is preferred to deal simultaneously with lymphnode disease and primary tumor.

Histology Degree of differentiation of SCC does not normally influence management of tumor alone. Management of verrucous carcinoma, a variant of SCC is identical to that of any other SCC. Malignant tumor of minor salivary gland require primary surgery. Lymphoma is managed by radiotherapy, or chemotherapy + radiotherapy. Post operative radio therapy for minor salivary gland tumor is often indicated to reduce risk of locoregional recurrence.

Age Modern Anaesthesia and post operative critical care facilities now allow major head and neck surgery to be carried with significant medical comorbidity and old age. Young patients should not be denied radio therapy for fear of inducing second malignancy eg: Sarcoma later.

Previous Radiotherapy Second course of radiotherapy to previously irradiated site is contraindicted as tumor is likely to be radio resistant. Re-irradiation will result in extensive tissue necrosis. Field Change: Surgery is preferred when multiple tumors are present or there is etensive premalignant change of the oropharyngeal mucosa. Radiotherapy is unsatisfactory as the entire oral cavity requires treatment, causing severe morbidity.

Management of premalignant conditions Elimination of associated etiological factors Cessation of smoking, elimination of the areca nut/pan habit and reduction in alcohol consumption A photographic record is useful for long term follow-up All erythroplakia and speckled leucoplakia should undergo incisional biopsy (multiple) Severe epithelial dysplasia and carcinoma in-situ should be ablated by surgical excision or laser vaporization. Small lesions, particularly on lateral border of tongue or buckle mucosa are managed with surgical excision and primary closure by undermining adjacent to mucosa

Large defects can be managed with laser vaporization and allowed to epitheliaze spontaneously With mild to moderate epithelial dysplesia treatment is facilitated by elimination of causative agents Patients who continue to smoke should be managed as for severe dysplasia and carcinoma in-situ Patients who cease smoking and nut-pan maybe followed up closely at three monthly interval

Localised disease (T1-T2) lesions are treated with curative intent by surgery or radiation. Small lesions that are well lateralised should be excised (partial glossectomy). Larger lesions where excision would compromise speech and swallowing ability should be treated with radiotherapyradiotherapy Patients treated with local or regionally advanced disease are treated most succesfuly with a combined modality therapy of surgery, radiation therapy and chemotherapychemotherapy

Up to 30% of patients with T1 (<2cm) have occult metastasis at presentation and should undergo simultaneous treatment of neck by either elective neck dissection or radiotherapy. When performing surgical excision of primary tumor, 2cm margin in all plains should be achieved to ensure a wide, complete excision. Resection resulting in partial or hemiglossectomy can be performed with either a cutting dithermi or laser. Advanced tumors (T3 and T4) often encroach upon the floor of the mouth and occasionally the mandible. In these circumstances a major resection of the tongue and floor of mouth and mandible is required. T4 tumors of oral tongue often cross midline, for which total glossectomy is the only option to achieve adequate tumor clearance. When a patient undergoes simultaneous neck dissection the resection of primary tumor should preferably be in continuity with the neck node specimen

Prognosis of Tongue Cancer Early diagnosis is the key prognostic factor in tongue cancer - influencing both tumor size and the likelihood of metastatic deposits The 5 year disease free rate is approximately 70% in early disease, falling to less than 30% in more advanced cases Tumors at the base of the tongue are associated with the worst prognosis due to the increased likelihood of them being diagnosed at a later stage

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