Case Report: Squamous Cell Carcinoma of the Tongue NYU- Woodhull Medical Center Case Report: Squamous Cell Carcinoma of the Tongue David R. Telles, DDS Jason Swantek, DDS Joshua M. Abrahams, DMD

Sqaumous Cell Carcinoma Statistics 94% of all oral malignancies 21,000 new cases diagnosed annually 6,000 Americans die each year from SCC Tobacco and alcohol is shown in the elevation of cancer risk more than 35-fold for men who smoke two or more packs of cigarettes and consume more than four alcoholic drinks per day1 Carcinoma of the Tongue Accounts for more than 50% of intraoral cancers in the US 20% occur on anterior lateral and ventral surfaces 4% occur on dorsum of tongue 66% of lingual carcinomas appear as painless, indurated masses or ulcers of the posterior lateral border of the tongue Etiology No single causative agent (Extrinsic and Intrinsic Factors) Risk Factors: Tobacco Smoking , Alcohol Phenols, Radiation, Iron Deficiency, Vit A deficiency, Candidal Infection Oncogenic viruses, Immunosuppression

78 y/o Hispanic Female CC: “My lower right side of my tongue hurts” HPI: Pt first noticed lesion approx 6 months prior which she notes has grown and become painful. Pt on presentation denied voice changes or dysphagia PMHx: HTN, Dislypidemia, Osteoarthritis Meds: Altace NKDA Social Hx: Denies Tobacco/ drug use, Hx of past chronic alcoholism when her husband was alive – 5x/wk for ~ 30 yrs – currently pt does not drink ROS: HEENT: burning tongue on R side for last with mild bleeding on palpation, PE: Erythroleukoplakic lesion on right lateral border of tongue approx. 1.5 cm x 2.0 cm No palpable Lymph nodes on H&N exam

Surgical Pathology Examination Incisional Biopsy 6/15/10: Pt taken to operating room for incisional biopsy of right lateral border of tongue lesion Results: Mild, moderate, severe dysplasia, carcinoma in situ, and superficially invasive squamous cell carcinoma Ulcer Carcinoma

Surgical Pathology Examination Excisional Biopsy 7/08/10: Pt taken to operating room for excisional biopsy of right lateral tongue lesion On same day of excisional biospy Panendoscopy was performed by ENT and noted to be negative Results: Specimen measured 2.5x2.0x1.0cm. All margins of excision including deep margin are free of neoplasm

Tumor-Node-Metastasis (TNM) Staging Primary Tumor Size (T) TX No available info on primary tumor T0 No evidence of primary tumor T1S Only Carcinoma in situ at primary site T1 Tumor is less than 2cm in greatest diameter T2 Tumor is 2-4cm in greatest diameter T3 Tumor >4cm in diameter T4 Massive tumor >4cm w/ involvement of antrum, pterygoid muscles, base of tongue, or skin Regional Lymph Node Involvement (N) NX Nodes couldn’t be or were not assessed N0 No clinically positive nodes N1 Single clinically + homolateral node less than 3cm in diameter N2 Single clinically + homolateral node 3-6cm in diameter or multiple clinically + homolateral nodes, none more than 6cm in diameter N2a – Single clinically + node 3-6cm in diameter N2b – Multiple clinically + homolateral nodes, none more than 6cm in diamter N3 Massive homolateral node or nodes, bilateral nodes, or contralateral node or nodes N3a – Clinically positive homolateral or nodes, one more than 6cm in dia N3b – Bilateral clinically + nodes N3c – Contralateral clinically + node or nodes Involvement By Distant Metastases (M) MX Distant metastasis was not assessed M0 No evidence of distant metastasis M1 Distant Metastasis is present Stage TNM Classification 5-Year Survival Rate Stage I T1 N0 M0 85% Stage II T2 N0 M0 66% Stage III T3 N0 M0 or T1, T2, T3, N1 M0 41% Stage IV Any T4 lesion, or Any N2 or N3 lesion, or any M1 lesion 9%

Histopathologic Grading Histopathologic Evaluation Tumors that closely resemble the original squamous epithelium seem to grow at a slower pace and are slower to metastasize (Low-grade, Grade 1, or well-differentiated) Less differentiated tumors receive higher grades and often enlarge rapidly, metastasize earlier (high-grade, grade III/IV, poorly differentiated Diagnosis of SCC Almost always made with routine light microscopy Hyperchromatic Nuclei Carcinoma Foci found within skeletal muscle

Treatment and Prognosis Guided by clinical stage of the disease Consists of wide (radical) surgical excision, radiation therapy, or combination Suspected local lymph node metastasis Radical Neck Dissection Removal of all ipsilateral cervical lymph node groups from levels I-V, together with spinal accessory nerve (SAN), SCM, Internal jugular vein (IJV) Modified Radical Neck Dissection Removal of all lymph node groups but with preservation of one or more nonlymphatic structures (SAN, SCM, IJV) According to Bellinger et. al. no demonstrable differences in rates of locoregional control or survival between surgery and irradiation for T1 and T2 lesions. Surgical resection is typically employed for stage I and II lesions combined therapy using surgery and postoperative radiotherapy is indicated for stage III and IV disease.

References Bellingers Otorhinolaryngology: Head and Neck Surgery 16th Ed. 1996 Neville, Oral and Maxillofacial Pathology, 2nd Edition, WB Saunders Company, 2002