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MANAGEMENT OF TONGUE
CANCER
MODERATOR: Dr. S. B. Choudhury (Asst.Proff)
PRESENTER: Dr. Bashab Bijoy Roy
Tongue cancer
Tongue cancer
TONGUE
Tongue cancer
Tongue cancer
BLOOD SUPPLY:
The tongue receives its blood supply primarily
from :
LINGUAL ARTERY a branch of the External
Carotid Artery.
LINGUAL VEINS drain into the Internal jugular vein.
There is also a secondary blood supply to the root of
tongue from the tonsillar branch of the facial
artery and the ascending pharyngeal artery.
Tongue cancer
Tongue cancer
Tongue cancer
Tongue cancer
Tongue cancer
CARCINOMA OF TONGUE
ETIOLOGY:
7’ S OF TONGUE CANCER :
 SMOKING
 SPIRIT
 SPICES
 SHARP TOOTH
 SUNLIGHT
 SEPSIS
 SYPHILIS
TOBACCO-
 90% of tongue cancer patients has history of tobacco use.
 Risk of carcinoma increases with amount of tobacco used &
duration of habit.
 Exposure to tobacco causes progressive sequential morphologic
changes of mucosa leading to neoplastic transformation.
 Such changes may be reversible if tobacco exposure is
eliminated early.
 40% of patients who persisted smoking after presumable cure of
tongue cancer developed second cancer as compared to 6% of
those who stopped smoking.
Agents like - Chewable tobacco, cigarette smoking, pan
masala,etc
ALCOHOL
 70-75% patients with tongue cancer consume alcohol
 6 times more risk in drinker
 Alcohol itself is a carcinogen & act as a direct irritant
Tongue cancer
ETIOLOGY CONTD…
 Poor oral & dental hygiene.
 Fanconi’s anemia.
 Vitamin A deficiency.
 Viruses- HSV -1 … HPV-11 & 16.
 Fresh fruits and vegetables are
protective.
PRE-MALIGNANT CONDITIONS
High risk lesions- definite risk of malignancy
1. Leukoplakia :
2. Erythroplakia : 17 -20 times more malignant than
leukoplakia.
3. Chronic hyperplastic candidiasis.
Medium risk lesions-
1. Oral submucosal fibrosis.
2. Syphillitic glossitis
3. Plummer-vinson syndrome-( sideropenic dysphagia due to
iron deficiency)
Equivocal risk lesions-
1. Oral lichen planus
2. Discoid lupus erythematosus
3. Dyskeratosis congenita
Tongue cancer
TYPICAL PRESENTATION:
 A middle aged man coming to OPD -holding
an handkerchief over his mouth to control
the excessive saliva which may be blood
stained (due to chronic non healing ulcer
of tongue) &
has a improper speech (disarticulation -
due to restriction of tongue movement)
Tongue cancer
MOST COMMON VARIETY OF TONGUE CARCINOMA –
Squamous cell carcinoma
LOCAL INVASION –OF CA TONGUE
It may spread anteriroly – involving the mandible
Inferiorly – involving the floor of mouth
Tongue cancer
Tongue cancer
OTHER IMPORTANT EXAMINATIONS
CA TONGUE- CT IMAGE & PET SCAN IMAGE
MRI IMAGE OF CA TONGUE
Tongue cancer
Tongue cancer
Tongue cancer
Tongue cancer
TREATMENTS AVAILABLE
AIMS OF SURGERY:
 Complete excision of primary tumor 3
dimensionally with R0 resection (microscopically
clear margin).
 Removal of Neck lymph nodes.
 Reconstruction of tissue loss-( for rapid healing
, restoration of function & appearance to improve
quality of life.)
ACCESS :
 For tumor clearance to be achieved access of oral
cavity is very important:
 Mainly 3 different access techniques are used:
1. TRANSORAL APPROACH- for small tumors.
2. LIP SPLIT TECHNIQUE- through mandible .
3. VISOR INCISION.
Tongue cancer
FOR LYMPH NODE CLEARANCE -
Tongue cancer
Tongue cancer
INCISIONS FOR NECK DISSECTION
FOR SMALL TUMORS <2 CM
 Tumor located at tip of tongue / lateral border of anterior
2/3rd of tongue that are approachable : PER ORAL
RESECTION with 1cm tumor free margin & primary
closure.
 LASER EXCISION can also be used- minimal bleed/ scar &
rapid healing.
T1 & SMALL T2 TUMORS :
For T1 /small T2 tumors of anterio- lateral tongue
 Can be treated by BRACHYTHERAPY.
 By using IRIDIUM wire implants
 Can increase the risk of local osteoradionecrosis
of adjacent mandible.
 Should be combined with elective neck radiation if
tumor size exceeds 3 cm.
BRACHYTHERAPY
FOR LESIONS TOO LARGE FOR LOCAL EXCISION
 Small superficial well differentiated lesions of oral
tongue which are too large for local excision &
tumor not involving the mandible - PARTIAL
GLOSSECTOMY with SPARING OF MANDIBLE is
done along with +
Block dissection of Neck nodes .
Even If no nodes (N0) involved – Selective neck
dissection
is must.
Tongue defect covered with- free skin graft OR
pectoralis major myocutaneous flap OR with radial
forearm free flap (best flap)
Tongue cancer
MANDIBULECTOMY
 Marginal mandibulectomy- it is done in
cancer involving lower gingival or extending
to mandible without clinical or radiological
involvement or with minimal cortical
invasion.
 Segmental mandibulectomy- when
cancer directly invades the mandible
FOR LARGE TUMORS / CA TONGUE BASE
 TOTAL GLOSSECTOMY- indicated for massive local
carcinoma of tongue.
 Approach- either lip split technique OR visor’s
approach
 Floor of mouth, mandible up to ascending rami , some
tissue of pharyngeal & laryngeal mucosa along with the
tongue is removed.
 Reconstruction- can be done by PMMF/ radial
forearm free flap.
 If defect is very large – ALT FLAP( Anterio-lateral
thigh flap).
 Mandibular reconstruction- by K-wires OR
titanium plates/ iliac crest bone graft.
MANDIBULAR TITANIUM IMPLANT
CA POSTERIOR 1/3RD OF TONGUE
 As this site is anatomically difficult for surgery, so
TELE THERAPY / EBRT is useful .
 Median translingual pharyngotomy can be done.
 A temporary tracheostomy is necessary for
patients with flap reconstruction & nasogastric /
gastrostomy tube feeding upto 2 weeks.
Tongue cancer
Tongue cancer
AT A GLANCE-
POOR PROGNOSTIC FACTORS-
 Increasing Tumor thickness >4mm
 High grade tumors
 Poorly differentiated tumors
 Vascular/lymphatic invasion
 Level III & IV has poor prognosis
 B/L or contralateral nodes
 Nodes involved >3 in number
 Nodal size>3cm
 Nodal extracapsular spread
THANK YOU

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Tongue cancer

  • 1. MANAGEMENT OF TONGUE CANCER MODERATOR: Dr. S. B. Choudhury (Asst.Proff) PRESENTER: Dr. Bashab Bijoy Roy
  • 7. BLOOD SUPPLY: The tongue receives its blood supply primarily from : LINGUAL ARTERY a branch of the External Carotid Artery. LINGUAL VEINS drain into the Internal jugular vein. There is also a secondary blood supply to the root of tongue from the tonsillar branch of the facial artery and the ascending pharyngeal artery.
  • 14. ETIOLOGY: 7’ S OF TONGUE CANCER :  SMOKING  SPIRIT  SPICES  SHARP TOOTH  SUNLIGHT  SEPSIS  SYPHILIS
  • 15. TOBACCO-  90% of tongue cancer patients has history of tobacco use.  Risk of carcinoma increases with amount of tobacco used & duration of habit.  Exposure to tobacco causes progressive sequential morphologic changes of mucosa leading to neoplastic transformation.  Such changes may be reversible if tobacco exposure is eliminated early.  40% of patients who persisted smoking after presumable cure of tongue cancer developed second cancer as compared to 6% of those who stopped smoking. Agents like - Chewable tobacco, cigarette smoking, pan masala,etc ALCOHOL  70-75% patients with tongue cancer consume alcohol  6 times more risk in drinker  Alcohol itself is a carcinogen & act as a direct irritant
  • 17. ETIOLOGY CONTD…  Poor oral & dental hygiene.  Fanconi’s anemia.  Vitamin A deficiency.  Viruses- HSV -1 … HPV-11 & 16.  Fresh fruits and vegetables are protective.
  • 18. PRE-MALIGNANT CONDITIONS High risk lesions- definite risk of malignancy 1. Leukoplakia : 2. Erythroplakia : 17 -20 times more malignant than leukoplakia. 3. Chronic hyperplastic candidiasis. Medium risk lesions- 1. Oral submucosal fibrosis. 2. Syphillitic glossitis 3. Plummer-vinson syndrome-( sideropenic dysphagia due to iron deficiency) Equivocal risk lesions- 1. Oral lichen planus 2. Discoid lupus erythematosus 3. Dyskeratosis congenita
  • 20. TYPICAL PRESENTATION:  A middle aged man coming to OPD -holding an handkerchief over his mouth to control the excessive saliva which may be blood stained (due to chronic non healing ulcer of tongue) & has a improper speech (disarticulation - due to restriction of tongue movement)
  • 22. MOST COMMON VARIETY OF TONGUE CARCINOMA – Squamous cell carcinoma
  • 23. LOCAL INVASION –OF CA TONGUE It may spread anteriroly – involving the mandible Inferiorly – involving the floor of mouth
  • 27. CA TONGUE- CT IMAGE & PET SCAN IMAGE
  • 28. MRI IMAGE OF CA TONGUE
  • 34. AIMS OF SURGERY:  Complete excision of primary tumor 3 dimensionally with R0 resection (microscopically clear margin).  Removal of Neck lymph nodes.  Reconstruction of tissue loss-( for rapid healing , restoration of function & appearance to improve quality of life.)
  • 35. ACCESS :  For tumor clearance to be achieved access of oral cavity is very important:  Mainly 3 different access techniques are used: 1. TRANSORAL APPROACH- for small tumors. 2. LIP SPLIT TECHNIQUE- through mandible . 3. VISOR INCISION.
  • 37. FOR LYMPH NODE CLEARANCE -
  • 40. INCISIONS FOR NECK DISSECTION
  • 41. FOR SMALL TUMORS <2 CM  Tumor located at tip of tongue / lateral border of anterior 2/3rd of tongue that are approachable : PER ORAL RESECTION with 1cm tumor free margin & primary closure.  LASER EXCISION can also be used- minimal bleed/ scar & rapid healing.
  • 42. T1 & SMALL T2 TUMORS : For T1 /small T2 tumors of anterio- lateral tongue  Can be treated by BRACHYTHERAPY.  By using IRIDIUM wire implants  Can increase the risk of local osteoradionecrosis of adjacent mandible.  Should be combined with elective neck radiation if tumor size exceeds 3 cm.
  • 44. FOR LESIONS TOO LARGE FOR LOCAL EXCISION  Small superficial well differentiated lesions of oral tongue which are too large for local excision & tumor not involving the mandible - PARTIAL GLOSSECTOMY with SPARING OF MANDIBLE is done along with + Block dissection of Neck nodes . Even If no nodes (N0) involved – Selective neck dissection is must. Tongue defect covered with- free skin graft OR pectoralis major myocutaneous flap OR with radial forearm free flap (best flap)
  • 46. MANDIBULECTOMY  Marginal mandibulectomy- it is done in cancer involving lower gingival or extending to mandible without clinical or radiological involvement or with minimal cortical invasion.  Segmental mandibulectomy- when cancer directly invades the mandible
  • 47. FOR LARGE TUMORS / CA TONGUE BASE  TOTAL GLOSSECTOMY- indicated for massive local carcinoma of tongue.  Approach- either lip split technique OR visor’s approach  Floor of mouth, mandible up to ascending rami , some tissue of pharyngeal & laryngeal mucosa along with the tongue is removed.  Reconstruction- can be done by PMMF/ radial forearm free flap.  If defect is very large – ALT FLAP( Anterio-lateral thigh flap).  Mandibular reconstruction- by K-wires OR titanium plates/ iliac crest bone graft.
  • 49. CA POSTERIOR 1/3RD OF TONGUE  As this site is anatomically difficult for surgery, so TELE THERAPY / EBRT is useful .  Median translingual pharyngotomy can be done.  A temporary tracheostomy is necessary for patients with flap reconstruction & nasogastric / gastrostomy tube feeding upto 2 weeks.
  • 53. POOR PROGNOSTIC FACTORS-  Increasing Tumor thickness >4mm  High grade tumors  Poorly differentiated tumors  Vascular/lymphatic invasion  Level III & IV has poor prognosis  B/L or contralateral nodes  Nodes involved >3 in number  Nodal size>3cm  Nodal extracapsular spread