Tongue Cancer Final

TONGUE CANCER
JDP Wisnubroto
Faculty of Medicine of Brawijaya University
Saiful Anwar State General Hospital
Malang
Munas Medan 15112018
Definition
• Tongue cancer is the malignancy in two third
anterior of the tongue, usually occuring in
males 50 to 70 years old.
• Often develops from leukoplakia, prolonged
dental ulcer, or syphilitic glossitis.
Dhingra PL & Dhingra S. 2014. Disease of Ear, Nose, & Throat and Head & Neck Surgery 6th Edition. Elsevier.
Epidemiology
• Cancer in oral cavity
– 30% malignancy in head and neck*
– 11th cancer with the highest number of patients**
– Estimated 263000 new cases occur per year**
– The mortality rate is 127,700 cases per year
(2008)**
• 90% cavum oris cancer  squamous cell
carcinomas (SCCs)*
*Alberta Health Service. 2014. Oral Cavity Cancer.

**Ferlay J et al. 2010. GLOBOCAN 2008 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]. Available from:
http://globocan.iarc.fr
Risk Factors
• Smoking  6-times higher in smokers than non-smokers
• Tobacco chewing
• Alcohol  6-times higher in heavy drinkers than non-drinkers
• Nutrient deficiency
– Riboflavin deficiency contributes to cancer incidence in alcohol
consumers
– Paterson–Brown–Kelly syndrome or Plummer–Vinson syndrome (iron
deficiency anemia) contributes to oral cavity and hypopharynx cancer.
• Dental infection, jagged sharp teeth and ill-fitting dentures  causing
chronic infection that can develop into cancer
RISK FACTORS FOR ORAL CAVITY TUMOR  6S

Smoking, Spirits, Sharp jagged tooth, Sepsis, Syndrome of Plummer–Vinson, Syphilitic glossitis.
Location
• Most often location 
middle of tongue
lateral border or
ventral part of the
tongue.
• Rarely found at the tip
or the dorsal part of
the tongue.
Location
Indian Council Medical Research. 2014. Consensus Document for Management of Tongue Cancer. Aravali Printers and Publications.
Distribution
– Infiltration can occur in the lingual muscles,
causing ankyloglossia, or disseminate into the
base of the mouth, alveoli, and the mandibule.
– Metastase in the lymph nodes can occur in
submandibular and superior jugular lymph nodes
(from lateral border of the tongue) and in
submental and juguloomohyoid lymph nodes.
– Lymph nodes involvement can appear bilateral or
contralateral.
Clinical Manifestations
1. Exophytic lesions resembling papilloma
2. Non-healing ulcer with irregular edges,
grayish white base with induration
3. Submucosal nodules with tissue induration
Clinical Manifestations
Diagnosis
Symptoms Signs
• Pain in the tongue, at the site • Lesion (often without pain
of ulcer and asymptomatic for a
• Pain in ipsilateral ear period of time)
– N. lingual & n. • Nodule inside the mouth
auriculotemporal 
mandibular branch of n. • Lymph nodes enlargement
Trigerminal in the neck
• Dysphagia, difficulty in talking
and sticking the tongue out
• Bleeding from the mouth 
terminal symptom
Diagnosis
All patients with lesion in the oral mucosal unknown for 2 weeks  referred
to a specialist, which includes:
• White or reddish lesion in oral • Pain
mucosa • Difficulty or pain on swallowing
• Mucosal defect or ulcers • Difficulty talking
• Swollen oral cavity • Decrease in tongue mobilization
• One or more teeth loosened • Feeling numb at the tongue,
unrelated to periodontal disease teeth, or lip
• Persistent foreign body sensation, • Bleeding for an unknown cause
especially the unilateral one • Swollen neck
• Fetor
• Dental occlusion
Klaus-Dietrich Wolff et al. The Diagnosis and Treatment of Oral Cavity Cancer. Dtsch Arztebl Int. 2012 Nov; 109(48): 829–835. doi: 10.3238/arztebl.2012.0829
Diagnosis – Further examinations
Histological Imaging
• Biopsy • USG  to evaluate neck
– Punch biopsy from the most nodules undetected
representative area, avoiding
necrotic sites clinically in the early stages.
– Incisional biopsy  • CT/MRI  mandatory
submucosal/patch/veruka
lesion or punch biopsy (reccomendation level B).
unavailable.
• Cytology
– Adjunct for biopsy. If the result
is negative, but sign and
symptoms are positive, biopsy
needs to be done.
Klaus-Dietrich Wolff et al. The Diagnosis and Treatment of Oral Cavity Cancer. Dtsch Arztebl Int. 2012 Nov; 109(48): 829–835. doi: 10.3238/arztebl.2012.0829
Staging
Staging
Management
• Objectives :
– treat primary tumor in the tongue,
– control metastase into the neck,
– maintain tongue function as well as
possible.
– Small-sized tumor (T1N0)  gives good response
with surgery or radiotherapy
– T2N0  treated with excision surgery with
prophylactic neck dissection or can be treated
with radiotherapy including neck nodules to
eliminate micrometastase.
– Stage III or IV tumors combination therapy
including surgery and post-operative radiotherapy.
• Surgery procedures that can be done
depending on the size and the extension of
tongue primary lesion consist of:
– Hemiglossectomy  including base of the mouth,
segmental
– Hemimandibulectomy
– Block dissection of neck nodes  known as
“commando operation.”
Management
Management - Operative
• Primary tumor excision  resection done with
known borders.
– Initial assesment needed by digital palpation and
imaging to identify depth border
– Minimum limit  1 cm
• Access for surgery:
– Peroral
– Mandibulotomy (paramedian, leaving n. Mental)
– Pull through (combination of the neck and intraoral
approaches)
• Mandibular management
– Assessing mandibular involvement clinically and
radiologically
– Dissemination can occur through occlusant surface or
direct erosion
• Indication
– Marginal mandibulectomy  no tumor invasion in
mandibule
– Segmental mandibulectomy  tumor invasion in
mandibule, soft tissue involvement that makes the
tumor border unclear
• Criteria for unresectable primary tumor
– Ankyloglossia
– Skin involvement by direct extension
– Tumor extension into infratemporal fossa /
masticator space and base of the skull
• Neck Management
1. Clinically no nodule in early stage lesion (Stage 1
T1N0M0 dan Stage II T2N0M0)
1. Observation
• Low metastase risk (T1, thickness <4mm, well
differentiated)
• Negative palpation and ultrasound
2. Elective Neck Dissection
• Tumor thickness >4 mm, cannot be followed up, tumor
invading the neck, unreliable physical examination
3. Elective Neck Irradiation
• If primary tumor treated with radiotherapy
2. Neck dissection extent
– Selective neck dissection (dissection level I-III)
3. Special cases
– Dissection level IV  accompanied with level I-
III (extended SOHD), does not need dissection
level V
– Level IIB dissection  increasing risk for nerve
dysfunction
• Reconstruction
– Primary closure  if excision was V-shaped
– Skin graft  for dorsal tongue defect
– Local Flap  generally in nasolabial skin flap
– Regional Flap  submental artery island flap
– Distant Flap  pectoralis major mucocutaneus
flap
– Free Flap  radial forearm artery flap
• T1 and T2 without nodule (N0)  Does not need
reconstruction
• T1 and T2 with nodule  Free radial artery forearm flap
(FRAFF) or anterolateral thigh (ALT) flap are preferred.
• T3 and T4
– Free flaps :
• Free radial artery forearm flap (FRAFF)
• Anterolateral thigh (ALT) flap. •
– Pedicled flaps :
• Pectoralis majormyo-cutaneous flap (PMMC)
• Pectoralis major myo-fascial flap (PMMF)
Management of Radiotherapy
• EBRT with or without chemotherapy is generally
employed in 3 situations:
– adjuvant to primary surgery to enhance loco-
regional control (LRC) for cases with unfavorable
pathological features,
– primary treatment for cases unable to tolerate or
unsuited for surgery
– salvage treatment in the persistent or recurrent
disease setting.
• General indications for PORT include:
– T3 or T4 tumor; compromised surgical resection
margins (<5 mm from the inked surface of the
specimen)
– presence of lympho-vascular invasion (LVI) and/or
peri-neural invasion (PNI)
– positive lymph nodes with or without
extracapsular invasion (ECE)
• Brachytherapy may be employed as a sole modality
for :
– early disease with a well-defined primary tumor,
or as an
– adjuvant to surgery for cases with close or positive
resection margins.
– Alternatively it may be used as a “boost”
technique to the primary tumor in addition to
EBRT
Management of Chemotherapy
Chemo may be used in several different situations :
• adjuvant chemotherapy
• neoadjuvant or induction chemotherapy
• Chemoradiationtherapy
• Chemo (with or without radiation therapy)
– can be used to treat cancers that are too large or have
spread too far to be removed by surgery. The goal is to
slow the growth of the cancer for as long as possible
and to help relieve any symptoms the cancer is
causing
• The chemo drugs used most often for cancers of the
oral cavity and oropharynx are:
– Cisplatin
– Carboplatin
– 5-fluorouracil (5-FU)
– Paclitaxel
– Docetaxel
– Hydroxyurea
• Other drugs that are used less often include
– Methotrexate
– Bleomycin
– Capecitabine
Targeting Therapy
• The epidermal growth factor (EGFR) and its
signal transduction pathway play an important
role in head and neck cancer.
• Over-expression of EGFR has been confirmed
in OSCC and has been reported to be
associated with a poor prognosis
Role of Radiotherapy and Chemoradiotherapy in
Oral Cancer
Management Pathway
THANK YOU

Tongue Cancer Final

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*Alberta Health Service. 2014. Oral Cavity Cancer.

RISK FACTORS FOR ORAL CAVITY TUMOR  6S

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