Tongue carcinoma is common, with the lateral margin being the most common site. Symptoms include a non-healing sore or swelling of the tongue. Diagnostic workup involves biopsy and imaging of the primary tumor and neck lymph nodes. Treatment depends on tumor stage but commonly includes surgery such as glossectomy with neck dissection, and may involve reconstruction. Posterior 1/3 tumors carry a poorer prognosis due to late detection and higher risk of bilateral nodal spread. Thorough examination of any tongue complaints is important for early detection and treatment.
Tongue carcinoma is common, with the lateral margin being the most common site. Symptoms include a non-healing sore or swelling of the tongue. Diagnostic workup involves biopsy and imaging of the primary tumor and neck lymph nodes. Treatment depends on tumor stage but commonly includes surgery such as glossectomy with neck dissection, and may involve reconstruction. Posterior 1/3 tumors carry a poorer prognosis due to late detection and higher risk of bilateral nodal spread. Thorough examination of any tongue complaints is important for early detection and treatment.
Original Description:
Tongue carcinoma has become a devastating cause of morbidity in this era of tobacco consumers.
Tongue carcinoma is common, with the lateral margin being the most common site. Symptoms include a non-healing sore or swelling of the tongue. Diagnostic workup involves biopsy and imaging of the primary tumor and neck lymph nodes. Treatment depends on tumor stage but commonly includes surgery such as glossectomy with neck dissection, and may involve reconstruction. Posterior 1/3 tumors carry a poorer prognosis due to late detection and higher risk of bilateral nodal spread. Thorough examination of any tongue complaints is important for early detection and treatment.
Tongue carcinoma is common, with the lateral margin being the most common site. Symptoms include a non-healing sore or swelling of the tongue. Diagnostic workup involves biopsy and imaging of the primary tumor and neck lymph nodes. Treatment depends on tumor stage but commonly includes surgery such as glossectomy with neck dissection, and may involve reconstruction. Posterior 1/3 tumors carry a poorer prognosis due to late detection and higher risk of bilateral nodal spread. Thorough examination of any tongue complaints is important for early detection and treatment.
Histologically 1. Squamous cell carcinomacommonest (Approximately 75% of all tongue SCCs arise from the anterior two thirds of the tongue). 2. Adenocarcinoma- from minor salivary glands or mucous glands. 3. Melanomas. 4. Transitional cell carcinoma and lymphoepithelioma rarely in posterior 1/3rd of tongue.
SYMPTOMS
A sore in the tongue that does not heal (most common
symptom) Pain in the tongue that does not go away (also very common) A persistent red painless patch/ulcer/swelling which may later become painful in the tongue. A sore throat or a feeling that something is caught in the throat that does not go away. Increased salivation
Difficulty and pain on swallowing (CA of post.1/3 of tongue)
Dysphagia ( CA of post 1/3 of tongue) Voice changes (CA of post 1/3 of tongue) Inability to articulate Difficulty moving the jaw or tongue Swelling of the jaw that causes dentures to feet poorly or become uncomfortable A lump or mass in the neck Weight loss Persistent bad breath Features of bronchopneumonia-duo to aspiration
PATIENT WORK-UP
HISTORY CLINICAL EXAMINATION INVESTIGATIONS
INVESTIGATIONS Primary: Punch biopsy FNAC of neck lymph nodes Indirect and direct laryngoscopy-post.1/3 growth CXR Orthopantomogram ECG Routine blood investigations
Investigations for staging:
CT scan - Face + Neck + Chest MRI USG of neck or primary + USG guided FNAC of suspicious lymphadenopathy PET scan
Investigations for reconstruction:
Allens test of vascular supply to hand if a radial forearm flap
anticipated. MRA of leg vessels if composite fibular reconstruction anticipated. Colour doppler of chest and abdomen if DCIA (deep circumflex iliac artery) free flap anticipated.
TNM STAGING FOR
ORAL CAVITY CARCINOMA Primary Tumor TX Unable to assess primary tumor T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor is < 2 cm in greatest dimension T2 Tumor > 2 cm and < 4 cm in greatest dimension T3 Tumor > 4 cm in greatest dimension T4 (lip) Primary tumor invading cortical bone, inferior alveolar nerve, floor of mouth, or skin of face (e.g., nose or chin) - T4a (oral) Tumor invades adjacent structures (e.g., cortical bone, into deep tongue musculature, maxillary sinus) or skin of face - T4b (oral) Tumor invades masticator space, pterygoid plates, or skull base and/or encases the internal carotid artery
Regional lymphadenopathy
Nx Unable to assess regional lymph nodes
N0 No evidence of regional metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension - N2a Metastasis in single ipsilateral lymph node >3 cm and < 6 cm - N2b Metastasis in multiple ipsilateral lymph nodes, all nodes < 6 cm - N2c Metastasis in bilateral or contralateral lymph nodes, all nodes < 6 cm N3 Metastasis in a lymph node > 6 cm in greatest dimension
Distant metastases
MX Unable to assess for distant metastases
M0 No distant metastases M1 Distant metastases
TREATMENT Treatment goals:
To eradicate primary tumour and LN metastasis
To maintain function Cosmetic reconstruction
Factors affecting choice of treatment:
Tumour factor Patient factor Resource factor
TREATMENT MODALITIES
Surgery Radiotherapy Chemotherapy
According to stage:
T1 and T2: RT and surgery equally acceptable.
Larger lesions are best managed by combined modality treatment.
Comparative highlights between surgery and RT:
Early lesions:5 year survival for RT or surgery ranges 80%90%
Local necrosis and bone exposure more with RT.
SURGERY
Wide excision with 1cm clearance in margin and depth-in <
1cm tumour or in ca in situ.
Partial glossectomy with 2cm clearance with removal of ant.
1/3 of tongue-in 1-2 cm tumour
Hemiglossectomy in tumour >2 cm size
Larger tumour preoperative radiotherapy followed by
hemiglossectomy done.
If mandible involved-hemimandibulectomy is done.
Procedure involving hemiglossectomy+ hemimandibulectomy+radical neck dissection called as COMMANDO OPERATION Reconstruction of tongue and other area after surgery: By deltopectoral flap, forehead flap, pectoralis major muscle flap, skin grafting.
Management of neck:
Treatment of cervical lymphatics is recommended for virtually
all patients.
When the primary site is addressed surgically, modified
radical neck dissection (MRND) or selective neck dissection (SND) is performed.
Depth of invasion of the primary tumor can direct the need
for elective lymph node dissection with early stage lesions.
Carcinoma of posterior 1/3 of
tongue:
Lesion may remain asymptomatic for long time & Clinically
may be missed easily.
Referred pain in the ear, bleeding from mouth, visible mass in
posterior third of tongue is late local features.
Induration on palpation in posterior third tongue is diagnostic
of the carcinoma.
Lymph node spread is common (70%). Bilateral nodal spread
is common.
Carcinoma posterior third of the tongue is often poorly
differentiated and so carries poor prognosis.
Blood spread can occur into bones, liver and lungs in posterior third cancers.
T1, T2, N0 and N1 diseases are treated by surgical wide
excision or often by total glossectomy using midline mandibulotomy incision (mandible split) with neck dissection on both sides (MRND one side).
Post surgery radiotherapy is needed if it is a poorly
differentiated type or nodal status is more than N1.
Advanced lesions need palliative radiotherapy or
chemotherapy.
T4 lesions are often treated by total glossectomy with
laryngectomy and neck dissection but overall outcome is not good.
TAKE HOME MESSAGE:
Any complain of sore throat or lesion over tongue
should properly examined to exclude premalignant condition or malignancy of tongue..............
If not than the patient may lose his/her tongue as well
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