Dr. Ahmed Khan Sangrasi, Assistant Professor, Dept. of Surgery,
LUMHS, Jamshoro Carcinoma of Tongue(Oropharyngeal)
Slide 2
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
Slide 3
Tobacco when kept in mouth leaches out carcinogens, which act
on oral mucosa causing neoplastic changes. Habit of smoking is also
equally dangerous
Slide 4
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.
Slide 5
Tobacco in Pakistan most commonly consumed in the form of
gutka, quid pan or smoking in the form of bidi of cigarette.
Slide 6
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.
Slide 7
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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.
Slide 9
ORAL LEUCOPLAKIA PATCH
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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.
Slide 12
Erythroplakia
Slide 13
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.
Slide 14
Oral Sub Mucous Fibrosis
Slide 15
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
Slide 16
Smf is equally common in gutka eating ladies
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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.
Slide 19
The next stage after the precancerous lesion is the Cancerous
lesions.
Slide 20
The most common form of cancer is Squamous cell carcinoma. It
normally starts from any of the precancerous lesion in the
mouth.
Slide 21
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.
Slide 22
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
Slide 23
Cancer Of Cheek after tobacco quid habit
Slide 24
SAME PATIENT WITH THE CANCER LESION COMING EXTRA ORALLY
Slide 25
Cancer of buccal mucosa after tobacco habit going
extra-orally
Slide 26
CANCER STARTING FROM BUCCAL VESTIBULE FOLLOWING HABIT OF PAN
WITH TOBACCO
Slide 27
Cancer of Buccal mucosa invading extra-oral tissues following
tobacco quid habit
Slide 28
Cancer of labial mucosa invading extra-oral tissues following
tobacco quid habit
Slide 29
CANCER OF CHEEK FOLLOWING EATING OF GUTKA
Slide 30
Cancer of labial mucosa after tobacco quid habit
Slide 31
Same patient with Cancer Of Gums
Slide 32
CANCER OF GUMS FOLLOWING EATING OF GUTKA
Slide 33
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.
Slide 34
CANCER OF LOWER LIP
Slide 35
Cancer of palate It is usually an ulcerative lesion and may
spread extensively before involving underlying bone.
Slide 36
Cancer of Palate after habit of smoking
Slide 37
Slide 38
CANCER OF MAXILA AFTER SMOKING HABIT
Slide 39
CANCER OF PALATE
Slide 40
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.
Slide 41
Alveolar cancer after tobacco quid habit
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Relapse case He was operated for cancer of lower jaw in oct
00
Slide 44
Relapsed cancer in upper jaw in July 04
Slide 45
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.
Slide 46
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.
Slide 47
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.
Slide 48
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
Slide 49
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
Slide 50
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
Slide 51
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.
Slide 52
Cancer of Tongue following tobacco consumption
Slide 53
Cancer of Tongue
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Squamous cell carcinoma of the base of the tongue.
Slide 57
Squamous cell carcinoma of the tongue in a 32 year-old chronic
smoker.
Slide 58
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
Slide 59
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
Slide 60
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.
Slide 61
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.
Slide 62
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.
Slide 63
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.
Slide 64
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
Slide 65
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
Slide 66
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
