CANCER OF THE TONGUE

Curs de Lb. Engleza ptr Facultatea de Stomatologie

Observations have been made on 653 patients. Whereas in 1925 there were ten men to one woman among the patients with cancer of the tongue, this ratio has gradually fallen to 2:1. They differentiate between small and large, rather than early and late, lesions since reliable statements about the length of the history were rare. The lymph nodes had become involved in 57 per cent of the patients when first seen, and in about one-half of the remaining 43 per cent the lymph nodes became involved later. Histologically, all but eight of the tumors were squamous-cell carcinoma. In interstitial radium therapy, the implantation was carried out under under anesthesia, with an endotracheal tube and a throat pack. The position of the standard radium needles is checked by roentgenograms; this is necessary for the calculation of the dose. With a dose rate of from 40 to 50 per hour, a total dose of 7.000 to 8.000 can be given in seven days. The authors carried out 573 tongue implants in 507 patients. Conventional Roentgen therapy with 200 or 400 kV has proved disappointing, and these rays should be used only in dosages of 2 million volts. The authors used teleradium units whenever external irradiation seemed indicated, and recently they used radioactive cobalt. They believe that radical surgery is rarely necessary, primary radium resistance or postirradiation recurrences being about the only indications for radical operations. The treatment of choice for cervical lymph nodes remains radical or block dissection of the neck under certain well-defined conditions. Taking into account the great palliative value, the authors believe that radium therapy remains the method of choice in the great majority of patients.

NEOPLASIA OF THE ORAL CAVITY

Anatomy Handbook

The anatomical contents of the oral cavity include the upper and lower alveolus, teeth, lips and the anterior two-thirds of the tongue. Virtually all oral cavity cancers are of the malignant squamous cell variety. Adenoid cystic carcinoma can arise from minor salivary glands but is rare. Premalignant lesions in the oral cavity include leucoplakia and erythroplakia. In virtually all neoplasia of the oral cavity one or more of several aetiological factors are present. Smoking and alcohol abuse are very common. Chronic dental infection, e.g. caries, may result in malignant change, as may lesions seen in tertiary syphilis. Carcinoma of the lip Carcinoma of the lip is common in outdoor workers and in regions close to the equator, presumably due to the effects of ultraviolet light. Tobacco smokers show a higher incidence of lip cancer. Historically, smoking a clay pipe was the major cause. Clinical features The lower lip, perhaps due to its greater size, is most frequently affected. Dyskeratosis usually manifests as a white patch on the lip, termed actinic cheilitis. Included in the differential diagnosis is keratoacanthoma, syphilis and tuberculosis. A biopsy will confirm the diagnosis. Management A lip shave and advancement of the vermilion is performed in actinic cheilitis. Any neoplastic lesion requiring less than a third of the lip to be excised can be removed by modified V incision and primary closure. Larger tumours will require local skin flaps for reconstruction. Radical neck

dissection will be necessary if metastatic nodal disease is present. Radiotherapy in small early lesions also produces excellent results, and control may be achieved using the argon laser. Carcinoma of the tongue The incidence of tongue cancer is diminishing due to improvements in dental hygiene and the fall in popularity of chewing tobacco. The lateral border of the tongue is the commonest site affected. Clinical features A persistent ulcer, usually painless, is the common presentation. If allowed to grow, the lesion will ultimately cause tongue fixation and invade the mandible. The patient will then experience difficulty in chewing, swallowing and speech. About a third of patients will have a metastatic neck gland at presentation, which may be on the contralateral side of the neck due to the decussating nature of the lymphatic drainage in this area. The diagnosis is confirmed by biopsy. Management Treatment of small lesions without neck metastases is by either surgery or radiotherapy. A wedge excision may be employed, but implanted radium needles can produce the same cure rate. Larger lesions will require a partial glossectomy, resection of the mandible and neck dissection. Carcinoma of floor of mouth Squamous carcinoma at this site tends to present late. Most lesions will have already invaded the periosteum and bone of the mandible. Clinical features `Dysphagia or odynophagia (pain on swallowing) are common symptoms. Pain is usually a major feature and signifies deep invasion. There may also be referred otalgia. An orthopantogram or CT may reveal bone erosion of the mandible. Biopsy is mandatory for tissue diagnosis and prior to embarking on major surgery. Management Radiotherapy is usually not offered as a primary form of treatment as any subsequent excision has a high risk of producing osteoradionecrosis of irradiated bone. After surgical excision, the soft tissue defect is reconstructed using either a pedicled or free flap. Mandibular reconstruction is also feasible. A radical neck dissection will be required as the presence of nodal disease is almost universal. Carcinoma of the alveolar ridge The lower alveolar ridge is most commonly affected. In the elderly, an illfitting denture may be the presenting symptom. Most lesions will have spread to bone and the adjacent floor of mouth. The mandible is either invaded directly by tumor or via the inferior dental nerve canal. In the latter case the contiguous spread may be as far posterior as the skull base. Treatment is along similar lines to that of carcinoma of the floor of mouth. Carcinoma of the hard palate Squamous carcinoma is rare in this site. Adenoid cystic carcinoma is not uncommon, as are benign minor salivary gland tumours. The former cancer tends to extend along the perineural spaces of the greater palatine nerves and may spread into the cranium. Treatment of adenoid cystic carcinoma is surgery, possibly followed by postoperative radiotherapy. Any defect in the hard palate can be occluded with a dental obturator. Carcinoma of the buccal lining The buccal lining is a very common site for cancer on the Indian subcontinent, probably resulting from metaplastic change induced by betel nut chewing. The lesion may be ulcerative or exophytic. A biopsy will confirm the diagnosis. Early small lesions may be successfully excised and primarily sutured. Wider resection will require skin grafting. Radiotherapy should be used in extensive lesions, which are usually incurable due to invasion of the pterygoid muscle region.