CASE REPORT TONGUE TUMOR I.

IDENTITY

Name Age Gender Jobs Address Date of Entery

: Nn. S : 28 years : Female : Housewife : Gunung Jati : ! "une 2! #

II. ANAMNESIS (AUTOANAMNESIS)

The Main Complaint

$atients %om&lain t'ere are bum&s on t'e tongue

A Hi to!" o# The Di ea e No$

$atients %om&lain t'ere are bum&s on t'e tongue sin%e two mont's ago. At first lum& is small and does not feel &ain. (ut o)er time t'e lum& is enlarged and &ainful swallowing. *om&laints of nausea+ )omiting+ fe)er+ s'ortness of breat'+ 'eada%'e denied by t'e &atient. $atient admitted t'at s'e li,es to eat s&i%y-food and 'ot drin,s.$atient ne)er %om&lained of &ain li,e t'is before. $atient is not a smo,er or al%o'oli%. $atients admitted 'a)e ast'ma sin%e t'e age of . years. A Hi to!" o# Pa t Illne :

/'e &atient denied 'a)ing diabetes mellitus+ 'y&ertension+ and &atients 'a)e a 'istory of ast'ma. A Hi to!" o# %amil" Di ea e : /'e &atient admitted t'at in family ne)er e0&erien%ed anyt'ing li,e t'is

III. PHYSICA& E'AMINATION

GENE1A2 S/A/3S Awarness General Awarness 4ital Sign : /D $ S 1 Head : Normo%e&'al eyes : 9on"ungti)a anemis -5S,lera i,teri, -5$u&il refle0 -5Ne%, : /'yroid not &al&able enlarged 2ym&' nodes not &al&able enlarged /'ora,s *or : : (eing Si%, : *om&os mentis : !56! mmHg

: 87 05minutes : #6o* : 28 05 minutes

:: i,tus %ordis is not )isible $: i,tus %ordis &al&able on :*S 4 line mid%la)i,ula $: %ardia% borders easily assessed A: (J regular :-::+ murmurs ;-<+ gallo& ;-<

$ulmo :: symmetri%al &iston mo)ement in a stati% state and dynami% $: )o%al fremitus at t'e rig't and left 'emit'ora0 $: resonant to bot' lung field A: 4esi%ular+ r'on,i - 5 -+ w'ee=ing - 5 Abdomen :

:: %on%a)e+ symmetri%al+ surgi%al wound ;-< A: (owel ;>< normal $: /im&ani w'ole abdominal field $: soft+ tenderness ;><+ &al&able &resen%e of &ast 2

E0tremity. : 2eft 1ig't Su&erior: edema ;-<+ warm a,ral 1ig't inferior 2eft : edema ;-<+ %old a,ral Genital: Not %'e%,ed 2o%alist status. :

A bum& on t'e ba%, left side of t'e tongue wit' a diameter si=e 20 %m+ red ;-<+ firm boundaries ;><+ &ain ;-<

I(.

E'AMINATION SUPPORT

Date+ # ?ei 2! # Da!ah R)tin 2A( A(* 2C? ?@N G1AN32 2C? D ?@ND G1AN32D 1(* HG( H*/ MC( MCH ?*H* 1DA $2/ 1ES32/ 7.8 2. !.. 8.2 #!.E 6.. 7 .6 8.E7 2.# #8.8 **.+ 0+., #2.! #.7 28. & & P1 g5dl D !B#5 F2AGS 3N:/ !B#5 !B#5 !B#5 !B#5 D D D !B75 g5dl D N@1?A2 8.!- 2.! .!-..! !. - .! 2.!-8.! 2..!-.!.! 2.!- !.! .!.!-8!.! 8.!-7.2! .!- 6.! #..!-...! ,-.-./--.02.-.3+.# .!-#..! !.!- 7.! .!.!-8!!.!

?$4 $*/ $@A

6. !.2!2 2.7 D D

6.!-

.!

!.2!!-!..! !.!- 8.!

(/ */ 9gds 2ED 3reum.

: 2F#!G : #F#!G : 87 mg5dl : ! um5"am : 28+! mg5dl

9reatinin. : !+7 mg5dl Ront1en Tho!a4 Photo : $'oto asymmetri% and la%,ing ins&iration *ast does not a&&ear enlarged+ sinuses and normal dia&'ragm

$ulmo:

in%reased mar,s of &ulmonary Soft tissue does not seem &at%'es

:m&ression: /'ere does not a&&ear a%ti)e &ulmonary /( /'ere does not a&&ear %ardiomegali

(.

DIAGNOSIS 5ANDING . /ongue /umor 2. /ongue *arsinoma #. Hemangioma

II.

DIAGNOSIS 6ER7A /ongue /umor

III.

PENATA&A6SANAAN

?edi,amentosa : . *efta=olin #H 2. 9etorola% #H #. 1anitidin #H

Surgesion

I(.

PROGNOSIS Ad 4itam Ad Fun%tionam Ad Stasionam : Dubia ad bonam : Dubia ad bonam : Dubia ad bonam

Ca e P!e entation Ton1)e t)mo!

/. Anatom"

/'e tongue is basi%ally a mass of mus%le t'at is almost %om&letely %o)ered by a mu%ous membrane. :t o%%u&ies most of t'e oral %a)ity and oro&'aryn0. :t is ,nown for its role in taste+ but it also assists wit' masti%ation ;%'ewing<+ deglutition ;swallowing<+ arti%ulation ;s&ee%'<+ and oral %leaning. Fi)e %ranial ner)es %ontribute to t'e %om&le0 inner)ation of t'is multifun%tional organ. /'e embryologi% origins of t'e tongue first a&&ear at 8 wee,sI gestation. J K /'e body of t'e tongue forms from deri)ati)es of t'e first bran%'ial ar%'. /'is gi)es rise to 2 lateral lingual swellings and median swelling ;,nown as t'e tuber%ulum im&ar<. /'e lateral lingual swellings slowly grow o)er t'e tuber%ulum im&ar and merge+ forming t'e anterior two t'irds of t'e tongue. $arts of t'e se%ond+ t'ird+ and fourt' bran%'ial ar%'es gi)e rise to t'e base of t'e tongue. @%%i&ital somites gi)e rise to myoblasts+ w'i%' form t'e intrinsi% tongue mus%ulature. From anterior to &osterior+ t'e tongue 'as # surfa%es: ti&+ body+ and base. /'e ti& is t'e 'ig'ly mobile+ &ointed anterior &ortion of t'e tongue. $osterior to t'e ti& lies t'e body of t'e tongue+ w'i%' 'as dorsal ;su&erior< and )entral ;inferior< surfa%es /'e median sul%us of t'e tongue se&arates t'e body into left and rig't 'al)es. /'e terminal sul%us+ or groo)e+ is a 4-s'a&ed furrow t'at se&arates t'e body from t'e base of t'e tongue. At t'e ti& of t'is sul%us is t'e foramen %e%um+ a remnant of t'e &ro0imal t'yroglossal du%t. /'e base of tongue %ontains t'e lingual tonsils+ t'e inferiormost &ortion of AaldeyerFs ring. 6

/./ &in1)al papillae /'e surfa%e of t'e body of t'e tongue deri)es its %'ara%teristi% a&&earan%e from t'e &resen%e of lingual &a&illae+ w'i%' are &ro"e%tions of lamina &ro&ria %o)ered wit' e&it'elium.J2K /'ere are 8 ty&es of lingual &a&illae: )allate ;%ir%um)allate<+ foliate+ filiform+ and fungiform. /'e )allate &a&illae are flat+ &rominent &a&illae t'at are surrounded by troug's. :n 'umans+ t'ere are 8- 2 )allate &a&illae+ lo%ated dire%tly anterior to t'e terminal sul%us. /'e du%ts of t'e lingual glands of )on Ebner se%rete lingual li&ase into t'e surrounding troug's to begin t'e &ro%ess of li&olysis.J#K /'e foliate &a&illae are small folds of mu%osa lo%ated along t'e lateral surfa%e of t'e tongue. /'e filiform &a&illae are t'in and longL t'ey are t'e most numerous &a&illae and are lo%ated along t'e entire dorsum of t'e tongue+ but t'ey are not in)ol)ed in taste sensation. /'e fungiform &a&illae are mus'room s'a&ed and are dis&ersed most densely along t'e ti& and lateral surfa%es of t'e tongueL 'umans 'a)e 2!!-#!! of t'ese. Ea%' )allate+ foliate+ and fungiform &a&illa %ontains taste buds ;2.!+ !!!+ and 7!! taste buds+ res&e%ti)ely<. Ea%' taste bud is inner)ated by se)eral ner)e fibers. :n 'umans+ all taste buds %an &er%ei)e t'e . different taste Mualities: salt+ sweet+ bitter+ a%id+ and umami. Ea%' taste bud %onsists of taste re%e&tor+ basal+ and edge %ells. A'en a taste mole%ule binds to a taste re%e&tor+ t'e re%e&tor %ell de&olari=es+ %ausing an influ0 of *a >>+ w'i%' results in t'e release of an un,nown neurotransmitter. From t'ere+ t'e neural &at'way de&ends on t'e lo%ation of t'e taste bud t'at was stimulated. :n t'e anterior two t'irds of t'e tongue+ t'e %'orda tym&ani bran%' of t'e fa%ial ner)e ;%ranial ner)e 4::< is stimulated. /'e lingual-tonsillar bran%' of t'e glosso&'aryngeal ner)e ;%ranial ner)e :H< relays taste information from t'e &osterior one t'ird of t'e tongue. /aste fibers from t'e anterior two t'irds of t'e tongue first tra)el wit' t'e lingual ner)e and t'en are relayed to t'e %'orda tym&ani ner)e. /'is ner)e enters t'e tem&oral bone from t'e infratem&oral fossa+ w'ere it "oins t'e fa%ial ner)e and tra)els to t'e geni%ulate ganglion+ w'ere its &seudouni&olar %ell bodies are lo%ated. From t'e geni%ulate+ taste fibers tra)el in t'e ner)us intermedius to t'e nu%leus of t'e solitary tra%t lo%ated in t'e medulla oblongata. Similarly+ taste fibers from t'e &osterior one t'ird of t'e tongue tra)el wit' t'e lingual-tonsillar ner)e to t'e inferior glosso&'aryngeal ganglion and t'en to t'e nu%leus of t'e solitary tra%t. Se%ond-order neurons t'en &ro"e%t taste fibers to t'e &arabra%'ial nu%leus of t'e &ons. /'e %entral tegmental tra%t %arries taste sensation from t'e &ons to t'e t'alamus. /'e &at'way ends in t'e frontal o&er%ulum and insular %orte0. /.0 (a 8)lat)!e 2i,e most of t'e 'ead and ne%, region+ t'e tongue deri)es its arterial

blood su&&ly from t'e e0ternal %arotid artery. /'e lingual artery bran%'es off t'e e0ternal %arotid artery dee& to t'e stylo'yoid mus%le. At first it tra)els su&eromedially+ but after a s'ort distan%e it %'anges dire%tion and mo)es anteroinferiorly. /'e 'y&oglossal ner)e ;%ranial ner)e H::< %rosses o)er it laterally before it enters t'e tongue dee& to t'e 'yoglossus mus%le. Ait'in t'e tongue+ t'e lingual artery gi)es rise to its # main bran%'es: t'e dorsal lingual+ dee& lingual+ and sublingual arteries. /'e dorsal lingual artery su&&lies t'e base of t'e tongue. /'e dee& lingual artery tra)els on t'e lower surfa%e of t'e tongue to t'e ti&. A bran%' to t'e sublingual gland and t'e floor of t'e mout' is ,nown as t'e sublingual artery. /'e )eins of t'e tongue &arallel t'e lingual artery bran%'es. /'e dee& lingual )ein begins at t'e ti& of t'e tongue and tra)els &osteriorly to "oin t'e sublingual )ein. /'is drains into t'e dorsal lingual )ein+ w'i%' a%%om&anies t'e lingual artery. Dire%tly or indire%tly+ t'is )ein em&ties into t'e internal "ugular )ein. /.3 Ne!9e )ppl" ?otor inner)ation for all of t'e mus%les of t'e tongue %omes from t'e 'y&oglossal ner)e--wit' t'e e0%e&tion of t'e &alatoglossus+ w'i%' is su&&lied by t'e &'aryngeal &le0us ;fibers from t'e %ranial root of t'e s&inal a%%essory ner)e%arried by t'e )agus ner)e<. General sensation of t'e anterior two t'irds of t'e tongue is su&&lied by t'e lingual ner)e+ a terminal bran%' of t'e t'ird di)ision of t'e trigeminal ner)e ;4#<. /aste sensation for t'is &ortion of t'e tongue is %arried by t'e %'orda tym&ani bran%' of t'e fa%ial ner)e. /'e &osterior one t'ird of t'e tongue relays general and sensation )ia t'e lingual-tonsillar bran%' of t'e glosso&'aryngeal ner)e. Some general and taste sensation from t'e base of tongue anterior to t'e e&iglottis is %arried by t'e internal laryngeal bran%' of t'e su&erior laryngeal ner)e ;*N H<. /.+ &"mphati8 :!aina1e /'e lym&'ati% drainage of t'e tongue is %om&le0. 2ym&'ati%s from t'e ti& of t'e tongue tra)el to t'e submental lym&' nodes. /'is %an be i&silateral or bilateral de&ending on t'e site of t'e lesion. 2ym&' from t'e medial anterior two t'irds of t'e tongue tra)els to t'e dee& %er)i%al lym&' nodes+ and lym&' from t'e lateral anterior tongue goes to t'e submandibular nodes.

0. De#inition

A To)n1e t)mo! i a a;no!mal :e9elopment o# the to)n1e 8ell. Ma" o! ma" not ;e 8en8e!o) . 5)t mo tl" 8an ;e a 8en8e! 8ell.

/ongue %an%er is a ty&e of malignan%y t'at o%%urs w'en t'ere is an un%ontrolled growt' of %an%er %ells in t'e tongue. /ongue %an%er is a %ommon form of oral %an%er+ but a relati)ely rare form of %an%er in general. /'e ma"ority of %ases of tongue %an%er are due tosMuamous %ell %ar%inoma. /ongue %an%er is most treatable and %urable if %aug't in t'e earliest stage of t'e disease. 3ntreated and5or ad)an%ed tongue %an%er %an s&read into t'e dee&er tissues of t'e mout' and ne%,. :n ad)an%ed stages+ tongue %an%er %an s&read t'roug' t'e lym&' nodes and blood to ot'er &arts of t'e body w'ere t'e %an%er %ells %an form anot'er %an%erous tumor. /'is is %alled metastasis. /ongue %an%er and ot'er forms of oral %an%er 'a)e a 'ig' ris, of re%urring after treatment+ and t'e deat' rate from tongue %an%er is 'ig'er t'an t'at of some ot'er forms of %an%er+ su%' as %er)i%al %an%er and s,in %an%er. 3. Epi:emiolo1" :t is relati)ely %ommon+ wit' #D of all malignan%ies arising wit'in t'e oral %a)ity. /ongue %an%er is more %ommon t'an all forms of oral %a)ity %an%er e0%e&t t'ose of t'e li& and o%%urs wit' in%reasing age. :t is un%ommon before t'e age of 8! and t'e 'ig'est in%iden%e of t'e disease is in t'e 7t' and 6t' de%ades wit' se0 in%iden%e being a #: male &redominan%e. Geogra&'i%ally+ t'e tumour is found worldwide+ but t'ere is signifi%ant )ariation in in%iden%e. /'e disease o%%urs wit' 'ig'est in%iden%e in :ndian &o&ulations. All %an%ers of t'e 'ead and ne%, s'ow a strong asso%iation wit' al%o'ol %onsum&tion and toba%%o smo,ing+ &arti%ularly of %igarettes - in fa%t+ toba%%o is t'oug't to be im&li%ated in well o)er 8!D of %ases of sMuamous %ell %ar%inoma of t'e 'ead and ne%,. *'roni% e0&osure of t'e e&it'elial surfa%es of t'e 'ead and ne%, to t'ese irritants are t'oug't to result in a Nfield %an%erisationN seMuen%e of 'y&er&lasia+ dys&lasia and %ar%inoma. /'at is+ t'e de)elo&ment of &remalignant lesions may t'en undergo malignant %'ange to be%ome a %an%er. Smo,ing and al%o'ol a%t synergisti%ally in t'e de)elo&ment of 'ead and ne%, %an%er - t'e ris, w'en bot' of t'ese fa%tors is &resent is more t'an double t'e ris, of e0&osure to one fa%tor alone./'ere is a dose-res&onse relations'i& between e0&osure to toba%%o smo,ing and t'e de)elo&ment of 'ead and ne%, %an%er - t'e more you smo,e+ t'e greater t'e ris,. Smo,ers are u& to 2. times more li,ely to de)elo& 'ead and ne%, %an%er t'an t'eir nonsmo,ing %ounter&arts. $assi)e smo,ing+ toba%%o %'ewing and %igar smo,ing are also ris, fa%tors for t'e de)elo&ment of 'ead and ne%, %an%er. 3& to t'e &oint of de)elo&ment of o)ert %ar%inoma+ many of t'e %'anges asso%iated wit' %igarette smo,ing will re)erse if t'e &atient Muits smo,ing.Al%o'ol %onsum&tionas a ris, fa%tor for t'e de)elo&ment of 'ead and ne%, %an%er also s'ows a dose-res&onse relations'i& - wit' 'ea)y drin,ers being at greater ris,. :n addition+ drin,ers of s&irits may be at a greater ris, t'an t'ose w'o drin, wine.*'roni% )iral infe%tion is also asso%iated wit' t'e de)elo&ment of 'ead and ne%, %ar%inoma. /'e E&stein-(arr 4irus is strongly asso%iated wit' t'e de)elo&ment of naso&'aryngeal %an%er+ w'ilst Human $a&illoma 4irus+ Her&es Sim&le0 4irus and Human :mmunodefi%ieny 4irus 'a)e been asso%iated wit' t'e de)elo&ment of a number of different %an%ers of t'e 'ead 9

and ne%,. /'is is t'oug't to be due to t'eir interferen%e wit' t'e fun%tion of tumour su&&ressor genes and on%ogenes.@t'er ris, fa%tors in%lude immune defi%ient states ;su%' as &ost solid-organ trans&lant<L o%%u&ational e0&osures to agents su%' as asbestos and &er%'loroet'yleneL radiationL dietary fa%torsL a geneti% &redis&osition to t'e de)elo&ment of t'e diseaseL and &oor oral 'ygiene.*an%ers of t'e oral %a)ity o%%ur wit' 'ig'est in%iden%e in %ountries w'ere t'e betel nut is %'ewed. Ait' %an%ers of t'e li&s+ sun e0&osure is an additional ris, fa%tor in de)elo&ment. /'is ty&e of tumour s&reads by lo%al e0tension and t'roug' t'e destru%tion of ad"a%ent tissue. 2ym&'ati% in)asion wit' s&read to t'e %er)i%al lym&' nodes is %ommon at diagnosis. Haematogenous s&read to distant sites su%' as t'e li)er+ bones and lungs may also 'a)e o%%urred at t'e time of diagnosis. +. Sta1in1 Sta1e I: /'e %an%er is less t'an 2 %entimeters in si=e ;about in%'<+ and 'as not s&read to lym&' nodes in t'e area ;lym&' nodes are small almond s'a&ed stru%tures t'at are found t'roug'out t'e body w'i%' &rodu%e and store infe%tion-fig'ting %ells<. Sta1e II: /'e %an%er is more t'an 2 %entimeters in si=e+ but less t'an 8 %entimeters ;less t'an 2 in%'es<+ and 'as not s&read to lym&' nodes in t'e area. Sta1e III: Eit'er of t'e following may be true: /'e %an%er is more t'an 8 %entimeters in si=e. /'e %an%er is any si=e but 'as s&read to only one lym&' node on t'e same side of t'e ne%, as t'e %an%er. /'e lym&' node t'at %ontains %an%er measures no more t'an # %entimeters ;"ust o)er one in%'<. Sta1e I(: Any of t'e following may be true: /'e %an%er 'as s&read to tissues around t'e li& and oral %a)ity. /'e lym&' nodes in t'e area may or may not %ontain %an%er. /'e %an%er is any si=e and 'as s&read to more t'an one lym&' node on t'e same side of t'e ne%, as t'e %an%er+ to lym&' nodes on one or bot' sides of t'e ne%,+ or to any lym&' node t'at measures more t'an 7 %entimeters ;o)er 2 in%'es<. /'e %an%er 'as s&read to ot'er &arts of t'e body. The TNM ta1in1 " tem Anot'er met'od of staging oral %ar%inomas is referred to as t'e /N? met'od. :n t'is met'od / des%ribes t'e tumor+ N des%ribes t'e lym&' nodes+ and ? des%ribes distant metastasis. T' $rimary tumor %annot be assessed T- No e)iden%e of &rimary tumor Ti *ar%inoma in situ T/ /umor 2 %m or less in greatest dimension T0 /umor more t'an 2 %m but not more t'an 8 %m in greatest dimension T3 /umor more t'an 8 %m in greatest dimension. ;2i&< /umor in)ades ad"a%ent stru%tures ;e.g.+ t'roug' %orti%al bone+ into dee& Je0trinsi%K mus%le of tongue+ ma0illary sinus+ s,in< 10

T+ ;@ral %a)ity< /umor in)ades ad"a%ent stru%tures ;e.g.+ t'roug' %orti%al bone+ into dee& Je0trinsi%K mus%le of tongue+ ma0illary sinus+ s,in< N' 1egional lym&' nodes %annot be assessed N- No regional lym&' node metastasis N/ ?etastasis in a single i&silateral lym&' node+ # %m or less in greatest dimension N0 ?etastasis in a single i&silateral lym&' node+ more t'an # %m but not more t'an 7 %m in greatest dimensionL in multi&le i&silateral lym&' nodes+ none more t'an 7 %m in greatest dimensionL in bilateral or %ontralateral lym&' nodes+ none more t'an 7 %m in greatest dimension N0a ?etastasis in single i&silateral lym&' node more t'an # %m but not more t'an 7 %m in greatest dimension N0; ?etastasis in multi&le i&silateral lym&' nodes+ none more t'an 7 %m in greatest dimension N08 ?etastasis in bilateral or %ontralateral lym&' nodes+ none more t'an 7 %m in greatest dimension N3 ?etastasis in a lym&' node more t'an 7 %m in greatest dimension M' $resen%e of distant metastasis %annot be assessed M- No distant metastasis M/ Distant metastasis <. Dia1no ti8 Any dis%ussion of diagnosis must be &refa%ed wit' t'e issue of dis%o)ery. A'ile an annual s%reening for oral %an%er is im&ortant+ it is &ossible t'at you will noti%e some %'ange in your mout' or t'roat t'at needs e0amination between your annual s%reenings. Cou are t'e most im&ortant fa%tor in an early diagnosis. Cou s'ould always %onta%t your do%tor or dentist immediately if you noti%e t'e following sym&toms in yourself or a lo)ed one: a. A sore or lesion in t'e mout' t'at does not 'eal wit'in two wee,s. b. A lum& or t'i%,ening in t'e %'ee,. %. A w'ite or red &at%' on t'e gums+ tongue+ tonsil+ or lining of t'e mout'. d. A sore t'roat or a feeling t'at somet'ing is %aug't in t'e t'roat. e. Diffi%ulty %'ewing or swallowing. f. Diffi%ulty mo)ing t'e "aw or tongue. g. Numbness of t'e tongue or ot'er area of t'e mout'. '. Swelling of t'e "aw t'at %auses dentures to fit &oorly or be%ome 11

un%omfortable. i. *'roni% 'oarseness. /'ese sym&toms may be %aused by ot'er+ less serious &roblems+ but t'ey also indi%ate t'e &ossible &resen%e of oral %an%er. @nly a &rofessional will be able to tell you definiti)ely. Some t'in, t'at a )isit to t'eir medi%al do%tor is t'e a&&ro&riate %ourse of a%tion. (ut remember t'at dentists are trained in t'is sim&le+ Mui%, s%reening+ w'i%' in)ol)es t'e e0amination of t'e oral %a)ity as a w'ole and not "ust your teet'. (esides a )isual e0amination of all t'e tissues in your mout'+ your do%tor will feel t'e floor of your mout' and &ortions of t'e ba%, of your t'roat wit' 'is fingers+ in t'e sear%' for abnormalities. A t'oroug' oral s%reening also in%ludes indire%t e0amination of t'e naso&'aryn0 and laryn0+ and in)ol)es manually feeling t'e ne%, for swollen lym&' nodes+ and ot'er abnormalities su%' as 'ardened masses. Cour do%tor will also %'e%, t'e mout' for w'ite &at%'es+ red &at%'es+ ul%erations+ lum&s+ loose teet'+ and re)iew your dental 0-rays for abnormalities. (e sure to tell t'e do%tor if you 'a)e been a toba%%o user in any form. /oba%%o use is im&li%ated in many %ases of oral %an%er. After t'e &'ysi%al e0amination of your mout'+ if your do%tor finds any areas t'at are sus&i%ious+ 'e may re%ommend a bio&sy. /'is is sim&ly ta,ing a small &ortion of t'e sus&i%ious tissue for e0amination under a mi%ros%o&e. /'e most traditional ty&e of bio&sy is in%isional. :t may be done by t'e do%tor w'o e0amines you+ or you may be referred to anot'er do%tor for t'e &ro%edure. :n an in%isional bio&sy+ t'e do%tor will remo)e &art or all of t'e lesion de&ending on its si=e and 'is ability to define t'e e0tent of it at t'is early stage. /'e sam&le of tissue is t'en sent to a &at'ologist w'o e0amines t'e tissue under a mi%ros%o&e to %'e%, for abnormal+ or malignant %ells. A'en dealing wit' an area of signifi%ant mass+ su%' as an enlarged lym&' node+ fine needle as&iration %ytology ;fine needle bio&sy or FN(< 'as found an in%reasing role in diagnosis. /'e te%'niMue is reliable and relati)ely ine0&ensi)e. :n it+ a small needle atta%'ed to a syringe is inserted into t'e Muestionable mass+ and %ells are as&irated+ or &ulled out into t'e syringe as t'e do%tor draws ba%, t'e &iston of t'e syringe. /'e su%%ess of t'is met'od de&ends on 'ow a%%urately t'e needle is &la%ed+ and+ as wit' all bio&sies+ on t'e s,ill and e0&erien%e of t'e tissue &at'ologist w'o will be e0amining t'e %ells. :t is li,ely t'at t'e do%tor will insert t'e needle and draw out %ellular material from se)eral different lo%ations in t'e mass to ensure t'at a t'oroug' and re&resentati)e sam&le 'as been ta,en. :n one study %ondu%ted during t'e early 8!Is by resear%'ers Frable and Frable+ a E2 &er%ent a%%ura%y rate was a%'ie)ed in dete%ting t'e &resen%e of tumors and EE &er%ent rate in %orre%tly diagnosing benign %ells wit' t'is te%'niMue. A'ile t'ere was an initial fear t'at t'is te%'niMue would lead to tumor %ell seeding+ &ulling u& additional %an%erous %ells t'roug' t'e outside of t'e needle tra%t+ no %onfirmed %ases of new growt's attributable to t'is te%'niMue 'a)e been found. /'is is an issue wit' bot' fine needle and in%isional bio&sy. Anot'er form of in%isional bio&sy is referred to as a &un%' bio&sy. :n t'is %ase+ a )ery small %ir%ular blade is &ressed down into t'e sus&e%t area %utting a round border. /'e do%tor t'en &ulls on t'e %enter of t'is area+ and wit' a s%al&el or a &air of small tissue s%issors sni&s it free of t'e surrounding tissue+ remo)ing a &erfe%t &lug of %ells from t'e sam&led area. As

12

before t'is is sent to a &at'ologist for e0amination. /'e area w'ere t'e &lug was remo)ed will not bleed mu%'+ and 'eals normally wit'out t'e need for any stit%'es sin%e it is so small. Some dental offi%es are doing a Nbrus' bio&syN w'ere a sam&ling of %ells is %olle%ted by aggressi)ely rubbing a brus' against t'e sus&e%t area. A'ile t'is 'as some usefulness in &reliminary e)aluation of a sus&e%t area+ it is not a stand alone &ro%edure+ and if a &ositi)e find returns+ t'is must be %onfirmed by a %on)entional in%isional bio&sy. /'e entire &oint of %ourse+ is t'at no treatment de%isions s'ould be made before t'ere is %onfirmation of malignan%y. E)en in t'e %ase of w'at would seem to be an ob)ious malignan%y+ a&&earan%es %an o%%asionally be misleading+ 'en%e t'e need for a &ro&er bio&sy. Also+ t'e degree of differentiation between 'ealt'y and malignant tissues+ along wit' t'e stage of t'e disease will influen%e treatment strategy and &rognosis. @t'er ways to determine t'e &resen%e or e0tent of oral %an%er e0ist. For instan%e+ radiogra&'s+ also referred to as 0-rays+ %an assist in determining t'e &otential growt' of a tumor into bone. A'ile oral %an%ers unli,e many ot'er malignan%ies %an usually be seen wit' t'e na,ed eye+ some %an%ers are lo%ated internally in t'e body+ ma,ing t'eir dete%tion diffi%ult. Different s%anning o&tions+ some of w'i%' assist in determining t'e &resen%e of tumors or growt's+ and some of w'i%' %an e)en dete%t malignan%y+ are ne%essary in t'ese instan%es.

*/+ or *A/ ;%o-a0ial tomogra&'y< s%an te%'nology 'as de)elo&ed ra&idly o)er t'e last few de%ades+ and t'ese s%ans %an &ro)ide images of great diagnosti% Muality and usefulness. A */ s%an %ould be des%ribed as a series of 0-rays+ ea%' one a )iew of a #mm se%tion of t'e area being s%anned+ w'i%' are t'en mani&ulated by a %om&uter+ allowing do%tors a dynami% )iew of t'e affe%ted soft tissue areas of t'e body wit' mu%' greater detail t'an a sim&le 0ray. Howe)er+ */ is only able to dete%t t'e a%tual &resen%e of masses+ and only a bio&sy %an )erify t'at t'e mass is malignant. Anot'er re%ent te%'nology+ ?agneti% 1esonan%e :maging ;?1:<+ is 'el&ful in &ro)iding a%%urate )iews of t'e affe%ted area. ?1: is a &ro%edure in w'i%' &i%tures are %reated using magnets and radio freMuen%ies lin,ed to a %om&uter imaging

13

system. /'e 'ydrogen atoms in t'e &atientIs body rea%t to t'e magneti% field and emit signals t'at are analy=ed by a %om&uter to &rodu%e detailed images of organs and stru%tures in t'e body. @%%asionally a dye is in"e%ted into t'e bloodstream during s%anning to bring greater detail to t'e soft tissue areas of t'e s%an. Again+ t'is &ro%edure is only able to dete%t t'e a%tual &resen%e of masses+ and it still reMuires a bio&sy for %onfirmation.

$E/+ or $ositron Emission /omogra&'y+ &ro)ides anot'er ,ind of image of t'e bodyIs interior. :nstead of ta,ing a &i%ture of t'e bones+ li,e an H-ray+ or t'e internal organs and soft tissue+ li,e a ?1:+ $E/ s%anning lets do%tors dis&lay t'e bodyIs a%tual metabolism. Sin%e %ells use a sim&le sugar+ glu%ose+ as a sour%e of energy+ $E/ %an tra%, down 'ow mu%' glu%ose is being metaboli=ed in different areas of t'e body. (e%ause %an%er %ells are di)iding ra&idly+ t'ey brea, down glu%ose mu%' faster t'an normal %ells. /'e in%reased a%ti)ity will s'ow u& on a $E/ s%an+ and %an indi%ate bot' &rimary and metastati% tumors. Alt'oug' less freMuently used for oral %an%er dete%tion+ ultrasonogra&'y is anot'er way to &rodu%e &i%tures of areas in t'e body. :n it+ 'ig'-freMuen%y sound wa)es ;ultrasound< are boun%ed off organs and tissue. /'e &attern of e%'oes &rodu%ed by t'ese wa)es %reates a &i%ture %alled a sonogram. :t is useful in finding masses wit' in an area+ if &al&ation dis%loses somet'ing of Muestionable nature. 1adionu%lide s%anning %an s'ow w'et'er %an%er 'as s&read to ot'er organs elsew'ere in t'e body. :n it+ t'e &atient swallows or re%ei)es an in"e%tion of a mildly radioa%ti)e substan%e+ and a s%anner measures and re%ords t'e le)el of radioa%ti)ity in %ertain organs to re)eal abnormal areas. All t'ese ty&es of s%ans are still used largely for %onfirmation or measuring e0tent. /'e best indi%ator of tumor in)ol)ement is still t'e %lini%al assessment+ relying on bot' dire%t e0amination of t'e area as well as bio&sy. /'e ability to dete%t %an%er at t'e earliest stages+ as well as its &re%ise lo%ation in t'e body+ %an im&ro)e t'e sur)i)al rate of t'is disease+ and allow for less disfiguring ways to address t'e tumors and lesions asso%iated wit' oral %an%er. :f t'e &at'ologist e0amining t'e %ells from a &atient finds oral %an%er+ t'e

14

&atientIs do%tor needs to ,now t'e stage+ or e0tent+ of t'e disease in order to &lan t'e best treatment. Staging a %an%er in)ol)es trying to %arefully establis' t'e degree to w'i%' t'e %an%er 'as s&read+ and to w'at e0tent it in)ol)es ot'er areas of t'e mout' and ne%,+ or e)en distant lo%ations elsew'ere in t'e body. After determining 'ow mu%' t'e %an%er 'as s&read+ do%tors also use t'is &oint of diagnosis to grade a %an%er+ w'i%' is a way of e0&ressing 'ow ra&idly t'e %an%er is s&reading+ if at all. /'e aggressi)eness of t'is s&reading is des%ribed using t'e terms well differentiated+ moderately differentiated+ or &oorly differentiated. A well-differentiated %an%er is not o)erly aggressi)e in t'e rate it is s&readingL a moderately differentiated %an%er is intermediately aggressi)eL and a &oorly differentiated is mu%' more aggressi)e in t'e s&eed wit' w'i%' it is s&reading. /'ese staging tests and e0aminations almost always in%lude in%isional bio&sy+ and often one or more of t'e ty&es of s%ans listed abo)e. ?ost oral lesions allow for a small in%isional bio&sy+ one t'at %an be &erformed w'ile t'e &atient is %ons%ious. 2o%al anest'esia is adeMuate in most %ases. For lesions or tumors in dee&er tissues or less a%%essible areas+ a general anest'eti% %an &ro)ide a better o&&ortunity to &erform t'e bio&sy and also to ma,e a full %lini%al assessment of t'e lesion. Following bio&sy %onfirmation of t'e &resen%e of an oral %an%er+ a &atient undergoes a t'oroug' assessment of t'eir o)erall 'ealt'+ and t'e state of t'eir disease. /'e &atientIs o)erall fitness in anti%i&ation of treatment is determined. ?any &atients affli%ted by oral %an%er+ t'oug' %ertainly not all+ are elderly. @lder &atients may be suffering from ot'er illnesses+ and t'ey are also at ris, of 'a)ing ot'er %an%ers in t'e res&iratory or digesti)e tra%t. /'ese Nsyn%'ronous %ar%inomasN of t'e 'ead and ne%,+ lungs+ or eso&'agus o%%ur as freMuently as ! &er%ent of t'e time wit' elderly oral %an%er &atients. /'erefore+ %'e%,ing for %an%er in t'ese areas as well+ %an be &art of t'e diagnosti% &ro%ess. :n many ways+ t'e diagnosti% stage of treatment affe%ts e)eryt'ing t'at follows+ and so %are s'ould be ta,en to bot' a%%urately and effe%ti)ely determine t'e malignan%y and stage of t'e %an%er. /'is detailed diagnosis gi)es t'ose &res%ribing treatment s&e%ifi% ,nowledge+ w'i%' in turn allows for s&e%ifi%+ more su%%essful treatment. 2. T!eatment Number of generalities &redominate as &'iloso&'i% tenets of tongue malignan%y management. /'e general beliefs are t'at su&erfi%ial lesions are treated wit' single-modality t'era&y ;eg+ radiation or surgery< and t'at large lesions are treated wit' multi&le modalities ;eg+ %ombined surgery and radiation<. Additionally+ %er)i%al nodes are treated wit' eit'er surgery or radiation t'era&y+ and sur)i)al in%reases if mi%ros%o&i%ally &ositi)e nodes are &resent. /'e t'era&euti% de%ision must ta,e into %onsideration t'e &atientIs age+ lifestyle+ and willingness to &arti%i&ate in t'e t'era&euti% regimen. /'e treatments 'a)e substantially different morbidities and may result in signifi%ant differen%es in Muality of life. 15

:f &ossible+ a younger &atient is treated surgi%ally to a)oid radiation t'era&y be%ause of t'e ,nown late ad)erse effe%ts of radiation. Additionally+ &remature use of radiation t'era&y eliminates t'is modality from future %onsideration if t'e disease re%urs. :n an older &atient+ eit'er modality may be %'osen if t'e lesion is su&erfi%ial and small. A)oid using a modality t'at &reser)es greatest fun%tion but &la%es t'e &atient at a greater ris, of lo%al or regional re%urren%e. 2./ Ra:iation the!ap" 1adiation t'era&y may be used as a single-modality treatment for small or su&erfi%ial tongue lesions. /'e lo%al %ontrol rates for / and /2 oral tongue %an%ers are similar for surgery and radiation t'era&y. Howe)er+ radiation t'era&y 'as t'e ad)antage of &reser)ing normal anatomy and tongue fun%tion. /'ree main te%'niMues of radiation t'era&y administration may be used. E0ternal beam radiot'era&y using a single i&silateral &ortal or bilateralo&&osed &ortals may be sele%ted+ de&ending on tumor si=e and lo%ation+ nodal status+ and t'e &ossible in%lusion of interstitial im&lants. A se%ond te%'niMue is bra%'yt'era&y+ w'ereby t'e tumor is treated by im&lanting a series of 'ollow needles+ t'roug' w'i%' radioa%ti)e seeds are in"e%ted during t'e lengt' of t'e treatment.J.K /'is may be used as a single modality or %an be used following a &artial glosse%tomy wit' %ontrolled fro=en se%tions. @ne of t'e ad)antages of t'is te%'niMue is t'e almost dire%t administration of t'e radiation to t'e tumor bed. @ften+ t'is te%'niMue is used after t'e tumor bed 'as been &reliminarily treated wit' e0ternal beam radiot'era&y. (ra%'yt'era&y may result in signifi%ant tongue edema+ ne%essitating an ele%ti)e tra%'eotomy. A t'ird te%'niMue is ort'o)oltage radiot'era&y. ?ost su%%essful in %oo&erati)e &atients wit' well-marginated and e0o&'yti% lesions+ %one t'era&y is administered &rior to e0ternal beam radiation t'era&y. An intraoral %one is &la%ed against t'e tumor bed. Eit'er ort'o)oltage or ele%trons may be gi)en wit' eMual %ontrol rates. :n early or moderately ad)an%ed tumors ;ie+ / + /2+ early /#<+ &osto&erati)e radiation t'era&y is %onsidered if ad)erse 'istologi%al features are noted in t'e &at'ology s&e%imen of t'e &rimary tumor or t'e s&e%imen from ele%ti)e ne%, disse%tion. For ad)an%ed lesions+ %ombined treatment wit' surgery is ad)isable. ?ost &atients initially undergo surgi%al rese%tionL 'owe)er+ many &atients 'a)e re%ently been treated wit' 'ig'-dose ;t'era&euti%< &reo&erati)e radiation t'era&y wit' eit'er e0ternal beam radiot'era&y alone or e0ternal radiation t'era&y &lus interstitial radiot'era&y followed by surgi%al rese%tion of t'e residual tumor. /'e latter te%'niMue results in a less-e0tensi)e tongue rese%tion+ 'o&efully wit'out %om&romising t'e &rognosis. 1adiation t'era&y is %onsidered a )alid o&tion for t'e &rimary management of small oral tongue %an%ers in &atients w'o refuse surgery 16

or t'ose w'o are &oor surgi%al %andidates. 2.0 Chemothe!ap" /'e role of %'emot'era&y in t'e management of %an%er of t'e oral tongue is still un%lear. Early tumors are not treated wit' t'is modality be%ause of t'e 'ig' su%%ess of eit'er radiation t'era&y or surgery. $atients w'o &resent wit' e0tensi)e &rimary lesions or wit' distant metastases and &oor &rognoses are good %andidates for %'emot'era&y. Fa%tors to %onsider if %ontem&lating %'emot'era&y in%lude stage of disease+ general medi%al status+ &otential effi%a%y+ and toleran%e to ad)erse effe%ts. A new strategy for using %'emot'era&euti% agents is %on%omitant %'emoradiation. Ait' t'is modality+ %'emot'era&y is administered at t'e same time as radiation t'era&y. /'is a&&roa%' 'as multi&le benefits+ w'i%' in%lude synergism+ radiosensiti=ation+ benefi%ial anti&roliferati)e effe%ts+ &ossible im&ro)ed lo%oregional %ontrol+ and &ossible im&ro)ed sur)i)al. 2.3 S)!1i8al /'e ideal surgi%al a&&roa%' to oral tongue tumors de&ends on t'e tumor si=e and t'e in)ol)ement of ad"a%ent stru%tures. For most small / and /2 lesions %onfined to t'e tongue+ &eroral 'ori=ontal wedge e0%ision wit' &rimary anterior-to-&osterior %losure may be a%'ie)ed Muite easily. Ait' larger lesions and im&aired tongue mobility+ im&lying dee& tongue infiltration or floor-of-mout' e0tension+ a more radi%al a&&roa%' is reMuired. /'e tongue may be a&&roa%'ed t'roug' a lateral &'aryngotomy. :f more e0&osure is ne%essary+ a mandibulotomy may be reMuired for a%%ess if t'e mandible is free of tumor. A'en t'e tumor in)ol)es or e0tends to t'e gingi)a+ %onsider rese%tion of t'e mandible. Anot'er strategy is to use t'e %ombination of a glosse%tomy and bra%'yt'era&y. :n t'is setting+ %ontrolled margins of e0%ision are obtained+ followed by t'e use of bra%'yt'era&y needles &rior to awa,ening from general anest'esia. /'e &atient is t'en monitored &osto&erati)ely for 88 'ours+ during w'i%' t'e radiation on%ologist &ro%eeds wit' t'e bra%'yt'era&y dosimetry and im&lantation of radioa%ti)e seeds for &eriods of u& to 62 'ours. /'e needles are t'en remo)ed and t'e &atientIs re%o)ery &ro%eeds in-'os&ital until t'e &atient meets dis%'arge goals. *. P!o1no ti8 Early diagnosis is t'e ,ey &rognosti% fa%tor in tongue %an%er - influen%ing bot' tumour si=e and t'e li,eli'ood of metastati% de&osits. /'e . year disease free rate is a&&ro0imately 6!D in early disease+ falling to less t'an #!D in more ad)an%ed %ases. /umours at t'e base of t'e tongue are asso%iated wit' t'e worst &rognosis due to t'e in%reased li,eli'ood of t'em being diagnosed at a later stage. Furt'ermore+ aetiologi%al fa%tors asso%iated wit' tongue %an%er ;&rimarily smo,ing and al%o'ol< render sur)i)al worse for &atients t'an for

17

ot'er malignan%ies. /'e Nfield %an%erisationN %on%e&t means t'at t'ey are at in%reased ris, of de)elo&ing se%ond &rimary tumours in t'e 'ead and ne%, region+ as well as being at signifi%ant ris, from %ardio)as%ular and li)er disease asso%iated wit' t'eir lifestyle.

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. Sadler /. Head and ne%,. :n: Sun (. Langman's Medical Embryology. Et' ed. $'iladel&'ia: 2i&&in%ott Ailliams O Ail,insL 2!!8:#82-#E!. 2. Gray H. Anatomy of the Human Body. $'iladel&'ia: 2ea O Febiger+ (artleby.%omL E 8+ 2!!!:JFull /e0tK.Natte. Atlas of Human Anatomy+ &g E7 #. Domingo santiago torres et al.2!!8. (enign tumor of t'e oral mu%osa : A study of #!! &atients. ?edi%ina @ral S.2. $g E 72- E 76 8. .'tt&:55emedi%ine.meds%a&e.%om5arti%le5 8EE8#8-o)er)iewPaw2aab7b# .. 'tt&:55 www. %are'os&ital.%om5'ealt'library5en%y%lo&ediades% 7. Aeb.sMu.edu.om5med-lib5&g# E.&df 6. 'tt&:55www.oral%an%erfoundation.org5fa%ts5stagesQ%an%er.'tml 8. 'tt&:55www.rig'tdiagnosis.%om5t5tongueQ%an%er5 E. 'tt&:55www.)irtualmedi%al%entre.%om5diseases5tongue-%an%er-sMuamous-%ell%ar%inoma-of-t'e-tongue57 2P$rognosis !. 'tt&:55www.do,terbeda''erryyud'a.%om5

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